Textbook of Sports Medicine Basic Science and Clinical Aspects of Sports Injury and Physical Activity Edited by Michael Kjær, Michael Krogsgaard Peter Magnusson, Lars Engebretsen Harald Roos,Timo Takala Savio L-Y Woo
Blackwell Science
Textbook of Sports Medicine
Textbook of Sports Medicine Basic Science and Clinical Aspects of Sports Injury and Physical Activity Edited by Michael Kjær, Michael Krogsgaard Peter Magnusson, Lars Engebretsen Harald Roos,Timo Takala Savio L-Y Woo
Blackwell Science
© by Blackwell Science Ltd a Blackwell Publishing company Blackwell Science, Inc., Main Street, Malden, Massachusetts -, USA Blackwell Publishing Ltd, Garsington Road, Oxford, Ox DQ Blackwell Science Asia Pty Ltd, Swanston Street, Carlton South, Victoria , Australia Blackwell Wissenschafts Verlag, Kurfürstendamm , Berlin, Germany The right of the Authors to be identified as the Authors of this Work has been asserted in accordance with the Copyright, Designs and Patents Act . All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act , without the prior permission of the publisher. First published ISBN --- Catalogue records for this title are available from the British Library and the Library of Congress Set in ‒/ pt Ehrhardt by SNP Best-set Typesetter Ltd., Hong Kong Printed and bound in India by Thomson Press (India) Commissioning Editor: Stuart Taylor Managing Editor: Rupal Malde Production Editor: Jonathan Rowley Production Controller: Kate Charman For further information on Blackwell Science, visit our website: http://www.blackwellpublishing.com
Contents Editors and Contributors, ix Preface, xv Introduction,
Part 1: Basic Science of Physical Activity and Sports Injuries: Principles of Training .
Cardiovascular and respiratory aspects of exercise — endurance training, Sigmund B. Strømme, Robert Boushel, Bjørn Ekblom, Heikki Huikuri, Mikko P. Tulppo & Norman L. Jones
.
Metabolism during exercise — energy expenditure and hormonal changes, Jan Henriksson & Kent Sahlin
.
Skeletal muscle: physiology, training and repair after injury, Michael Kjær, Hannu Kalimo & Bengt Saltin
.
Neuromuscular aspects of exercise — adaptive responses evoked by strength training, Per Aagaard & Alf Thorstensson
.
Biomechanics of locomotion, Erik B. Simonsen & Paavo V. Komi
.
Connective tissue in ligaments, tendon and muscle: physiology and repair, and musculoskeletal flexibility, Peter Magnusson, Timo Takala, Steven D. Abramowitch, John C. Loh & Savio L.-Y. Woo
.
Cartilage tissue — loading and overloading, Karola Messner, Jack Lewis, Ted Oegema & Heikki J. Helminen
.
Bone tissue — bone training, Peter Schwarz, Erik Fink Eriksen & Kim Thorsen
Part 2: Aspects of Human Performance .
Recovery after training — inflammation, metabolism, tissue repair and overtraining, Jan Fridén, Richard L. Lieber, Mark Hargreaves & Axel Urhausen
.
Principles of rehabilitation following sports injuries: sports-specific performance testing, Malachy McHugh, Jens Bangsbo & Jan Lexell
v
vi
Contents
.
Physical activity and environment, Peter Bärtsch, Bodil Nielsen Johannsen & Juhani Leppäluoto
.
Nutrition and fluid intake with training, Leif Hambræus, Stefan Branth & Anne Raben
.
Ergogenic aids (doping) and phamacological injury treatment, Ulrich Fredberg, Timo Säppälä, Rasmus Damsgaard & Michael Kjær
Part 3: Physical activity: Health Achievements vs. Sports Injury .
Epidemiology and prevention of sports injuries, Roald Bahr, Pekka Kannus & Willem van Mechelen
.
Exercise as disease prevention, Ilkka Vuori & Lars Bo Andersen
.
Physical activity in the elderly, Stephen Harridge & Harri Suominen
.
Exercise in healthy and chronically diseased children, Helge Hebestreit, Oded Bar-Or & Jørn Müller
.
Disabled individuals and exercise, Fin Biering-Sørensen & Nils Hjeltnes
Part 4: Exercise in Acute and Chronic Medical Diseases .
Cardiovascular and peripheral vessel diseases, Mats Jensen-Urstad & Kerstin Jensen-Urstad
.
Exercise and infectious diseases, Bente Klarlund Pedersen, Göran Friman & Lars Wesslén
.
Osteoarthritis, L. Stefan Lohmander & Harald P. Roos
.
Exercise in the treatment of type and diabetes, Hannele Yki-Järvinen & Flemming Dela
.
Asthma and chronic airway disease, Malcolm Sue-Chu & Leif Bjermer
.
Amenorrhea, osteoporosis, and eating disorders in athletes, Michelle P. Warren, Jorun Sundgot-Borgen & Joanna L. Fried
Contents .
Physical activity and obesity, Pertti Mustajoki, Per Björntorp & Arne Astrup
.
Gastrointestinal considerations, Frank Moses
Part 5: Imaging in Sports Medicine .
Imaging of sports injuries, Inge-Lis Kanstrup, Hollis G. Potter & Wayne Gibbon
Part 6: Sports Injury: Regional Considerations. Diagnosis and Treatment .
Lower leg, ankle and foot, Jon Karlsson, Christer Rolf & Sajkari Orava
.
Knee, Lars Engebretsen, Thomas Muellner, Robert LaPrade, Fred Wentorf, Rana Tariq, James H.-C. Wang, David Stone & Savio L.-Y. Woo
.
Hip, groin and pelvis, Per Hölmich, Per A.F.H. Renström & Tönu Saartok
.
Head, Liying Zhang, King H. Yang, Albert I. King & Lars Engebretsen
.
Spine, Jens Ivar Brox
.
Shoulder, Michael R. Krogsgaard, Richard E. Debski, Rolf Norlin & Lena Rydqvist
.
Elbow, wrist and hand, Nicholas B. Bruggeman, Scott P. Steinmann, William P. Cooney & Michael R. Krogsgaard
.
Practical sports medicine, Sverre Mæhlum, Henning Langberg & Inggard Lereim
.
Multiple Choice Answers, Index,
vii
Editors and Contributors Per Aagaard Team Denmark Test Center, Sports Medicine Research Unit, University of Copenhagen, Bispebjerg Hospital, Copenhagen, DK-N, Denmark Steven Abramowitch Musculoskeletal Research Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA , USA
Lars Bo Anderson Institute of Exercise and Sports Science, University of Copenhagen, DK-N, Denmark Arne Astrup Research Department of Human Nutrition, Royal Veterinarian and Agricultural University, DKF, Frederiksberg, Denmark Roald Bahr The Norwegian University of Sport and Physical Education, Oslo, N-, Norway Jens Bangsbo Laboratory for Human Physiology, August Krogh Institute, University of Copenhagen, DK-Ø, Denmark
Oded Bar-Or Children’s Exercise and Nutrition Centre, McMaster University, West Hamilton, Ontario, CANL L, Canada
Peter Bärtsch Division of Sports Medicine, Department of Internal Medicine, University of Heidelberg, DE-, Heidelberg, Germany Fin Biering-Sørensen Clinic for Spinal Cord Injuries, Rigshospitalet, University of Copenhagen, DK-Ø, Denmark
Leif Bjermer Department of Lung Medicine, University Hospital, Norwegian University of Science and Technology, Trondheim, N-, Norway
Per Björntorp Department of Heart and Lung Diseases, University of Gothenburg, Sahlgrenska Hospital, SE- , Sweden
Robert Boushel Department of Exercise Science, Concordia University, Montreal, Quebec, CAN-HB R, Canada
Stefan Brauth Department of Medical Sciences, Uppsala University Hospital, SE-, Sweden Jens Ivar Brox Department of Orthopaedics, Section for Physical Medicine and Rehabilitation, Rikshhospitalet, Oslo, N-, Norway Nicholas Bruggeman Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN , USA William P. Cooney Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN , USA Rasmus Damsgaard Copenhagen Muscle Research Centre, Rigshospitalet, Copenhagen, DK-Ø, Denmark Richard E. Debski Musculoskeletal Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA , USA
Flemming Dela Department of Medical Physiology, Panum Institute, University of Copenhagen, DK-N, Denmark
ix
x
Editors and Contributors
Bjorn Ekblom Department of Physiology and Pharmacology, Karolinska Institute, University of Stockholm, SE, Sweden
Lars Engebretsen Department of Orthopaedic Surgery, University of Oslo, Ullevål Hospital, NO-, Norway Erik Fink Eriksen Department of Endocrinology, Aarlus University Hospital, DK-C, Denmark Ulrich Fredberg Department of Medicine, Silkeborg Central Hospital, DK-, Denmark Jan Fridén Department of Hand Surgery, Sahlgrenska University Hospital, SE-, Göteborg, Sweden Joanna L. Fried Department of Obstetrics and Gynaecology, Columbia University, New York, NY , USA Göran Friman Department of Medical Services, Section of Infectious Diseases, Uppsala University Hospital, SE, Sweden
Wayne Gibbon Department of Sports Medicine, University of Leeds, LS NL, UK Leif Hambraeus Department of Medical Sciences, Nutrition Unit, Uppsala University, SE-, Sweden Mark Hargreaves Department of Exercise Physiology, School of Health Sciences, Deakin University, Burwood, AUS-, Australia
Steve Harridge Department of Physiology, Royal Free & University College Medical School, London, NW PF, UK
Helge Hebestreit Pneumologie/Sportsmedizin, Universitäts-Kinderklinik, Würzburg, DE-, Germany Heikki Helminen Department of Anatomy, University of Kuopio, FIN-, Finland Jan Henriksson Department of Physiology and Pharmacology, Karolinska Institute, University of Stockholm, SE, Sweden
Nils Hjeltness Department of Spinal Cord Injury, Sunnaas Hospital, Nesoddtangen, Norway Per Hölmich Department of Orthopaedic Surgery, Amager Hospital, University of Copenhagen, DK-S, Denmark
Heikki V. Huikuri Department of Medicine, Division of Cardiology, University of Oulo, FIN-, Finland Kerstin Jensen-Urstad Department of Clinical Physiology, Karolinska Hospital, Stockholm, SE-, Sweden
Mats Jensen-Urstad Department of Cardiology, Karolinska Hospital, Stockholm, SE-, Sweden Norman L. Jones Department of Medicine, McMaster University, Hamilton, Ontario, CAN-LN Z, Canada Hannu Kalimo Department of Pathology, Turko University Hospital, Turko, FIN-, Finland Pekha Kannus Accident and Trauma Research Center, UKK Institute, Tampere, FIN-, Finland Inge-Lis Kanstrup Department of Clinical Physiology, Herlev Hospital, University of Copenhagen, DK-, Denmark
Jon Karlsson Department of Orthopaedics, Sahlgrenska University Hospital/Östra, Gothenburg, SE-, Sweden
Albert I. King Bioengineering Center, Wayne State University, Detroit, MI , USA
Editors and Contributors
xi
Michael Kjær Sports Medicine Research Center, University of Copenhagen, Bispebjerg Hospital, Copenhagen, DK- NV, Denmark
Pavo Komi Department of Biology of Physical Activity, University of Jyväskylä, FIN-, Finland Michael Krogsgaard Department of Orthopaedic Surgery, Bispebjerg Hospital, University of Copenhagen, DK NV, Denmark
Henning Langberg Sports Medicine Research Unit, Bispebjerg Hospital, Copenhagen, DK- NV, Denmark Robert F. La Prada, Sports Medicine and Shoulder Divisions, Department of Orthopaedic Surgery, University of Minnesota, MN , USA
Juhani Leppäluoto Department of Physiology, University of Oulo, FIN-, Finland Ingard Lerein Department of Orthopaedic Surgery, Region Hospital of Trondhjem, NO-, Norway Jack Lens Department of Orthopaedic Surgery, University of Minnesota, MN , USA Jan Lexell Brain Injury Unit, Neuromuscular Research Laboratory, Department of Rehabilitation, Lund University Hospital, SE-, Sweden
Richard L. Lieber Department of Orthopaedics and Bioengineering, University of California and V.A. Medical Center, La Jolla, CA -, USA John C. Loh Musculoskeletal Research Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA , USA
Stefan Lohmander Department of Orthopaedics, University Hospital, Lund, SE-, Sweden Sverre Mæhlum Norsk Idrettsmedisinsk Institutt (NIMI), University of Oslo, NO-, Norway Peter Magnusson Team Denmark Test Center, Sports Medicine Research Unit, University of Copenhagen, Bispebjerg Hospital, Copenhagen, DK- NV, Denmark Willem van Mechelen Department of Social Medicine, Vreie Universität, Amsterdam, NL-, The Netherlands
Karola Messner Department of Neuroscience and Locomotion, Division of Sports Medicine, Faculty of Health Sciences, Linköping, SE-, Sweden Malachy McHugh Nicholas Institute of Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, NY , USA
Frank Moses Gastroenterology Service, Walter Reed Army Medical Center, Washington DC, -, USA Thomas Muellner Department of Orthopaedic Surgery, University of Vienna, Austria Jørn Müller Department of Growth and Reproduction, Rigshospitalet, University of Copenhagen, DK-Ø, Denmark
Pertti Mustajoki Department of Medicine, Helsinki University Central Hospital, FIN-, Finland Bodil Nielsen Johansen Institute of Exercise and Sports Science, August Krogh Institute, University of Copenhagen, DK-Ø, Denmark
Rolf Norlin Linköping Medical Center, SE-, Linköping, Sweden
xii
Editors and Contributors
Ted Oegena Department of Orthopaedic Surgery, University of Minnesota, MN , USA Sakari Orava Tohturitalo Hospital, Turka, Fin-, Finland Bente Klarlund Pedersen Finsencentret, Department of Infectious Diseases, University of Copenhagen, DKØ, Denmark
Hollis Potter Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY , USA Anne Raben Research Department of Human Nutrition, Centre for Advanced Food Studies, Royal Veterinarian and Agricultural University, DK-F, Denmark
Per Renström Section of Sports Medicine, Department of Orthopaedics, Karolinska Hospital, Stockholm, SE, Sweden
Christer Rolf Centre of Sports Medicine, University of Sheffield, S TA, UK Harald Roos Department of Orthopaedic Surgery, Helsingborg Hospital, Helsingborg, SE-, Sweden Lena Rydqvist Linköping Medical Center, SE-, Linköping, Sweden Kent Sahlin Department of Physiology and Pharmacology, Karolinska Institute, University of Stockholm, SE, Sweden
Bengt Saltin Copenhagen Muscle Research Centre, Rigshospitalet, University of Copenhagen, DK-Ø, Denmark
Tönu Saartok Section of Sports Medicine, Department of Orthopaedics, Karolinski Hospital, Stockholm, SE , Sweden
Peter Schwartz Department of Endocrinology, Rigshospitalet, University of Copenhagen, DK-N, Denmark Erik Simonsen Institute for Medical Anatomy, Panum Institute, University of Copenhagen, DK-N, Denmark Scott Steinman Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN , USA David Stone Musculoskeletal Research Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA , USA
Sigmund B. Strømme The Norwegian University of Sport and Physical Education, Oslo, NO-, Norway Malcolm Sue-Chu Department of Lung Medicine, University Hospital, Norwegian University of Science and Technology, Trondheim, N-, Norway Jorun Sundgot-Borgen Norwegian University of Sport and Physical Education, Oslo, NO-, Norway Harri Snominen Department of Health Sciences, University of Jyväskylä, FIN-, Finland Timo Säppälä National Public Health Institute, Helsinki, FIN-, Finland Timo Takala Department of Biology of Physical Activity, University of Jyväskylä, FIN-, Finland Rana Tariq Department of Radiology, Ulleval University Hospital, Oslo, N-, Norway Kim Thorsen Department for Sports Medicine, Norrland University Hospital, Umeå University, SE-, Sweden
Alf Thorstensson Department of Sport and Health Sciences, University College of Physical Education and Sports, Department of Neuroscience, Karolinska Institute, Stockholm, SE-, Sweden
Editors and Contributors
xiii
Mikko P. Tulppo Merikoski Rehabilitation and Research Centre, University of Oulu, FIN-, Finland Axel Urhausen Institute of Sports and Preventitive Medicine, Department of Clinical Medicine, University of Saarland, D-, Saarbruecken, Germany
Ilkka Vuori UKK Institute for Health Promotion Research, Tampere, FIN-, Finland James H.-C. Wang Musculoskeletal Research Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA , USA Michelle Warren Department of Obstetrics and Gynaecology, Colombia University, College of Physicians and Surgeons, New York, NY , USA Fred Wentort Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN , USA Lars Wesslén Department of Medical Sciences, Section of Infectious Diseases, Uppsala University Hospital, Uppsala, Sweden
Savio L.-Y. Woo Musculoskeletal Research Center, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA , USA
King H. Yang Bioengineering Center, Wayne State University, Detroit, Michigan, MI , USA Hannele Yki-Järvinen Department of Medicine, University of Helsinki, FIN-, Helsinki, Finland Liying Zhang Bioengineering Center, Wayne State University, Detroit, Michigan, MI , USA
Preface
In past decades the number of exercising individuals and the area of sports medicine have grown considerably. Sports medicine has developed both in terms of its clinical importance with appropriate diagnosis and adequate rehabilitation following injury as well as its potential role in the promotion of health and prevention of life-style diseases in individuals of all ages. Furthermore, lately the medical field has gained improved understanding of the use of physical activity as a treatment modality in patients with a variety of chronic diseases and in rehabilitation after disabilities, injuries and diseases. Common to these advancements is the fact that a certain amount of clinical experience has to be coupled with sound research findings, both basic and applied, in order to provide the best possible recommendations and treatments for patients and for the population in general. There is a tradition in Scandinavia for an interaction between exercise physiology and clinical medicine and surgery, and it is apparent that both areas have hypotheses, inspiration and possible solutions to offer each other. It is therefore apparent that a textbook on sports medicine must attempt to incorporate all of these aspects to be comprehensive. A historical or classical reference has been selected as an introduction to each chapter to reflect the impact that a specific scientific work has had on that field. Having several authors collaborating on each chapter in the book ensures both diversity and a degree of consensus in the text, which will hopefully make the book usable as a reference book, and as a textbook both at the pre- and postgraduate levels. It has been our goal to address each topic within sports medicine in a scientific way, highlighting both where knowledge is well supported by research, as well as areas where the scientific support is minimal or completely lacking. It is the intention that the book will help the people who work clinically within the area of sports medicine in their daily practice, and that it will also provide the basis for further research activity within all areas of sports medicine. Moreover, we wish to highlight where knowledge and methodologies from different, and often distant, areas can interact to create a better understanding of, for example, the mechanisms behind development of tissue injury and its healing. The editorial group has been delighted that some of the world’s leading experts have agreed to participate in this project, and they have all contributed with informative and very comprehensive chapters. I greatly appreciate their contribution and that of the editorial group who worked hard on the completion of the book. Additionally, I wish to acknowledge all other contributors who have helped with the practical procedures of this project. Finally, I hope the reader of this book will share the research dreams, the clinical interest, and the enthusiasm in relation to the sports medicine topics with that of the authors and the entire editorial group. Michael Kjaer Copenhagen, September
xv
Introduction MICHAEL KJ ÆR MICHAEL KROGSGA ARD PETER MAGNUS S ON LARS ENGE B RE TSE N HARALD ROOS TIMO TAK A LA SAVIO L-Y WOO
The exercising human: an integrated machine Physiological boundaries have fascinated man for a long time, and achievements like climbing up to more than m above sea level without oxygen supply or diving down to more than m in water without special diving equipment are at the limit of what textbook knowledge tells us should be possible for humans. Likewise, athletes continue to set new standards within sports performance, and patients with chronic diseases master physical tasks of a very challenging nature, like marathon running, that hitherto were thought impossible. Muscles, tendons and bone are elegantly coupled together to provide an efficient system for movement, and together with joint cartilage and ligaments they allow for physical activity of various kinds. In order to provide energy to contracting muscles, ventilation often rises –-fold and cardiac pump function can increase up to -fold during strenuous exercise in welltrained individuals in the attempt to deliver sufficient oxygen to allow for relevant oxidative processes that can be initiated within seconds. In addition, working skeletal muscles can by training achieve substantial increases in their capacity to both store energy and to extract and utilize oxygen. With regards to endurance capacity, humans are still left with the fact that the size of the heart relative to the skeletal muscle is relatively small — even in top-class runners — compared to basically all other animal species. To drive the human machinery, local as well as dis-
tant substrate stores provide fuel for energy combustion, allowing for very prolonged exercise bouts. A controlled interplay between exercise intensity, energy metabolism and regulatory hormones takes place, and intake of different food stores can cause the muscle to adjust its fuel combustion to a large degree. The initiation of signals from motor centers to start voluntary movement and afferent signals from contracting muscle interact to achieve this and several signalling pathways for circulatory and metabolic control are now identified. The brain can make the muscles move, and can at the same time use substances for fuel that are released from muscle. Furthermore, intake of different food sources can cause the muscle to adjust its fuel combustion to a large degree. Training can cause major tissue and organ adaptation and it is well known that this to a large degree depends upon both genetic and trainable factors (Table ). More recent studies on identical twins have allowed for a discrimination of these two factors in relation to exercise and have shown that between and % of the variation in parameters like maximal oxygen uptake or muscle strength are likely to be attributed to genetic factors. Rather than discourage humans from starting training on this background, it is fascinating to identify factors responsible for training improvements in, for example, muscle tissue. It is evident that contractile force can elicit transcription and translation to produce relevant changes in the amount of contractile or mitochondrial proteins, but the underlying mechanism in both muscle and connective
Introduction
Table The capacity of various tissues and systems, and their ability to adapt to physical activity or inactivity. Decrease in function or maximal load with 3–4 weeks of inactivity (%)
Function
Increase during single bout of physical activity ultimate tensile strength
Improvement with training (%)
Cardiorespiratory Ventilation CO O2 extraction VO2
35-fold 6-fold 2–3-fold 12–18-fold
0 90 25 50–60
Muscle metabolism Glycogen/fat stores Oxidative capacity
– –
100 300
Connective tissue Tendon Ligament Bone Cartilage
100 MPa 60–100 MPa 50–200 MPa 5–40 MPa
20 20 5–10 5–10
–
100–200
60
– –
40 80
20 30
Muscle Strength Fibre CSA Type I Type II
Time required for adaptation Months–years
40 30 40 Weeks–months 50 40–100 Months–years 30 30 30 30 Months–years
CO: cardiac output;VO2: whole body oxygen uptake; CSA: cross-sectional area.
tissue is not understood. Interestingly, substances are now being identified (e.g. mitogenactivated protein kinases) where subtypes are differentially activated by either metabolic stress or by the degree of contractile stress, to cause either increased cell oxidative capacity or muscle cell hypertrophy, respectively. We are therefore at a point where we can begin to master the study of the adaptation of the human body not only to acute exercise, but also to loading and overloading, and this will provide us with prerequisites for study of the ultimate adaptation potential that the human organism achieves, and thereby better describe also on an individual level why tissue becomes overloaded and injured.
The delicate balance between training adaptation and injury — the dilemma of rehabilitation It is important for the clinician who treats the recreational or elite athlete to have a thorough understanding of the injury, and also the ability of the affected tissue to adapt to immobilization, remobilization and
training. One example is the considerable plasticity that skeletal muscle tissue displays. While strength is lost (up to %) rapidly within a few weeks of immobilization, it can be regained over the next couple of months, and strength can be augmented up to -fold with training for extended periods (months/year). Bone loss also (up to %) occurs rapidly within weeks of immobilization and is subsequently regained in the following months of rehabilitation. However, somewhat in contrast to muscle, extended training periods have a relatively modest impact on bone tissue augmentation. Connective tissue loss in tendon is also comparable to muscle and bone; however, in contrast, its slower metabolism requires perhaps up to months or more before complete tissue recovery from an injury and subsequent inactivity. Thus, an injury that demands a limb to be immobilized for a given length of time may require different time periods for the various tissues to return to their preinjury levels. In this context it is important for the clinician to note that the cardiovascular system recovers the fastest after
Introduction a period of relative inactivity, which may create a dilemma: the athlete wants to take the rehabilitation and training program to new and challenging levels, but the different tissues may not be able to withstand the associated loads, and re-injury or a new so-called ‘overload injury’ may result. Thus, a thorough understanding of how tissues adapt to physical activity or lack thereof is paramount for the effective treatment and rehabilitation of the injured person. While acute injury during exercise may intuitively be somewhat easy to understand, it may be more challenging to grasp the insidious and frequent ‘overuse’ injuries that occur with training. Some important observations in the field of sports medicine have been made in recent decades that have improved our understanding of these injuries. An awareness of the subject’s loading pattern is important, of course. The recreational athlete who runs km/week may subject each lower limb to approximately landings and take-offs in that time period. In contrast, the long distance runner who runs km/week may subject each lower limb to approximately landings and takeoffs. Clearly, a certain degree of appropriate tissue adaptation has already taken place to withstand these vastly different loads, but nevertheless, injuries may be sustained by both the recreational and elite athlete and therefore remains an enigma. Interestingly, the weekly loading of tissue induced by sports participation is equivalent to that established by national authorities as the upper limits for what is tolerable for manual labour, suggesting that perhaps there is an inherent tissue limitation to loading. Disadvantageous alignment, like severe pes planus or genu valgus, for example, may be important factors in determing who can withstand a given loading pattern, although such internal factors cannot entirely explain overuse injury. It has become generally accepted that it takes appreciable time for tissues like connective tissue to adapt to a new or increasing demand, even for the most genetically fortuitous. Therefore, any desired progression or change in a training program should be gradual. However, more detailed information with respect to the training frequency, duration and intensity that is required to avoid an injury is currently lacking, and thus preventative efforts in this respect remain difficult. At the same time, it is becoming increasingly
appreciated that tissues need restitution periods to ‘adapt’ to the previous bout of physical activity. This is put into practice, for example, by the tri-athlete who loads the cardiovascular system considerably on a daily basis, but stresses the musculo-skeletal system alternately by training either cycling, running or swimming, which may help to avoid injury. It is during the restitution period that tissues are allowed to recover, or further adapt to an increasing demand by either expanding their quantity or improving their quality. It is likely that in years to come researchers will furnish new and improved measurement techniques that will yield important detailed information about tissue adaptation to physical activity and restitution.
Sports injuries and development of treatment: from recreational sports to elite athletes In many situations the transformation from overload symptoms to a sports injury is poorly defined and understood. Intensified research in anatomy, biochemistry, physiology and mechanisms of tissue adaptation to mechanical loading is needed to provide the basic understanding of overload injury pathogenesis. Although this in itself represents a paramount challenge, it seems even more difficult to understand an individual’s disposition for developing symptoms. Why does one individual develop severe Achilles tendon pain in connection with a certain amount of running, while others do not? Why are overhead activities very painful for some athletes but not for others? Why is the functional stability of a cruciate ligament deficient knee or a mechanically unstable ankle joint different between persons despite the same activity level? Obviously it would be essential to identify the weakest link in each individual case, but knowledge of the individual specific factors is very incomplete. Could there be physiologically different levels for initiation of symptoms in different individuals? It is well known that persons with decreased sensory inputs, for example caused by diabetic polyneuropathy, have a high rate of overload injuries like tendonitis or stress fractures, simply because the natural alarm system is out of order. If a physiological difference in, for example, the threshold of sensory inputs exists in otherwise healthy people, the difference between a
Introduction
mechanical load that causes symptoms and one that results in tissue damage would vary from person to person. Treatment of sports injuries represents major challenges. First, the aim to reduce symptoms is demanded by the athlete, and several pharmacological treatments will work well at rest, but will not provide pain relief when the individual is exercising. Secondly, when surgical treatment is indicated to repair irreversible changes of tissues (e.g. rupture of anterior and posterior cruciate ligaments of the knee) or to change biomechanical inferior or insufficient movement patterns (e.g. multidirectional instability in the shoulder) the procedures need to be minimally invasive in order to leave the remaining tissue as intact as possible and to allow for a quick regeneration process. Thirdly, the rehabilitation procedures and time allowed for recovery will be challenged. This is because athletes are eager to return to their sports. In this aspect, similarities can be drawn to occupational and rehabilitation medicine, which aims towards getting the patient back to the functional level that is required to perform a certain labour task. In contrast to the little which is known about the individual-based factors, there is increasing knowledge about injury mechanisms in athletic performance. A number of specific pathological entities have been recognized, especially during the past two decades, e.g. secondary impingement and internal impingement of the shoulder in overhead athletes. On the basis of recognizing certain common patterns of injury and understanding their pathogenesis, specific treatments — surgical as well as nonsurgical — have been developed. Probably the first injury to be recognized as a specific lesion connected to sports performance was the Bankart lesion of the shoulder, described in , and the way to repair the lesion was obvious once the pathoanatomical background was established. Similarly, when the SLAP lesion of the labrum in the shoulder was described for the first time about years ago, the surgical treatment options could be defined (for further details see Chapter 6.5). Arthroscopy, which was introduced for knee disorders back in and developed for the treatment of shoulder, elbow and ankle disorders in the s, has made direct visualization of joint movement and intra-articular structures possible, and has increased
the understanding of many intra-articular sports injuries. For the individual athlete it has resulted in a much more specific diagnosis and treatment, and consequently rehabilitation has become faster and easier than after open surgery. Furthermore, the invention and development of magnetic resonance imaging in the early s, and the refinement and general availability of ultrasound investigation during the late s, has increased the spectrum of diagnostic tools significantly. What still requires specific attention is the relative use of these para-clinical supplements as compared with a good clinical examination and judgement. There is no doubt that the new ‘machine-tools’, developed to help the sports medicine practitioner, tend to be ‘over-used’ in the initial phase, which is often followed by a more balanced phase in which it becomes evident that patient history and clinical examination can never be replaced by para-clinical tools, but that the latter provides a fruitful supplement in the process of diagnosis in sports medicine. The collection of clinical information on symptomatic conditions in athletes can lead to identification of uniform patterns and logically based treatment modalities. Series of treated patients can also give information about the success rate of certain treatments, whereas only randomized studies can identify the best treatment strategy in a specific condition. Unfortunately, there are very few randomized studies in sports medicine and especially within traumatology. This is often due to a high demand for treatment to ensure fast recovery and return to sports participation, and it is unlikely that more than a small part of the surgical and nonsurgical treatment modalities will ever be evaluated by randomized studies. Even though more than anterior cruciate ligament (ACL) reconstructions are performed every year in the USA, it is unknown which treatment strategy is the most advantageous. There are different factors influencing the decision to perform ACL reconstruction: the chance to get back to sports, prevention of secondary meniscus and cartilage injury, prevention of giving-way or subluxation episodes, risk for anterior knee pain or other operative complications, or timing of surgery. There is no evidence for how these factors should be weighted, and it is unknown if routine reconstruction in all patients shortly after an ACL injury would reduce the risk of late complications and increase activity level better
Introduction than a more conservative approach with rehabilitation as primary treatment. It is very important to perform randomized trials at the same time as new treatments are introduced, as it is almost impossible to return to such studies later. Most rehabilitation programs are based on individual, clinical experience and theoretical principles. Just as with surgical treatment, evidence is still lacking on the effect of a number of general treatment principles. Rehabilitation is very costly, and it is desirable with further development of evidence-based rehabilitation strategies. New technologies will probably influence the treatment of sports injuries in the near future. Local availability of growth factors may reduce repair and remodelling time after injury or surgery. Scaffolds can be used to introduce a specific architecture. These can be taken over by living tissue, and in combination with controlled gene expression, injured tissue can possibly be restored completely. This will contribute to an avoidance of reconstruction with replacement tissue and accompanying suboptimal recovery, as well as ensure the absence of scar tissue otherwise seen in repair. In the recreational athlete, many overload conditions are often self-limiting. Nature’s alarm system works: overloading of tissues often results in symptoms (pain) long before irreversible changes of the tissue structures happen. With a gradual reduction of activity, symptoms and overloading disappears, and the athlete can resume normal activity again. Tennis elbow is a good example of this mechanism. During one season about % of middle-aged persons per-
forming recreational racquet sports will experience symptoms of tennis elbow. The majority of these cases resolve without specific treatment. The interesting phenomenon is, why humans often carry on with exercise despite symptoms and signs of overuse. Interestingly, inflammatory reactions within and around tendons are seen in humans and in a few animal species that are forced to run like race-horses, whereas almost all other species (like mouse, rat or rabbit) do not show signs of tendinitis or peritendinitis despite strenuous activity regimens. Elite athletes can be motivated to continue peak performance despite pain or other symptoms, and it can be difficult or impossible for the natural repair processes to take place. Not enough is known about tissue repair and rehabilitation to define the maximum activity in each individual that is compatible with a full and fast repair. The boundary between trivial, reversible conditions and irreversible, disabling injuries still has to be defined in many sports. As an example, there is an ongoing discussion about the risk for chronic brain damages in boxing. Furthermore, nearly nothing is known about the long-term effect of continued elite sports activity on degenerative changes in the knee after ACL reconstruction. With this lack of evidence about physical consequences of sports injuries, ethical considerations have a central place in advice and planning. The influence of psychological factors such as competition (matches only take up less than % of the active playing time in elite handball, more than % of the ACL injuries happen there), self-confidence and acceptance of personal limits have to be acknowledged and further knowledge is warranted.
Table Motivation and needs in different individuals with physical training.
Patient Recreational sports Elite athletes
Performance motivation
Disease-effect motivation
Prevention motivation
Guidelines for training
Tolerable amounts of training
+ + (function) + + + + (competition)
+++ – –
++ +++ (+)
+++ ++ +++
+ ++ +++
The motive for performing physical training can primarily be based upon a wish of increased performance either in sports or in everyday life, or be related to a wish of increased health and disease prevention.All three groups of individuals display an individually varying degree of which for achieving mental well-being in relation to exercise.The tolerable amount of training depends on the ability of the body to withstand loading and varies therefore significantly between athletes and patients, whereas both patients and athletes share a large request for specific guidelines in relation to the training they perform.
Introduction
Regular physical training: benefits and drawbacks For more than years, systematic exercise or sports have been carried out worldwide, and one can easily consider the average individual living today as being much more inactive than they were in the past. It is becoming more and more scientifically documented that physical inactivity is a major risk factor for disease and premature death, and that the magnitude of this lies on the level of other risk factors like smoking, obesity or drinking. Studies have uniformly concluded that being active or beginning physical activity even at an advanced age, will positively influence risk factors for development of inactivity-associated diseases. In spite of the fact that acute training is associated with a transient increased risk of cardiac arrest, taken in the population as a group, as well as the costly treatment of sports injuries, socio-economic calculation has found that, for the recreational athlete, these drawbacks are far outweighed by the cost-saving benefits of physical training such as lower incidence of diseases, faster hospital recovery after disease in general, as well as a lower frequency of infection and time away from work due to sickness. The field of sports medicine is therefore facing a major challenge in improving the level of physical activity in the general population, and for setting up overall guidelines.
Physical training and patients with chronic diseases Acute and chronic diseases are associated with both organ specific manifestations as well as by more general disturbances in function due to physical inactivity and sometimes even additional hormonal and cytokine-related catabolism. In general, physical training can counteract the general functional disturbances, and maybe even affect or prevent the primary manifestations of disease. It is important to note that the motivational aspects, as well as the requirements for supervision and guidelines, in the patient with a present disease differ markedly from healthy exercising individuals (Table ). In principle, most diseases can be combined with a certain degree of physical activity, but the amount of restrictions put upon the patient differs considerably between diseases (Table ). Certain diseases have been shown to be influenced greatly from physical activity
Table Effects of physical training upon different diseases. Diseases in which physical training will act preventively in disease development and positively upon primary disease manifestations Ischemic heart disease Recovery phase of acute myocardial infarction Hypertension Type-2 diabetes Obesity (most pronounced with respect to prevention) Osteoporosis Age-related loss of muscle mass (sarcopenia) Osteoarthritis (most likely only the prevention) Back pain Cancer (prevention of colon and breast cancer) Depression and disturbed sleep pattern Infectious diseases (prevention of upper respiratory tract infection) Diseases in which moderate or no direct effect can be demonstrated upon the primary disease manifestations, but where exercise will positively affect both health associated risk factors and the general disturbances in overall body function Peripheral vascular diseases (arterial insufficiency) Type-1 diabetes Bronchial asthma Chronic obstructive lung disease Chronic kidney disease Most forms of cancer Most acute and chronic liver diseases Rheumatoid arthritis Organ transplanted individuals Spinal cord injured individuals Most neurological and mental diseases Diseases in which much caution has to be taken or where exercise is to be discouraged, and where physical training often can have a worsening effect upon primary disease manifestations or may lead to complications Myocarditis or perimyocarditis Acute heart conditions (e.g. unstable angina, acute AMI, uncontrolled arrhythmia or third degree AV-block) Acute infectious diseases associated with fever (e.g. upper respiratory tract infection) Mononucleosis with manifest splenomegaly Aorta stenosis (chronic effect) Acute severe condition of many diseases mentioned above (e.g. severe hypertension, ketoacidosis in diabetes) Acute episodes of joint swelling (e.g. rheumatoid arthritis) or severe muscle disease (e.g. myositis)
Introduction (e.g. ischemic heart disease, type- diabetes), whereas other diseases are known to be relatively insensitive to exercise when it comes to primary disease manifestations (e.g. chronic lung disease, type- diabetes). In the later group of diseases, it should, however, be noted that physical training can still have a beneficial effect on health-related parameters that can be achieved by individuals in general. This effect is achievable even in the absence of any worsening of the primary chronic disease. This emphasizes the importance of also encouraging individuals with chronic (and not necessarily fatal) diseases to train on a regular basis from a general health perspective. In addition, almost all diseased individuals can exercise in order to counteract the general loss in function that their disease-related inactivity has caused. In very few cases, extreme caution has to be taken when performing exercise (e.g. acute infectious diseases) (Table ). In spite of current knowledge of the effect of physical training on diseases, the exact mechanisms behind this are still only partially described. To find such bio-
chemical and physiological pathways will be important not only for addressing which type and dose of physical training should be prescribed for the individual patient, but also for identifying more general ‘health-pathways’ by which muscular contractions can influence the health status of the individual. Especially in relation to disease, the influence of training on such pathways either by itself or in combination with pharmaceutical drugs will potentially play a role in treatment of disease and maintenance of health into old age. Specific identification of health-related pathways in our genes will furthermore provide insight into the genetic polymorphism and help to explain the interindividual variation in training responses and healthrelated outcome of these. Evidently, this will also open possibilities for genetic treatment of inherited disorders with regards to tissue and organ adaptability to training, and at the same time inadvertently provide opportunities for misuse of gene therapy in relation to doping, a question that will challenge the sports medicine field ethically.
Part 1 Basic Science of Physical Activity and Sports Injuries: Principles of Training
Chapter 1.1 Cardiovascular and Respiratory Aspects of Exercise — Endurance Training SIGMUND B. S TRØMME , ROBE RT BOUSHE L , BJØRN EKBLOM, HE I KKI HUI KURI , MIKKO P. TUL PPO & NORMA N L. J ONE S
Classical reference Krogh, A, Lindhard, J The regulation of respiration and circulation during the initial stages of muscular work. J Physiol (Lond) 1913; : –. This paper demonstrated changes in respiration and heart rate with the transition from rest to bicycle exercise. The investigators did experiments on themselves, and Fig. .. shows the changes in tidal air and heart rate at the onset of exercise. As will be noted, a very rapid increase in both ventilation and heart rate was observed, and this led to the conclusion that motor center activity in parallel with activation of skeletal muscle caused an increased stimulation of respiratory centers as well as the heart. This was called cortical irradiation, and has later been referred to as central command or feed-forward, and has become an important topic in the discussion of respiratory, circulatory, and hormonal changes during exercise.
Cardiovascular adaptation Cardiac output The pumping capacity of the heart is a critical determinant of endurance performance in exercise events such as running, cycling, rowing, swimming, etc., where a large fraction of total body muscle mass is contracting dynamically. Because of the large dependence on oxidative metabolism for the total energy turnover in exercise activities sustained for longer than min,
Fig. .. A recording of the tidal air on a spirometer (constructed by Krogh) at rest and at the beginning of exercise.
performance level is, as will be discussed later, largely dependent on the capacity for O2 delivery, and thus on the magnitude of maximal cardiac output. Maximal aerobic power (V˙2 max) is a classic measure of the capacity to perform endurance exercise, and may be described physiologically as the product of cardiac output and the extraction of O2 by muscle. For almost a century it has been recognized that a linear relationship exists between maximal oxygen uptake and cardiac output, and this relationship is also observed in other species [–]. It is estimated that –% of the interindividual difference in V˙2 max is
Chapter . 35
Cardiac output (L /min)
30 25 20 15 10 5
1
2
3 . VO2max (L /min)
4
attributable to the level of maximal cardiac output []. Looked at another way, during whole body exercise, only ~–% of maximal mitochondrial respiratory capacity is exploited because of the limits of O2 delivery [–]. Endurance training augments skeletal muscle oxidative capacity and O2 extraction, but the principal variant for improvements in V˙2 max is maximal cardiac output [–] (Fig. ..). On the other hand, differences in athletic performance amongst competitive athletes with similar V˙2 max are linked to peripheral mechanisms [], such as running economy. The basic question as to what limits maximal aerobic power (V˙2 max) will be discussed later in this chapter.
Cardiac structure The increase in maximal cardiac output (Q max) following endurance training results from a larger cardiac stroke volume (SV), whereas maximal heart rate (HRmax) is unchanged or even slightly reduced. While heart size is a function of total body size as well as genetic factors, the higher SV achieved by endurance training is attributed to enlargement of cardiac chamber size and to expansion of total blood volume []. On the basis of cross-sectional studies in both
5
Fig. .. Relationship between increases in cardiac output and maximal oxygen uptake in heart failure patients (circles), healthy males after days’ bedrest (squares), the same subjects before bedrest (inverted triangle), the same subjects after endurance training (upright triangle), and endurance athletes (diamonds).
female and male endurance-trained athletes, total heart volume is generally –% larger than sedentary size-matched controls, with morphologic differences seen in both the ventricles and the atria []. Chamber enlargement is also observed in endurance-trained paraplegics compared to sedentary matched controls []. There is a close relationship between cardiac volume and physical performance []. However, the cardiac hypertrophy is dependent on the type of sport carried out. There are two main types of myocardial hypertrophy. In weight lifters and other strengthtraining athletes heart wall thickness is increased, with only minor increases in heart cavity diameters, while endurance athletes have increased heart volume and cavity diameter with a proportional increase in wall muscle thickness []. The ratio of wall thickness to cavity diameter is unchanged in the endurancetrained individual but increased as a result of strength training []. The left ventricular hypertrophy in the endurancetrained individual is due to volume overload (‘eccentric’ hypertrophy), while the hypertrophy due to strength training develops as a consequence of pressure overload (‘concentric’ hypertrophy). Rowing, for
Cardiovascular and Respiratory Responses to Exercise instance, represents a mixture of volume and pressure overloading. In the former sarcomeres are added in series to increase cavity diameter, while in the latter sarcomeres are mainly added in parallel, causing wall thickening []. Both these are reversible processes since deconditioning from elite sport reduces cardiac size and volume towards what is normal for age and gender []. The cardiac morphology of the female athlete heart is the same as in men but the dimensions are in general smaller []. Structural and functional echocardiographic indices characterizing the normal limits of the athletic heart are shown in Table ... Whether or not cardiac hypertrophy (‘athlete’s heart’) predisposes the athlete to future cardiac problems has been discussed for many years [,]. However, the number and severity of cardiac arrhythmias seem to be the same in young athletes compared to untrained individuals of the same age and gender [], but increased in active elderly athletes []. However, a fast regression of ventricular hypertrophy through physical inactivity may cause some temporary increase in the number of arrhythmias [].
Table .. The upper normal healthy limits of cardiac dimensions associated with exercise training. From Urhausen & Kindermann, Sports Med ; : –.
Heart volume (mL/kg) Heart weight (g/kg) LV muscle mass (g/m2) LV mass/V·O2 max (g.min/L) LVED diameter (mm) Septum, LV post wall thickness Septum/LV post wall thickness Hypertrophic index (%)* Fractional shortening (%) Early/late transmitral flow velocity Left atrium thickness (mm)
Men
Women
20 7.5 170 80 63 (67a) 13
19 7 135 80 60 (63a) 12
1.4
1.3
48 >(22-) 27; ≠ exercise >1.0
45 >(22-) 27; ≠ exercise >1.0
43 (47a)
43 (45a)
*Hypertrophic index (%) = septum + LV thickness (mm)/LVED diameter (mm).
Functional adaptations In addition to structural adaptations, endurance training produces functional improvements in cardiac performance during exercise []. Most notable is a more rapid early and peak ventricular filling rate during diastole. An enlarged blood volume, together with greater ventricular compliance and distensibility, and a faster and more complete ventricular relaxation are important factors allowing stroke volume to increase even at high heart rates during exercise [,]. Improved myocardial relaxation allows for a more rapid lowering of ventricular pressure, optimizing the left atrial/ventricular pressure gradient for enhanced filling []. At the same time, the cardiac output is distributed more selectively to activated regions of skeletal muscle, from where the muscle pump facilitates venous return. As a result of an enlarged end-diastolic volume, left ventricular systolic performance is improved mainly by way of the Frank–Starling mechanism []. During submaximal exercise, myocardial work and O2 consumption are reduced in those who are endurance trained due to a lower heart rate at a given cardiac output as well as a reduced afterload attributable to lower peripheral resistance []. The enhanced diastolic filling and reduced afterload ensure that stroke volume is maintained or even progressively increased from submaximal to maximal exercise [], as compared to the sedentary person whose stroke volume plateaus at submaximal intensities and may fall as maximal exertion is approached [].
Myocardial vascularization and perfusion In a comparison of the cross-sectional area of proximal coronary arteries from endurance-trained and sedentary humans it has been suggested that coronary vascular volume may be increased by training []. It remains unresolved whether in humans endurance training increases coronary vascular dimensions beyond the vascular proliferation that accompanies normal training-induced cardiac hypertrophy. On the basis of studies in rats, endurance training has been shown to increase myocardial capillary density expressed as capillary/fiber ratio []. However, in larger animals, there is little evidence for increased capillary proliferation per fiber, nor is there evidence for proli-
Chapter .
Heart rate At the beginning of dynamic exercise, heart rate increases rapidly due to the inhibition of parasympathetic tone. If the exercise is light (heart rate < beats/min), the sympathetic activity applied to the heart and the vasculature does not increase and tachycardia occurs solely due to the reduction in parasympathetic tone []. As the workload increases, heart rate increases due to further vagal withdrawal and concomitant sympathetic activation (Fig. ..) []. The increase in sympathetic activation may be due to arterial baroreflex resetting, the muscle metaboreflex or muscle mechanoreceptor activation []. During heavy exercise, parasympathetic activity wanes and sympathetic activity increases in such a way that, at a workload corresponding to maximal oxygen consumption, little or no parasympathetic tone remains []. The analysis of heart rate variability (HRV) has become a frequently used tool for providing information on cardiovascular autonomic regulation at various phases of exercise, and also on the effects of physical training on cardiovascular autonomic regulation. The most commonly used HRV methods are time and frequency domain analysis techniques. The standard deviation of all normal-to-normal R–R intervals over
ct
ffe
Vagal blockade
he
at
p ym
e tic
S Heart rate
feration of collateral coronary vessels in the healthy non-ischemic heart. Commensurate with the reduction in myocardial work and O2 consumption at rest and during submaximal exercise after endurance training, coronary blood flow per unit myocardial mass is reduced []. However, studies in animals have shown that endurance training can increase maximal coronary perfusion per unit mass of the myocardium []. There are only modest increases in myocardial O2 extraction from rest to maximal exercise since extraction is very high even in the untrained state. However, there is evidence that exercise training elicits changes in vascular tone leading to an optimized distribution of blood flow, whereby more capillaries are recruited without a change in capillary density [,]. This is probably due to specific endothelium-mediated vasodilatation. Results from animal studies suggest that increased endothelial cell nitric oxide synthase, an enzyme that synthesizes nitric oxide from -arginine, contributes to such an adaptation [,].
ct
ffe
g Va
Rest
Sympathetic blockade
e al
. Max VO2
Fig. .. Schematic diagram showing the relative contributions of the sympathetic and parasympathetic systems to cardioacceleration at various levels of exercise. Comparisons are between the control state (broken line) and parasympathetic or sympathetic blockade. (Modified from [].)
an entire recording (SDNN) is a simple time domain method. This variable is considered to reflect both parasympathetic and sympathetic influences on the heart. The power spectrum of R–R intervals reflects the amplitude of heart rate fluctuations present at different oscillation frequencies. The different power spectral bands reveal different physiologic regulatory mechanisms; e.g. an efferent vagal activity is a major contributor to the high frequency component (see Fig. ..). A distinct cardiovascular adaptation to endurance training is a lowering of the heart rate at rest and during submaximal exercise. Maximal heart rate is unchanged or in some cases may be slightly reduced. The lowering of resting and submaximal heart rate is mediated by alterations in the autonomic nervous system, and by changes in the intrinsic automaticity of the sinus node and right atrial myocytes [,]. Both cross-sectional and longitudinal studies involving pharmacologic autonomic blockade and analysis of HRV indicate that increases in cardiac parasympathetic (vagal) tone make an important contribution to resting bradycardia [,]. The chronic increase in parasympathetic tone occurs within a few weeks after beginning regular training and this occurs independently of a lower intrinsic heart rate. In crosssectional studies, aerobic fitness and/or long-term
Cardiovascular and Respiratory Responses to Exercise (a) 1.5
Time (s)
HR = 55 beats/min, SDNN 88 ms
0.5 (b)
(c) 1.5
4
0 0.0
R–Rn+1 (s)
Power 103 (ms2)
Fig. .. Representative examples of R–R interval tachogram (a) and corresponding power spectra (b) and two-dimensional vector analyses of Poincaré plot (c) at rest ( min recording).
HF = 1727 ms2 LF = 1526 ms2 VLF = 2544 ms2
SD1 = 52 ms SD2 = 110 ms 0.1
0.2 0.3 Frequency (Hz)
aerobic training have been suggested to be associated with increased HRV, especially with vagally mediated respiratory sinus arrhythmia, at rest [,]. Some studies, however, have failed to show such an association [,]. The results from most longitudinal studies reveal decreased resting heart rate and increased vagal activity at rest after aerobic training [,]. During exercise in the trained, a given increase in cardiac output requires less increase in heart rate due to the maintenance of a larger stroke volume. Studies focusing on autonomic and endocrine responses to training indicate that heart rate is reduced during submaximal exercise (absolute load) in the trained due to a lower intrinsic heart rate, a reduction in sympathetic activity and circulating catecholamines, and a greater parasympathetic influence [,,]. Tulppo and colleagues [] found that higher levels of physical fitness were associated with an augmentation of cardiac vagal function during exercise, whereas aging resulted in more evident impairment of vagal function at rest. The lower sympathetic activity to the heart at a given submaximal work rate stems in part from diminished reflex signals originating from skeletal muscle due to less metabolite accumulation and attenuated discharge of metaboreceptors [].
0.4
0.5 0.5
R–Rn (s)
1.5
The mechanisms underlying the training-induced increase in vagal tone are thought to be greater activation of the cardiac baroreceptors in response to the enlargement of blood volume and ventricular filling [,], as well as changes in opioid [] and dopaminergic modulation of parasympathetic activity []. It is not fully resolved whether a lowering of intrinsic heart rate is a true adaptation to endurance training, but it appears that an intensive and lengthy training period may be necessary for this adaptation []. Primates with larger hearts have lower intrinsic heart rates and it has therefore been hypothesized that training-induced cardiac enlargement accounts for the lower intrinsic heart rate with training. A plausible mechanism for reduced intrinsic heart rate is that atrial enlargement reduces the stretch–depolarization stimulus, and thereby alters resting automaticity.
Blood pressure There is general agreement that endurance training elicits small reductions in resting blood pressure [,]. In addition, long-term exercise training has the beneficial effect of preventing the normal agerelated increase in blood pressure. A pressurelowering effect of endurance training has been shown to occur within days after initiating an exercise
Chapter . program []. Reduced adrenal medullary catecholamine output during exercise at a given absolute work rate may be of importance for the blood pressure lowering effect of training, as well as changes in sympathetic and renal dopaminergic activity. The reduction in resting diastolic blood pressure with training is significantly related to the increase in exercise capacity, which suggests that high-intensity training may be important. Attention is currently focused on determining the effectiveness of various training regimens which induce both reductions in resting blood pressure and significant improvements in functional capacity. During exercise at a given submaximal load, blood pressure and vascular resistance are reduced after endurance training. This adaptation is associated with reduced sympathetic activation and lower circulating catecholamines. At high exercise intensities and at maximal exercise, blood pressure is generally similar before and after training. Yet a given blood pressure is achieved by a lower vascular resistance and a higher cardiac output in the endurance trained.
Blood volume Blood volume (BV) is kept remarkably constant in many different situations and hyper- and hypovolemia are corrected fairly rapidly through the mechanism of renal absorption of sodium. Cross-sectional studies show that there is a close relationship between V˙2 max on the one hand and BV and total amount of hemoglobin (but not the hemoglobin concentration [Hb]) on the other. Exercise training increases blood volume. Plasma volume usually increases after a few days of training, while the expansion of erythrocyte volume takes longer []. The central venous compartment of blood volume is an important factor for cardiac output. The increased blood volume with physical training is regarded as a requisite for increased Qmax, although it may be that the blood volume increases in parallel with the increased V˙2 max. Acute plasma volume expansion (using Macrodex®) increases SV during submaximal and maximal exercise in well-trained individuals [,]. The explanation is that the enhanced BV causes an enhanced diastolic filling pressure (preload), which through a direct Frank–Starling mechanism increases
end-diastolic volume. End-systolic volume remains unchanged or decreases. Consequently SV is increased []. Since peak HR also remains unchanged, Qmax is increased. This increase in the well-trained athletes is just about enough to compensate for the reduced [Hb] and arterial oxygen content (Ca2), so that the V˙2 max is mainly unchanged compared to control experiments. However, in untrained or moderately trained individuals a corresponding plasma volume expansion may increase Qmax by a greater amount than that needed to compensate for the reduction of [Hb] during maximal exercise and, thus, increase V˙2 max [].
Peripheral vascular adaptations Regular physical activity results in peripheral vascular adaptations which enhance perfusion and flow capacity. Thus it has been shown that total leg blood flow during strenuous exercise increases in parallel with the rise in maximal aerobic power. In addition, the muscle arteriovenous oxygen difference is significantly greater after conditioning. Such adaptations may arise from structural modifications of the vasculature and alterations in the control of vascular tone [,]. The increase in capillary density of the muscle seems to be the major factor responsible for the rise in maximal oxygen extraction. Both cross-sectional and longitudinal studies have shown greater muscle capillary density in trained than in untrained individuals, and that physical inactivity is associated with reduced capillary density [,,]. Both capillary density and blood flow seem to increase in proportion with the rise in maximal aerobic power during long-term physical conditioning [,]. The rise in peak muscle blood flow appears to be achieved by enhanced endothelium-dependent dilatation (EDD) in the muscle which increases its vasodilator capacity in parallel with expanded oxidative capacity. Accordingly, the rise in cardiac output can occur without any rise in arterial pressure. An enhanced peak hyperemic blood flow appears to be an early adaptation to regular exercise [,]. A near % increase in flow-mediated EDD of the brachial artery after weeks of aerobic and anaerobic training was shown by Clarkson et al. []. Furthermore, a high correlation between maximal aerobic power and peripheral vasodilator capacity, measured by vascular conductance, has been demonstrated [,]. King-
Cardiovascular and Respiratory Responses to Exercise well et al. [] found a near % greater reduction in forearm vascular resistance to an endotheliumdependent stimulus in endurance athletes as compared to sedentary subjects. This reduction was directly related to maximal aerobic power. In endurance-trained older people a significantly greater EDD, as compared with age-matched sedentary subjects, has also been observed []. Additionally, Rinder et al. [] found that abnormal EDD discovered in older, otherwise healthy individuals could be improved with long-term endurance training. They also noted a significant and reasonably good correlation between maximal aerobic power and EDD. The mechanisms behind the enhanced endothelial function associated with physical training may involve exercise-induced increases in shear stress and pulsatile flow. According to Niebaur and Cooke [] chronic increases in blood flow induced by training may exert their effect on EDD by modulating the expression of endothelial cell nitric oxide synthase (NOS). It has been shown that endothelium-derived nitric oxide (NO) may influence vascular tone in the periods between exercise bouts. In animal studies, reactivity to stimuli which mediate their effects via NO is increased by training in coronary circulation, as mentioned previously in this chapter [,]. Human studies have produced evidence for a role of NO in the regulation of muscle blood flow [,]. NOS exists in several isoforms. Consequently, endothelial NOS is named eNOS. Another isoform, called neuronal NOS (nNOS), is located in the sarcolemma and cytosol of human skeletal muscle fibers, in apparent association with mitochondria []. Frandsen and coworkers [] have shown that endurance training may increase the amount of eNOS in parallel with an increase in capillaries in human muscle, while the nNOS levels remain unaltered.
Respiratory adaptation As there are many variables that contribute to the achievement of V˙2 max, it may be difficult to identify which mechanism is ‘limiting’. This applies particularly to respiratory responses, which are generally considered as non-limiting or ‘submaximal’ during maximal exercise. Ventilation at maximal exercise is not as high as the maximal achievable ventilation (MAV), but MAV (or maximal breathing capacity,
MBC) is usually measured over – s, and falls progressively by about % after – min. Thus whilst some athletes may achieve an MAV of – L/min, their sustainable maximal ventilation is – L/min, a value frequently achieved during maximal exercise. Of course, such values are accompanied by severe dyspnea, and it may be more helpful to understand factors contributing to limiting dyspnea, than to judge whether a ‘limiting’ ventilation has been reached. Trained individuals experience much less dyspnea than the untrained. Indeed, early in their experience of exercise, athletes may sense that they are able to exercise with much less dyspnea than their struggling peers, leading them to take up their sport in a serious way. The study and quantitative measurement of the intensity of dyspnea had to wait firstly for the introduction of the field of psychophysics by Stevens [], and secondly for the development of appropriate psychophysical techniques by Borg and Noble []. The application of these techniques has allowed the assessment of the separate contributions of many factors to dyspnea during exercise in health and disease, and provided some answers as to why the sense of effort in breathing is so much less in trained than in untrained individuals. Studies employing neurophysiologic techniques have suggested that the sense of dyspnea represents the conscious appreciation of the central outgoing command to the respiratory muscles []. Thus, consideration of all the factors contributing to the sensation spans the metabolic demands for ventilation; mechanical capacity to meet the demand; adopted patterns of breathing; pulmonary gas exchange efficiency; central control of breathing; respiratory muscle function; and sensory mechanisms by which the effort of breathing is appreciated. Furthermore, all these physiologic links are interdependent and capable of adaptation, apparently with the overall objective of minimizing discomfort and thereby enhancing performance.
Ventilatory demands of exercise The major demand on ventilation is CO2 production (V2); although this is closely related to metabolic oxygen consumption and pulmonary intake, many studies have dissociated the two and shown close corre-
Chapter . Before After
Ventilation (L/min)
80
60
40
20
0 1
2 CO2 output (L/min)
3
Fig. .. Reductions in ventilation at two power outputs in five subjects, before and after training; reductions in VE are closely · related to reductions in V2 (there was no change in V 2 at either power output) []. Open and filled symbols denote before and after training, respectively.
lation between V2 and ventilation (VE). At a given power or ATP turnover, V2 is quantitatively related to the balance between fat and carbohydrate as fuels, and the amount of lactate accumulating in the blood; increases in fat oxidation [] and reductions in lactate accumulation [,] may account for as much as a halving of VE at a given power in trained as against untrained subjects. Higher activities of fat metabolizing enzymes [], greater mitochondrial surface area [] and more efficient oxygen delivery mechanisms [] all contribute to the metabolic changes. Training-related reductions in VE closely parallel reductions in both V2 (Fig. ..) and plasma lactate concentrations [,,]. Thus, at a given power output, an increase of % in fat utilization will reduce ventilation by approximately %, and a reduction in plasma lactate concentration of mmol/L will be accompanied by a further, up to %, reduction. In some athletes changes may be much larger; moreover, when accompanied by the other changes described below, such small effects are magnified, so that ventilation in some athletes may be half that observed in untrained subjects exercising at comparable power [].
Ventilatory capacity In terms of dimensions, the maximal breathing capacity is a function of the total lung volume and the maxi-
mal flow rates in inspiration and expiration; volume is related to thoracic volume, and flow rates to airway cross-sectional area. For a given stature and weight both volume and maximal flow tend to be larger in athletes, but studies in twins suggest that this has a genetic basis, and that training has little influence []. Within these constraints, athletes employ a larger volume, by being able to achieve both a smaller endexpiratory and larger end-inspiratory volume. They also employ larger flow rates in both inspiration and expiration; indeed some athletes are capable of using virtually all their maximal flow-volume loop during exercise [,]. It seems likely that this is because of stronger and more fatigue-resistant respiratory muscles (see below). In older subjects there is a loss of elastic recoil; this reduces flow at low lung volumes and prevents them from achieving a reduction in endexpiratory volume, and contributes to an increase in respiratory effort in older athletes [].
Pulmonary gas exchange Pulmonary gas exchange efficiency is broadly related to ventilation–perfusion (V/Q) matching in the lungs, and to diffusion across the alveolar capillary membrane. In general, in healthy subjects larger lungs imply greater alveolar volume and surface area and larger pulmonary capillary volume. The range of V/Q ratios extends from zero (representing anatomic pathways between the right and left sides of the heart, or ‘shunt’) to infinity (representing anatomic airway dead space); areas in the lungs with a low V/Q ratio contribute to the alveolar–arterial P2 difference (A– a D2), and those with high V/Q to physiologic dead space (VD/VT). Both A–a D2 and VD/VT are minimized by increases in tidal volume. However, healthy untrained subjects as well as athletes appear to reach similar minimal values for both, and at higher levels of V˙2 there is no further reduction [,]. This phenomenon has been carefully studied, especially for A–a D2; in some athletes very wide A–a D2 have been observed, leading to arterial P2 values as low as mmHg (Fig. ..) []. When associated with a ‘rightward shift’ of the oxygen dissociation curve due to low arterial pH, such low Pa2 values translate into arterial O2 saturations of % or less. The cause of this ‘arterial desaturation’ and ‘failure of gas exchange’ has been debated, but
Cardiovascular and Respiratory Responses to Exercise
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Fig. .. Increasing exercise is associated with progressive increases in pulmonary blood flow; pulmonary capillary blood volume increases to a maximum of mL. Capillary mean transit time falls, and at maximum exercise approaches values as short as . s. From Dempsey [].
•
VO2 (L/min, STPD) Fig. .. Arterial blood gases and pH at rest and during submaximal and maximal treadmill exercise in a group of untrained [*] and three groups of trained subjects. One group of trained subjects (l) showed a significant fall in arterial P2, associated with higher P2 at maximal exercise. From Dempsey [].
remains unresolved []. There is no doubt that it occurs especially in elite athletes exercising at high V˙2, leading to theories that include relatively high venous P2, low venous O2 contents and very short pulmonary capillary transit times (Fig. ..) contributing to incomplete O2 diffusion. Interstitial pulmonary edema occurs in animal models of exercise but has never been shown in humans. Other possible factors include incomplete equilibration for CO2 in blood traversing the lung [] combined with low blood pH, leading to incomplete oxygenation of hemoglobin. The limiting process in CO2 equilibration appears to be the erythrocyte chloride exchanger which has a half-equilibration time that is in excess of pulmonary capillary transit time in heavy exercise [,].
Pattern of breathing Athletes breathe more slowly and deeply than nonathletes, and a slower breathing rate is one of the effects
of training. The volumes and flows determine the tidal volume and frequency of breathing during exercise; all other matters being equal, larger tidal volumes and slower frequencies lead to greater efficiency in breathing with lower values for the VD/VT ratio. Some subjects entrain breathing frequency with their pedaling or running cadence [], but there is scope for wide variation in such responses ( strides/breath vs. strides/breath, for example), so that the entrainment never dominates the pattern. Although the use of a given pattern of breathing is often assumed to be a selfoptimizing response to minimize the oxygen cost of breathing, it seems more likely that patterns are adopted consciously or unconsciously to minimize the sense of effort in breathing [].
Control of breathing Whilst the mechanisms responsible for the control of breathing during exercise remain a topic of continuing research [] beyond the scope of the present chapter, there is general agreement that increases in ventilation are a closely related function of the body’s CO2 production. Many have studied the ventilatory responses to increases in arterial P2 (VE/P2), in athletes and untrained subjects. The findings may be summarized as follows.
Chapter . There is a wide range in both VE/P2 (.– . L/mmHg) and VE/V2(– L/L) in trained and untrained individuals [,]. There is a relationship between the two indices: low responders to P2 have a low response to exercise []. There is a strong genetic component determining VE/P2 []. Training does not seem to change either VE/V2 or VE/P2 [,]. One might interpret these findings as indicating no influence of ventilatory control on performance. However, the effect of the variations in VE/V2 is substantial, even when associated with the normal range of variation in arterial P2. At an exercise power accompanied by a V2 of . L/min, ventilation may range from to L/min in normal subjects [], with a corresponding variation in breathing effort. A child taking up competitive swimming is presumably more likely to persist if she experiences little breathlessness compared to her panting friends. The ventilatory responses to hypoxia and P2 are closely correlated []; this fact may contribute to the lack of response to a falling P2, but also may be important in athletes at high altitude. A low ventilatory responsiveness might be seen to predispose to dangerous hypoxia; however, what has emerged from studies simulating the ascent of Mount Everest is that low responders are more likely to reach the summit and are less likely to suffer the deleterious cerebral and pulmonary effects of altitude []; these effects appear to be mediated by reductions in arterial P2 and associated alkalosis. In athletes who because of their sport have to breath hold for long periods of time, such as synchronized swimmers, the ventilatory response to hypoxia is blunted and breath hold times prolonged [].
The respiratory muscles As first systematically studied by Ringqvist [], the respiratory muscles show considerable variation in strength and endurance, in relation to stature, age and sex, with fairly obvious implications for the capacity to achieve and maintain ventilation during exercise [], and also for the sense of effort experienced in breathing. Subjects with stronger respiratory muscles achieve higher tidal volumes (and thus lower breathing
frequencies), and experience less dyspnea than those with weaker muscles []. The actions of the respiratory muscles differ; expiratory flow is mainly dependent on the elastic recoil of the respiratory system with only a minor contribution from expiratory muscle contraction until very high expiratory flows are recruited. Expiratory muscle contraction mainly acts to reduce end-expiratory lung volume and thus recruit the inspiratory recoil of the thorax and increase the precontraction length of the inspiratory muscles; in this way, they tend to ‘unload’ the inspiratory muscles []. The latter have to generate inspiratory flow against the lung recoil pressure, and thus carry the major responsibility for ventilatory work. Inspiratory muscle training mainly accompanies other aspects of endurance training, but resistive training is known to improve inspiratory muscle strength and endurance []. These considerations have important implications in aging athletes in whom there is the normal decline in lung elasticity; end-expiratory lung volume cannot be reduced to the same extent as in the young, forcing the inspiratory muscle to carry a greater proportion of the respiratory work during exercise []. Johnson et al. [] found that reductions in elastic recoil and increases in end-expiratory volume paralleled reductions in V˙2 max in a group of older ( ± years) people; such subjects are likely to have been limited by dyspnea.
Sensation of dyspnea Respiratory muscle oxygen consumption was once thought to increase disproportionately at high levels of ventilation, and thus contribute to a limitation of maximal oxygen intake, but more recent estimates suggest that patterns of breathing are adopted mainly to minimize dyspnea []. Because exercise is a voluntary activity, conscious humans stop exercise when the sensation of excessive effort and weakness in exercising muscle or of dyspnea becomes intolerable. A number of sensations related to breathing can be discriminated and scaled [], including inspiratory muscle tension and displacement, a sense of ‘satiety’ or appropriateness related to increases in arterial P2 [,], and a sense of effort related mainly to central outgoing command [] (Fig. ..). Both effort and dyspnea are less in trained compared
Cardiovascular and Respiratory Responses to Exercise Sense of APPROPRIATENESS
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Fig. .. Mechanisms contributing to sensations related to breathing during exercise. Whilst the changes in tension developed and displacement of inspiratory muscles can be discriminated and scaled, contributors to the sense of effort include difficulty in breathing (sense of impedance), sufficiency of the ventilatory response (‘satiety’), and the outgoing central motor command [].
Sense of DISPLACEMENT
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Severe 5 Somewhat severe 4 Moderate 3 Fig. .. Sense of dyspnea during exercise in healthy subjects, grouped according to strength of inspiratory muscles (measured as maximal inspiratory pressure, MIP), into four groups: very weak, MIP < % predicted; weak, –%; strong, –%; very strong, > %. From Hamilton et al. [].
Slight 2 Very slight 1 Just noticeable 0.5 Nothing at all 0
to untrained individuals, enabling them to maintain higher power for longer. The factors accounting for these differences are numerous and interactive. For dyspnea the reasons are mainly that the pressure generated by the respiratory muscles is relatively less in subjects with large lungs (due to lower elastance and resistance), and strong respiratory muscles (Fig. ..). Dyspnea is minimized in trained individuals chiefly through:
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minimizing V2, through utilization of fat and reduction in lactate production; maximizing P2, through lower VE/V2; reducing VD/VT, by increasing VT, a function of lung volume; and increasing inspiratory muscle strength. At an oxygen consumption of L/min, the first three factors could theoretically account for a difference in ventilation from L/min in an unfit individual to L/min in an elite endurance runner. As the
Chapter . sustained ventilatory capacity might be as low as L/min in the former, and as high as L/min in the latter, the percentage of breathing capacity being used might be as high as % in the untrained and as low as % in the athlete. The associated intensity of dyspnea may thus differ by as much as five-fold []. This example also emphasizes that there is great potential for a reduction in the sense of dyspnea by training, with important implications for elite performers, particularly in distance events.
Maximal aerobic power In elite athletes from endurance sports values for maximal aerobic power (V˙2 max) of > . L/min or > mL/min/kg body weight are frequently obtained. These extremely high values are primarily due to a large maximal cardiac output (Qmax). Values of more than L/min have been measured []. Since the arteriovenous oxygen difference (a-v 2 diff) during maximal exercise in these well-trained athletes does not differ from that in less trained individuals but is somewhat larger than in untrained individuals, the main cause for the high Qmax and, thus, V˙2 max in the well-trained athlete is the large stroke volume (SV); values exceeding mL during maximal exercise are reported []. In well-trained athletes the hemoglobin concentration [Hb] at rest and during exercise is not different from that obtained in untrained individuals of the same sex and age []. Although regular physical training can reduce the oxygen content of the mixed venous blood during maximal exercise in previous untrained individuals [], the [Hb] obviously sets the upper limits of the a-v 2 diff during maximal exercise. Therefore, any changes in [Hb] during exercise will have a direct influence on V˙2 peak, V˙2 max and physical performance. Oxygen transport and utilization includes a series of steps. In the following discussion the different steps of the oxygen cascade from lungs to mitochondria are considered in relation to the basic question: ‘What limits V˙2 max?’ During maximal exercise pulmonary ventilation (Ve) in untrained or moderately trained individuals reaches – L/min. Athletes from endurance events with high V˙2 max can reach a maximal Ve of L/min and over. In maximal voluntary ventilation
tests at rest (MVV40), when the individual is breathing as much as possible with a fixed breathing frequency ( breaths/min) for – s, the untrained individual may be able to ventilate – and athletes up to – L/min. These volumes far exceed what is used during a maximal exercise test, although they can hardly be maintained for any longer period of time. In addition, most individuals are able to voluntarily increase pulmonary ventilation during a maximal running or cycling test above what is obtained in the test. Furthermore, specific training of the respiratory muscles does not increase either V˙2 max or arterial oxygen saturation (Sa2) during maximal exercise above pretraining values []. The oxygen diffusion capacity of the lung (DL2) depends on many different factors. If DL2 limits V˙2 max then arterial oxygen pressure (Pa2) and Sa2 during maximal exercise will fall, unless alveolar ventilation is increased (to increase Pa2). However, during heavy exercise both Pa2 and Sa2 are mainly maintained unchanged or only slightly reduced compared to rest or submaximal exercise in both elite athletes and untrained individuals [,]. It should be noted that a certain arterial hypoxemia (desaturation) compared to rest has been observed in some well-trained athletes [,]. Whether this is due to hypoventilation, exercise-developed pulmonary edema, insufficient pulmonary capillary transit time, increased blood flow in arterial–venous anastomosis during heavy exercise or other factors is not known []. Another important point in this discussion is related to effects of changes in [Hb] during heavy exercise. If DL2 and/or Ve limit V˙2 max, then an increase in [Hb] would have no or very little effect. However, both an acute increase of [Hb] through ‘blood doping’ [,] and a more ‘chronic’ increase of [Hb] through administration of erythropoietin [] do increase V˙2 max. This speaks against a functional limitation of V˙2 max at the pulmonary level. Arguments have been put forward that factors related to the peripheral blood circulation (such as capillary density), oxygen utilization in the muscle cells (such as mitochondrial mass and enzyme concentrations) and other factors might limit V˙2 max. This is certainly true during heavy exercise carried out with small muscle groups, such as isolated dynamic arm work. In this
Cardiovascular and Respiratory Responses to Exercise situation the ‘peripheral factors’ are of utmost importance for, and certainly do limit, the aerobic energy turnover, performance and endurance []. However, during exercise with large muscle groups, such as running uphill and combined arm and leg exercise, there are several reasons supporting the idea that the ‘periphery’ does not limit V˙2 max. When a maximal rate of work performed by the legs only is divided into a combination of arm and leg work, neither V˙2 max [,] nor Qmax and arterial blood pressure [] are different from those obtained when using legs only. However, time to exhaustion is much longer when working with arms and legs compared to maximal leg work. For instance, there might be an increase in time to exhaustion from to min. This means that during the combined arm and leg work, when the ‘double product’ (HR · BP) is the same as during the work with legs only, the heart has been working for min beyond the point when the individual would have had to stop the work with legs only. Thus, the endurance capacity of the heart when working with legs only does not limit cardiac performance as has been suggested []. When comparing trained and untrained individuals there is no relation between V˙2 max and different markers of the peripheral energy turnover such as enzyme activity [,]. Furthermore, endurance training may increase and inactivity reduces mitochondria enzyme concentrations considerably without any or only minor changes in V˙2 max [,]. If ‘central’ (central circulation) and ‘peripheral’ factors (muscle enzyme concentration and mitochondrial volume) are matched, then aerobic energy turnover for a small muscle group would be of the same order of magnitude as that obtained at V˙2 max at the pulmonary level. Measurements of the a-v 2 diff and blood flow over a well-defined muscle group (musculus quadriceps femoris) during maximal exercise and consequent calculations of the maximal aerobic energy turnover for this muscle group show that estimated V˙ 2 peak per kilo muscle mass far exceeds that of the pulmonary V˙2 max per kg muscle mass when working with large muscle groups [,]. Thus, the local muscle capacity for aerobic energy turnover exceeds that which can be maximally obtained as V˙2 max during heavy exercise using large muscle groups. Changes in Ca2 and arterial oxygen availability will
ultimately cause corresponding changes in V˙2 max and muscle performance. Reductions of Ca2 through carbon monoxide loading, venesections or hypobaric hypoxia reduce V˙2 max; this, however, could be due to both central and peripheral limiting factors. But, as previously mentioned, both an ‘acute’ [,] and more ‘chronic’ [] increase in Ca2 will increase V˙2 max and physical performance more or less in proportion to the induced changes in Ca2. It seems obvious from these data that the central circulation — mainly the heart function including the blood (BV and [Hb]) — have important roles for both limiting and establishing high values of V˙2 max. Consequently, the next question is: ‘What limits the functional capacity of the heart?’. Since HRmax and Ca2 do not increase with physical training, the only structural factor that can explain individual differences in V˙2 max is the stroke volume (SV). There is a small increase in SV during transition from rest to light submaximal exercise. SV is well maintained or even increased [] during maximal exercise, indicating that the oxygen supply to the heart is adequate. The main cause for the increased SV during exercise is an enlarged end-diastolic volume (EDV) caused by augmented venous ‘filling’ pressure. As mentioned earlier in this chapter, this has been shown in experiments using plasma expanders during exercise. Such plasma expansion increases EDV, and thereby SV and Qmax as compared with peak values obtained before plasma expansion [,]. Although the plasma expansion reduces [Hb], normal peak O2 uptake can still be obtained due to the increased SV and Qmax []. Hammond et al. [] tested the hypothesis that the pericardium restricts heart size and thus limits SV and Qmax. They studied exercising pigs before and after pericardiectomy. During maximal treadmill running Qmax increased by % and V˙2 max by % due to an estimated % increase in EDV. This suggests that the EDV, restricted by the pericardium, sets the upper limit for SV during exercise and thus limits Q max. With advanced age V˙2 max declines due to both reduced Qmax and some reduction in a-v 2 diff. The reason for the former is a reduced peak HR, SV being mainly unchanged. Regarding the a-v 2 diff, there is an increase in oxygen content of mixed venous blood in the elderly, probably due to an inability to shunt blood
Chapter . to active muscles [], thus reducing a-v 2 diff. The effect of regular physical training in the elderly is essentially the same as in young persons; however, the magnitude is generally smaller. In conclusion, during exercise engaging large muscle groups (running uphill, simultaneous arm and leg work) the V˙2 max is limited by the central circulation. Since HRmax and Ca2 are practically unchanged by physical training, the V˙2 max is basically limited by SV. Thus, the principal variant for improvements in V˙2 max is maximal cardiac output.
Summary The pumping capacity of the heart is a critical determinant of endurance performance. The increased maximal cardiac output following endurance training results from a larger cardiac stroke volume, whereas maximal heart rate is unchanged or even slightly reduced. The higher stroke volume is due to enlargement of cardiac chamber size and to expansion of total blood volume. Plasma volume increases usually after a few days of training while the expansion of erythrocyte volume takes a longer time. Functional improvements in cardiac performance include a more rapid early and peak ventricular filling rate during diastole. The enlarged blood volume, together with greater ventricular compliance and distensibility, and a faster and more complete ventricular relaxation allow stroke volume to increase even at high heart rates. At the same time, the cardiac output is distributed more selectively to activated regions of skeletal muscle, from where the muscle pump facilitates venous return. Endurance training elicits small reductions in resting blood pressure. It remains unresolved whether endurance training increases coronary vascular dimensions beyond the vascular proliferation that accompanies normal training-induced cardiac hypertrophy. Endurance training results in peripheral vascular adaptations, which enhance perfusion and flow capacity in parallel with rise in maximal aerobic power. These adaptations are caused by an increase in capillary density, and alterations in the control of vascular tone. The rise in peak muscle blood flow appears to be achieved by enhanced endothelium-dependent dilatation in parallel with expanded oxidative capacity. Endothelium-derived nitric oxide (NO), synthesized
by nitric oxide synthase (NOS), may contribute to this adaptation. Training-related reductions in ventilation closely parallel reductions in both V2 and plasma lactate concentrations. Although largely genetically determined, a larger volume is exploited by athletes as they are able to achieve a smaller end-expiratory and larger end-inspiratory volume, mainly due to stronger and more fatigue-resistant respiratory muscles. Resistive training improves inspiratory muscle strength and endurance. Subjects with stronger respiratory muscles achieve higher tidal volumes (and thus lower breathing frequencies), and experience less dyspnea than those with weaker muscles, thus enabling them to maintain higher power for longer. The central circulation — mainly the heart function, including the blood volume and hemoglobin concentration — plays an important role in both limiting and establishing high values of maximal aerobic power. During exercise engaging large muscle groups (running uphill, simultaneous arm and leg work) the maximal aerobic power is limited by the central circulation. Since maximal heart rate and arterial oxygen content are practically unchanged by physical training, the maximal aerobic power is basically limited by the stroke volume. Thus, the principal variant for improvements in maximal aerobic power is maximal cardiac output.
Multiple choice questions Which of the following parameters does not increase appreciably as a response to endurance training: a maximal cardiac output b left ventricular end-diastolic volume c diastolic filling rate d left ventricular end-systolic volume e stroke volume f maximal heart rate. What is the relationship between cardiac output (CO), total peripheral resistance (TPR) and arterial pressure (BP): a CO = BP/TPR b BP = TPR/CO c CO = BP · TPR d TPR = CO/BP e BP = CO · TPR f TPR = BP/CO.
Cardiovascular and Respiratory Responses to Exercise Differences in athletic performance amongst athletes with similar V˙o2 max are linked to: a pulmonary gas exchange b hemoglobin concentration c total blood volume d diastolic filling pressure (preload) e work economy f heart rate variability. Physical training results in peripheral vascular adaptations which improve perfusion and blood flow capacity. Such adaptations may arise from: a increased capillary density b decreased resting heart rate c increased mitochondrial mass d enhanced endothelium-dependent dilatation e changes in endothelium-derived nitric oxide concentration f decreased neuronal nitric oxide synthase. The sensation of dyspnea is minimized in trained individuals through: a shift of the oxygen dissociation curve to the right b decreased anatomic dead space c minimization of V2, through utilization of fat and reduction in lactate production d increased vital capacity e maximizing P2, through lower VE/V2 f increased pulmonary capillary transit time.
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Cardiovascular and Respiratory Responses to Exercise Kanstrup I-L, Ekblom B. Acute hypervolemia, cardiac performance and aerobic power during exercise. J Appl Physiol ; : –. Krip B, Gledhill N, Jamnik V, Warburton D. Effect of alterations in blood volume on cardiac function during maximal exercise. Med Sci Sports Exerc ; : –. Gledhill N. The influence of altered blood volume and oxygen-transport capacity on aerobic performance. Exerc Sport Sci Rev ; : –. Ekblom B, Berglund B. Effect of erythropoietin administration on maximal aerobic power in man. Med Sci Sports Exerc ; : –. Ingjer F. Capillary supply and mitochondrial content of different skeletal muscle fiber types in untrained and endurance-trained men. A histochemical and ultrastructural study. Eur J Appl Physiol ; : –. Kingwell BA, Jennings GL. The role of aerobic training in the regulation of vascular tone. Nutr Metab Cardiovasc Dis ; : –. Hepple RT. Skeletal muscle: microcirculatory adaptation to metabolic demand. Med Sci Sports Exerc ; : –. Ingjer F. Maximal aerobic power related to the capillary supply of the quadriceps femoris muscle in man. Acta Physiol Scand ; : –. Laughlin MH. Endothelium-mediated control of coronary vascular tone after chronic exercise-training. Med Sci Sports Exerc ; : –. Sinoway LI, Shenberger J, Wilson J, McLaughlin D, Musch TI, Zelis R. A -day forearm work protocol increases maximal forearm blood flow. J Appl Physiol ; : –. Clarkson P, Montgomery H, Donald A et al. Exercise training enhances endothelial function in young men. J Am College Cardiol ; (Suppl.): A. Martin WH, Kohrt WM, Malley MT, Korte E, Stoltz S. Exercise training enhances leg vasodilatory capacity of year-old men and women. J Appl Physiol ; : –. Snell PG, Martin WH, Buckey JC, Blomquist CG. Maximal vascular leg conductance in trained and untrained men. J Appl Physiol ; : –. Kingwell BA, Tran B, Cameron JD, Jennings GJ, Dart AM. Enhanced vasodilatation to acetylcholine in athletes is associated with lower plasma cholesterol. Am J Physiol ; (Heart Circulation Physiol ): H–. Rywik TM, Blackman MR, Yataco AR et al. Enhanced endothelial vasoreactivity in endurance-trained older men. J Appl Physiol ; : –. Rinder MR, Spina RJ, Ehsani AA. Enhanced endotheliumdependent vasodilation in older endurance-trained men. J Appl Physiol ; : –. Niebaur J, Cooke JP. Cardiovascular effects of exercise role of endothelial shear stress. J Am College Cardiol ; : –. Duffy SJ, Tran BT, Harper RW, Meredith IT. Relative contribution of vasodilator prostanoids and NO to metabolic vasodilation in the human forearm. Am J Physiol ; (Heart Circulation Physiol): H–.
Rådegran G, Saltin B. Nitric oxide in the regulation of vasomotor tone in human skeletal muscle. Am J Physiol ; (Heart Circulation Physiol): H–. Frandsen U, Lopez-Gigueroa MO, Hellsten Y. Localization of nitric oxide synthase in human skeletal muscle. Biochem Biophys Res Comm ; : –. Frandsen U, Höffner L, Betak A, Saltin B, Bangsbo J, Hellsten Y. Endurance training does not alter the level of neuronal nitric oxide synthase in human skeletal muscle. J Appl Physiol ; : –. Stevens SS. Psychophysics. Introduction to its Perceptual, Neural, and Social Prospects. John Wiley & Sons Inc, New York . Borg GAV, Noble B. Perceived exertion. In: Wilmore JH, ed. Exercise and Sports Sciences Reviews, Vol. . New York: Academic Press, : –. Gandevia SC. Neural control in human muscle fatigue. changes in muscle afferents, motoneurons and motocortical drive. Acta Physiol Scand ; : –. Coggan AR, Habash DL, Mendenhall LA, Swanson SC, Kien CL. Isotopic estimation of CO2 production during exercise before and after endurance training. J Appl Physiol ; : –. Casaburi R. Mechanisms of the reduced ventilatory requirement as a result of exercise training. Eur Respiratory Rev ; : –. Taylor R, Jones NL. The reduction by training of CO2 output during exercise. Eur J Cardiol ; : –. Gollnick PD, Armstrong RB, Saubert IVCW, Piehl K, Saltin B. Enzyme activity and fiber composition in skeletal muscle of untrained and trained men. J Appl Physiol ; : –. Hoppeler H, Luthi P, Claassen H, Weibel ER, Howald H. The ultrastructure of the normal human skeletal muscle: a morphometric analysis on untrained men, women and welltrained orienteers. Pflügers Archiv für des Gesamte Physiologie ; : –. Saltin B, Rowell LB. Functional adaptation to physical activity and inactivity. Fed Proc ; : –. Casaburi R, Storer TW, Wasserman K. Mediation of reduced ventilatory response to exercise after endurance training. J Appl Physiol ; : –. Edwards RHT, Jones NL, Oppenheimer EA, Hughes RL, Knill-Jones RP. Interrelation of responses during progressive exercise in trained and untrained subjects. Q J Exp Physiol ; : –. Weber G, Kartodihardjo W, Klissouras V. Growth and physical training with reference to heredity. J Appl Physiol ; : –. Grimby G, Saltin B, Wilhelmsen L. Pulmonary flowvolume and pressure-volume relationship during submaximal and maximal exercise in young well trained men. Bull Eur Physiopathol Respiration ; : –. Johnson BD, Saupe KW, Seow KC, Dempsey JA. Mechanical constraints on exercise hyperpnea in athletes. Am Rev Respiratory Dis ; : A.
Chapter . Johnson BD, Reddan WG, Seow KC, Dempsey JA. Mechanical constraints on exercise hyperpnea in a fit aging population. Am Rev Respiratory Dis ; : –. Dempsey JA, Vidruk EH, Mitchell GS. Pulmonary control systems in exercise: update. Fed Proc ; : –. Dempsey JA. Is the lung built for exercise ? Med Sci Sports Exerc ; : –. Jones NL, Heigenhauser GJF. Getting rid of carbon dioxide during exercise. Clin Sci ; : –. Klocke RA. Velocity of CO2 exchange in blood. Annu Rev Physiol ; : –. Bechbache RR, Duffin J. The entrainment of breathing frequency by exercise rhythm. J Physiol (Lond) ; : –. Casan P, Villafranca CC, Kearon MC, Campbell EJM, Killian KJ. Contribution of respiratory muscle oxygen consumption to breathing limitation and dyspnea. Can Respiratory J ; : –. Killian KJ, Jones NL, Campbell EJM. Control of breathing during exercise. In: Altose MD, Kawakami Y, eds. Control of Breathing in Health and Disease. New York: Marcel Dekker, Inc, : –. Akiyama Y, Kawakami Y. Clinical assessment of the respiratory control system. In: Altose MD, Kawakami Y, eds. Control of Breathing in Health and Disease. New York: Marcel Dekker, Inc, : –. Jones NL. Use of exercise in testing respiratory control mechanisms. Chest ; : s–s. Rebuck AS, Jones NL, Campbell EJM. Ventilatory response to exercise and to CO2 rebreathing in normal subjects. Clin Sci ; : –. Saunders NA, Leeder SR, Rebuck AS. Ventilatory response to carbon dioxide in youth athletes: a family study. Am Rev Respiratory Dis ; : –. Hughes RL, Clode M, Edwards RHT, Goodwin TJ, Jones NL. Effect of inspired O2 on cardiopulmonary and metabolic responses to exercise in man. J Appl Physiol ; : –. Rebuck AS, Campbell EJM. A clinical method for assessing the ventilatory response to hypoxia. Am Rev Respiratory Dis ; : –. Dempsey JA, Schoene RB. Pulmonary system adaptations to high altitude. In: Bone RC, ed. Pulmonary and Critical Care Medicine. St Louis: Mosby, : –. Bjurstrom RL, Schoene RB. Control of ventilation in elite synchronized swimmers. J Appl Physiol ; : –. Ringqvist T. The ventilatory capacity in healthy subjects. An analysis of the causal factors with special reference to the respiratory forces. Scand J Clin Lab Invest (Suppl. ) ; : –. Freedman S. Sustained maximum voluntary ventilation. Respiratory Physiol ; : –. Hamilton AL, Killian KJ, Summers E, Jones NL. Muscle strength, symptom intensity, and exercise capacity in patients with cardiorespiratory disorders. Am J Respiratory Crit Care Med ; : –.
Leblanc P, Summers E, Inman MD, Jones NL, Campbell EJM, Killian KJ. Inspiratory muscles during exercise. a problem of supply and demand. J Appl Physiol ; : –. Pardy RL, Rivington RN, Despas PJ, Macklem PT. The effects of inspiratory muscle training on exercise performance in chronic airflow limitation. Am Rev Respiratory Dis ; : –. Johnson BD, Reddan WG, Pegelow DF, Seow KC, Dempsey JA. Flow limitation and regulation of functional residual capacity during exercise in a physically active aging population. Am Rev Respiratory Dis ; : –. Manning HL, Schwartzstein RM. Dyspnea and the control of breathing. In: Altose MD, Kawakami Y, eds. Control of Breathing in Health and Disease. New York: Marcel Dekker, Inc, : –. Gandevia SC, Killian KJ, McKenzie DK, Crawford M, Allen GM, Gorman RB et al. Respiratory sensations, cardiovascular control, kinaesthesia and transcranial stimulation during paralysis in humans. J Physiol (Lond) ; : –. Ekblom B, Åstrand P-O, Saltin B, Stenberg J, Wallström BM. Effect of training on circulatory response to exercise. J Appl Physiol ; : –. Inbar O, Weiner P, Azgad Y, Rotstein A, Weinstein Y. Specific inspiratory muscle training in well-trained endurance athletes. Med Sci Sports Exerc ; : –. Dempsey JA, Wagner PD. Exercise-induced arterial hypoxemia. J Appl Physiol ; : –. Powers SK, Lawler J, Dempsey JA, Dodd S, Landry G. Effects of incomplete pulmonary gas exchange of V˙ 2 max. J Appl Physiol ; : –. Prefaut C, Durand F, Mucci P, Caillaud C. Exerciseinduced arterial hypoxaemia in athletes. Sports Med ; : –. Celsing F, Svedenhag J, Pihlstedt P, Ekblom B. Effect of anaemia and stepwise-induced polycythaemia on maximal aerobic power in individuals with high and low hemoglobin concentration. Acta Physiol Scand ; : –. Saltin B, Nazar K, Costill DLE, Stein E, Jansson B, Essén Gollnick PD. The nature of the training response; peripheral and central adaptations to one-legged exercise. Acta Physiol Scand ; : –. Bergh U, Kanstrup-Jensen I-L, Ekblom B. Maximal oxygen uptake during exercise with various combinations of arm and leg work. J Appl Physiol ; : –. Åstrand P-O, Saltin B. Maximal oxygen uptake and heart rate in various types of maximal exercise. J Appl Physiol ; : –. Stenberg J, Åstrand P-O, Ekblom B, Royce J, Saltin B. Hemodynamic response to work with different muscle groups, sitting and supine. J Appl Physiol ; : –. Noakes TD. Challenging beliefs: ex Africa semper aliquid novi. Med Sci Sports Exerc ; : –. Hollozy JO. Biochemical adaptations to exercise. Aerobic metabolism. Exerc Sport Sci Rev ; : –.
Cardiovascular and Respiratory Responses to Exercise Saltin B, Henriksson J, Nygaard E, Andersen P. Fiber types and metabolic potentials of skeletal muscle in sedentary men and endurance runners. Ann New York Acad Sci ; : –. Henriksson J, Reitman JS. Time course of changes in human skeletal muscle succinate dehydrogenase and cytochrome oxidase activities and maximal oxygen uptake with physical activity and inactivity. Acta Physiol Scand ; : –. Örlander J, Kiessling KH, Ekblom B. Time course of adaptation to low intensity training in sedentary men: dissociation of central and local effects. Acta Physiol Scand ; : –.
Andersen P, Saltin B. Maximal perfusion of skeletal muscles in man. J Physiol (Lond) ; : –. Rådegran G, Blomstrand E, Saltin B. Peak muscle perfusion and oxygen uptake in humans: importance of precise estimates of muscle mass. J Appl Physiol ; : – . Hammond KK, White FC, Bhargava V, Shabetai R. Heart size and maximal cardiac output are limited by the pericardium. Am J Physiol ; : –. Gerstenblith G, Lakatta EG, Wiesfelt ML. Age changed in myocardial function and exercise response. Prog Cardiovascular Dis ; : –. Robinson BF et al. Circulation Res ; XIX: –.
Chapter 1.2 Metabolism during Exercise — Energy Expenditure and Hormonal Changes JAN HENRI KSSON & KE NT S AHL I N
Classical references Hohwü Christensen E, Hedman R, Holmdahl I. The influence of rest pauses on mechanical efficiency. Åstrand I, Åstrand P-O, Hohwü Christensen E, Hedman R. Intermittent muscular work. Åstrand I, Åstrand P-O, Hohwü Christensen E, Hedman R. Myohemoglobin as an oxygen-store in man. Acta Physiol Scand ; : –. In this series of three papers, the authors describe the energy expenditure and metabolism resulting from different application of work and rest periods while working on light and heavy workloads. The papers have had a large impact because they were the first, following the initial observations of Karrasch and Müller (Arbeitsphysiologie ; : –), to attract interest to the physiology and metabolism of intermittent work. In the first paper, data are given to support the fact that the energy cost per kJ of work is the same or practically the same whether the work is performed continuously for h with an easy load or discontinuously with heavier loads. The results disputed the hypothesis of Müller and coworkers that pauses would significantly increase the oxygen demand for a subsequent work period. In the second paper, the authors showed that an extremely heavy workload, when split into short periods of work and rest, was transformed to a submaximal load on circulation and respiration. To explain the low lactate concentrations after intermittent work (work periods of – s), the authors proposed two alternative hypotheses: (i) that the rate of formation of lactic acid during a heavy workload is the same, independent
of the length of the work period, but that lactic acid during the short periods of rest is eliminated almost at the same rate; and (ii) that the formation of lactic acid during the short work periods is reduced to a minimum because it can take place almost aerobically. From the results in the third paper, the authors dismiss the first hypothesis and conclude that approximately . L O2 must have been available in the working muscles at the beginning of each new work period. It is proposed that this amount of oxygen is bound to myohemoglobin (myoglobin) in the muscles and is being ‘reloaded’ during the pauses to constitute approximately half of the amount of oxygen used during a -s work period.
Biochemical pathways of ATP generation Hydrolysis of ATP is the immediate energy source for almost all energy-requiring processes in the cell: ATP + H2O Æ ADP + Pi + energy
()
The store of ATP is limited and must therefore be continuously replenished. Regeneration of ATP occurs through aerobic and anaerobic processes by which energy-rich chemical substances (carbohydrates, fat and phosphocreatine) are transformed into compounds with less stored energy (lactate, H2O, CO2 and creatine). This is achieved by sequences of chemical reactions by which part of the change in free energy is used for the synthesis of ATP through a reversal of reaction (). The ATP–ADP cycle constitutes a basic feature of energy metabolism in all cells and is an intermediate between energy-utilizing and energyconsuming processes.
Metabolism during Exercise Skeletal muscle is a unique tissue in terms of the large variation in energy turnover. Transition from rest to exercise involves a drastic increase in energy demand and the rate of ATP utilization can increase more than times. This corresponds to a utilization of the whole muscle store of ATP in about – s. To maintain a constant muscle ATP concentration, which is necessary for cellular homeostasis, the rate of ATP regeneration must equal the rate of ATP utilization. To meet the energy requirements skeletal muscle is faced with intricate problems related to supply of fuels and oxygen as well as control of the energetic processes. Adjustment of the rate of ATP regeneration to energy requirements is very precise and involves both feed-forward and feedback control mechanisms. A detailed discussion of the control of energy metabolism is outside the scope of this chapter and the reader is referred to other reviews or textbooks.
Aerobic processes of ATP generation The ultimate process of ATP formation is oxidative phosphorylation during which various substrates are oxidized with oxygen in the mitochondrion. The process is rather complex and will be described only briefly. The fuels for the aerobic processes are mainly pyruvate (derived from carbohydrates) and fatty acids (derived from triglycerides). These fuels are degraded by separate routes to acetyl-CoA within the mitochondrion. The acetyl group of acetyl-CoA is catabolized to CO2 in the TCA cycle (tricarboxylic acid cycle) by which electrons are transferred from the substrates to coenzymes (mainly NAD+). The electrons are transferred from the reduced coenzyme (NADH) to the electron transport chain with oxygen being the final electron acceptor. When electrons pass through the electron transport chain their energy level decreases and part of the energy is used to transfer protons through the mitochondrial membrane. When protons diffuse back through the membrane protein (ATP synthase) ADP is phosphorylated to ATP; the whole process is called oxidative phosphorylation. The efficiency of the aerobic processes in terms of oxygen, i.e. the amount of ATP produced per consumed oxygen (P/O2) is under debate. In textbooks, P/O2 ratio is often considered to be when carbohydrate (CHO) is oxidized, whereas with free fatty acids (FFA) the P/O2 ratio is about % less. The lower yield of ATP per
oxygen consumed may contribute to the lower power of this process. In this chapter we have used a P/O2 ratio of to estimate the power and capacity of oxidative phosphorylation. This is probably an overestimate since evidence exists that some of the proton gradient is dissipated by leakage of protons through the inner mitochondrial membrane[]. The extent of this leakage during exercise is uncertain. The efficiency in transforming stored chemical energy into work can be calculated from O2 utilization and performed work. The mechanical efficiency during cycling is about % when calculated from the exercise-induced increase in whole-body O2 uptake and about % when calculated from the O2 uptake by the leg muscles []. In contrast, during static contraction the mechanical efficiency is zero, since no external work is performed. Since more than % of the released energy is transformed to heat, the maintenance of a constant body temperature is a challenge for whole-body homeostasis during exercise.
Anaerobic processes of ATP generation Although the aerobic processes dominate during sustained exercise regeneration of ATP can also occur through anaerobic processes. Three different ATPgenerating anaerobic processes exist: Breakdown of PCr: ADP + PCr + H+ Æ ATP + creatine Glycolysis from glycogen: ADP + Pi + glucosyl unit Æ ATP + lactate + H+ ADP fusion: ADP + ADP Æ ATP + AMP
Breakdown of PCr PCr is a high-energy phosphate compound stored in muscle tissue at a concentration three times that of ATP. Creatine kinase (CK) is a highly active enzyme and catalyzes an equilibrium reaction: ADP + PCr + H+ ´ ATP + creatine
()
During exercise there is an increase in ADP, which by a mass action effect stimulates a shift of the reaction to the right (phosphorylation of ADP to ATP at the expense of PCr). During sustained exercise ADP remains elevated and PCr therefore remains low throughout the exercise period. The degree of PCr depletion at a steady state is related to the exercise intensity. PCr decreases even with low-intensity exercise. At
Chapter . a work rate of % of V˙2max PCr is reduced to % of the initial level and at a work rate of % of V˙2max PCr is reduced to % of the initial level []. During recovery from exercise ADP decreases and the reaction is shifted back to the left. The half-time for PCr resynthesis is about s and after – min recovery PCr is restored to the initial level. An overshoot in PCr above the pre-exercise level has been observed in fasttwitch muscle fibers after high-intensity exercise [] and in slow-twitch fibers after prolonged exercise at moderate intensity []. The mechanism for this overshoot is not known. The combination of reaction () (ATP hydrolysis) and () (PCr breakdown) results in increased levels of creatine and Pi. An increase in Pi is considered to interact with the contraction process and is a potential factor in fatigue (see below). After the original discovery by Harris et al.[] that supplementation with creatine can augment the muscle store of Cr and PCr by about % there has been great interest in exploring the role of creatine supplementation as an ergogenic aid. Many but not all studies have shown that creatine increases performance during high-intensity exercise especially when it is performed intermittently, whereas there is no documented effect during prolonged exercise. The mechanism for this ergogenic effect is probably related to an increased availability of high-energy phosphates (augmented store of PCr and increased rate of PCr resynthesis) []. Since breakdown of PCr involves uptake of protons the CK reaction has acid–base implications. At the onset of exercise when PCr breakdown is the dominant process an alkalinization of the order of . pH units has been observed, whereas during sustained high-intensity exercise the CK reaction is an important buffer process by which the acidosis incurred by lactate accumulation is counteracted. It has been estimated that the CK reaction accounts for about % of the total intracellular buffer capacity [].
Lactate formation During glycolysis muscle glycogen or blood-borne glucose are partially degraded to pyruvate or lactate in about well-defined enzymatic steps. Glycolysis from glycogen results in a higher yield of ATP ( moles of ATP per mole of glucosyl unit) than glycolysis from glucose ( moles ATP per mole glucose). Glycolysis to
pyruvate precedes the aerobic combustion of CHO in the mitochondrion and is therefore named aerobic glycolysis. Pyruvate can be transferred to lactate, which is a dead-end metabolite. Glycolysis to lactate is named anaerobic glycolysis, since the process does not require oxygen. However, formation of lactate may also occur in the presence of oxygen. The mechanism of lactate formation during submaximal exercise has been extensively discussed over a number of years and remains a controversial issue. However, it is accepted that lactate is formed by a mass action effect through the near-equilibrium reaction catalyzed by lactate dehydrogenase (LDH) and that increases in pyruvate, NADH/NAD+ ratio or H+ are metabolic changes in the cytosol that will promote lactate formation. Activation of glycolysis in excess of pyruvate oxidation and NADH influx to mitochondria will cause cytosolic increases in pyruvate and NADH and will therefore also lead to lactate formation. Factors such as oxygen deficiency, increased recruitment of fast-twitch fibers and low aerobic training status of the muscle (i.e. low mitochondrial and capillary density) are likely to be of importance for this imbalance. Lactate formation is associated with release of protons and when lactate accumulates the tissue becomes acidotic. Since acidosis may interfere with both the energetic processes and the contraction process lactate formation has become a major interest in exercise physiology.
ADP fusion The adenine nucleotides (AN) are related to each other through an equilibrium reaction catalyzed by adenylate kinase. ADP + ADP ´ ATP + AMP
()
During conditions of energetic deficiency muscle ADP concentration increases and reaction () is shifted to the right. The AN pool can be degraded further through irreversible deamination of AMP to inosine monophosphate (IMP) and ammonia (NH3). AMP Æ IMP + NH3
()
Deamination of AMP enables a further shift of reaction () to the right. The combined effect of ATP hydrolysis, ADP fusion and AMP deamination will lead to a net decrease in the AN pool corresponding to an
Metabolism during Exercise
Not limited
100 75
100 mol ATP
mmol ATP/kg muscle/min
150
50
59
50 25
0 3 mol ATP/min
0.37
0.94
PCr
Lactate
2 1 0 PCr
Glycolysis
CHOox
FFAox
Fig. .. Power of the energy-yielding processes in human skeletal muscle. Power values are based on reported experimental values in humans under the following conditions: PCr breakdown: . s electrical stimulation []; glycolysis: s cycling []; CHO oxidation: calculated from the following assumptions — O2 utilization by the leg muscles during two-leg · cycling is % of V 2 max ( L/min) [], working muscle mass kg, mol of ATP per mole of O2; FFA oxidation: assumed to be % of that of CHO oxidation (see text).
energy equivalent of moles of ATP per mole of AN. However, the amount of ATP that can be derived by this process is limited (– mmol ATP/kg muscle or about –% of total anaerobic energy release) and is therefore usually neglected as an energetic process during exercise.
Power and capacity of energetic processes There are two inherent limits to the energetic processes: the maximum rate (power) and the amount (capacity) of ATP that can be produced. The power and capacity vary drastically between different energetic processes and will also vary between individuals. Peak values of power and capacity in humans, observed in experimental studies, are shown in Figs .. and ... Factors such as muscle mass, muscle fiber type composition, training status and nutritional factors
CHOox
FFAox
Fig. .. Capacity of the energy-yielding processes in human skeletal muscle. Capacity values have been derived from the following assumptions: the whole store of muscle PCr ( mmol/kg w.wt) is utilized; maximal muscle lactate · formation during exercise at % V 2 max is mmol/kg w.wt including efflux to blood of %; muscle glycogen content of mmol/kg w.wt; a working muscle of kg. Amount of ATP that can be produced from oxidation of FFA is not limited; hence staple bar is cut off.
will be important determinants of the individual profile of power and capacity. The limitations of the energetic processes will set an upper limit for energy production and will consequently be a determinant of exercise capacity. The maximal intensity of the exercise is limited by the combined maximal power of the energetic processes. From the data in Fig. .. one can calculate that the combined power of PCr breakdown, glycolysis and CHO oxidation is . mol ATP/min of which anaerobic power contributes % or . mol ATP/min. Estimates of maximal power during a -s sprint, using a completely different approach (Fig. ..), give an ATP turnover of . mol/min. The difference is expected since the maximal power of oxidative phosphorylation can only be reached after some minutes of delay. Estimated maximal power of energetic processes is very similar to anaerobic energy utilization observed during s of sprint cycling (. mol/min; recalculated by assuming kg of active muscles) []. The duration of exercise is limited by the capacity of the recruited energetic processes. For instance with the data shown in Fig. .. oxidative combustion of the whole store of muscle glycogen would result in a total gain of moles of ATP. During exercise at %
Chapter .
ATP turnover (mol/min)
4
3
Aerobic Lactate ATP–PCr
2
1
0 Rest
Marathon
5000 m
Running speed:
5.5 m/s
6.4 m/s
Duration:
7610 s 780 s (2h, 7 min) (13 min)
400 m
100 m
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V˙2 max ( L/min), maximal rate of CHO oxidation is . mol ATP/min (Fig. ..). Assuming that the whole energy demand is covered solely by oxidation of CHO the duration of exercise would be min (/.). However, exercise at % V˙2 max is not limited by muscle glycogen level but by other factors such as accumulation of lactic acid and hence exercise is terminated after – min, long before muscle glycogen depletion. Experiments in humans have shown that exercise at % of V˙2 max results in glycogen depletion after about – min, coinciding with muscle fatigue, and is in a reasonable agreement with the estimates in Figs .. and ...
Breakdown of PCr Breakdown of PCr is the energy source that can sustain the highest rate of ATP production. The maximum rate of PCr breakdown presented in Fig. .. ( mmol ATP/kg muscle/min) was observed during short-term (. s) electrical stimulation of the quadriceps femoris muscle during isometric conditions []. The maximum value is close to Vmax of myosin ATPase activity measured in vitro. It is therefore possible that power during the first few seconds of exercise is limited by the ability to utilize ATP rather than by the rate of ATP regeneration. The amount of energy that can be produced from PCr is limited by the amount of PCr stored. In human skeletal muscle the concentration of PCr is about
Fig. .. ATP turnover at rest and during maximal running of different distances. ATP turnover over m has · been estimated from an assumed V 2 max of L/min and mol of ATP per O2. ATP turnover over other distances has been estimated from the speed of running (assuming that mechanical efficiency remains constant) and the energy required to accelerate to this speed (assumed efficiency of %). Relative recruitment of aerobic processes is from Newsholme et al. []. Relative contributions of ATP-PCr and lactate to energy turnover: -m values are from s cycling []; and m anaerobic ATP formation has been assumed to be limited by the capacity shown in Fig. ...
mmol/kg w.wt with about a % higher concentration in fast-twitch fibers than in slow-twitch fibers. With the maximal rate of PCr breakdown shown in Fig. .. complete depletion of the PCr store within about s would be expected. However contribution of ATP from other energy sources and decreased energy expenditure (fatigue) will prolong this time. From thermodynamic considerations the maximal rate of PCr breakdown would be expected to decrease when the PCr content of the muscle decreases. Availability of PCr may therefore be a limiting factor of power output even before the muscle content of PCr is totally depleted. It is well established that due to its high power and rapid recruitment PCr breakdown is an important energy source during high-intensity exercise and at the onset of exercise. However, there is evidence that the CK reaction also has a role in aerobic metabolism. CK is located both in the intermembrane space of the mitochondria (CKmit) and at sites of ATP utilization in the cytosol. During exercise PCr will regenerate ATP at the site of ATP utilization and creatine will diffuse to mitochondria. PCr is then regenerated by CKmit and diffuses back to the sites of ATP utilization. Through the action of this creatine shuttle the concentration of ADP in the vicinity of mitochondria will be high and oxidative phosphorylation will be stimulated. Experiments with permeabilized fibers have shown that creatine is an important activator of mitochondrial
Metabolism during Exercise respiration in cardiac tissue and slow-twitch fibers of skeletal muscle [], and recently creatine supplementation was shown to enhance aerobic metabolism during low-intensity exercise in humans [].
Glycolysis The maximum power of glycolysis in human muscle ( mmol ATP/kg muscle/min, Fig. ..) was obtained from a study of maximal cycling over s []. Glycogen is the major source of lactate, since the rate of glycolysis of blood-borne glucose is much slower than that of glycogen. The rate of glucose utilization is limited by muscle glucose uptake and by inhibition of glucose phosphorylation by hexose phosphates. During high-intensity exercise muscle glucose uptake increases but increases in hexose phosphates will limit utilization of glucose, which will accumulate in the working muscle []. Intense exercise results in a massive increase in lactate concentration both in muscle tissue and in blood. During cycling to fatigue at % of V˙2 max muscle lactate increased more than -fold (to mmol/kg w. wt) and muscle pH decreased from . at rest to . at fatigue []. Part of the formed lactate is exported to blood, (about % of total lactate production during this type of exercise []), resulting in increased lactate and decreased pH in blood. The main control of glycogenolysis and glycolysis is exerted by glycogen phosphorylase and phosphofructokinase (PFK), respectively. These enzymes catalyze non-equilibrium reactions and exhibit a complex and diverse mode of control []. The Vmax of glycogen phosphorylase and PFK is close to the observed maximum rate of glycolysis in vivo (for references see Connett & Sahlin []) and may therefore determine the limit of maximum glycolytic power. The activities of PFK and glycogen phosphorylase are reduced by acidosis. The product of glycolysis (lactic acid) can therefore reduce the rate of glycolysis through feedback inhibition and may be regarded as a safety mechanism, by which cellular damage due to excessive lactic acid accumulation is prevented. Both the power and the capacity of glycolysis (i.e. amount of produced lactate) may therefore be limited by product accumulation (i.e. H+). Factors such as muscle buffering capacity and export of lactic acid are likely to modulate the response.
Aerobic processes During two-leg exercise, muscle O2 utilization may increase -fold and with a V˙2 max of L/min the rate of ATP generation (assuming a P/O2 ratio of ) will be mmol/kg muscle/min (Fig. ..). It is generally agreed that the major determinant of whole-body maximal aerobic power (V˙2 max) is cardiac output, which sets an upper limit on O2 delivery. It has been estimated that exercise with a muscle mass of kg is sufficient to tax the maximal cardiac output in a sedentary subject []. The maximal aerobic power of the muscle tissue is therefore not utilized during two-leg exercise where the working muscle mass is about kg or more. However, during exercise with small muscle groups the rate of aerobic energy production may be limited by peripheral factors (e.g. mitochondrial density or O2 diffusion). During one-leg knee extension the estimated working muscle mass is only about kg and measured O2 utilization can increase -fold (to mL/min/kg muscle []). This corresponds to a power of mmol ATP/kg muscle/min, which is % of the maximum power of glycolysis. Several lines of evidence suggest that oxidation of fatty acids cannot proceed at the same rate as for carbohydrate (CHO) oxidation. First, it has been shown that isolated mitochondria have a lower maximal rate of respiration and at a given energy state (ATP/ADP ratio) a lower submaximal rate of respiration with palmitate compared with pyruvate []. Secondly, it is known that ultradistance running, which results in a depletion of the body storage of carbohydrates and a switch to fat oxidation [], causes a decline in the power output to about % of V˙2 max. The reason for the lower rate of aerobic ATP formation from fat is under debate. Oxidation of FFA provides an approximately % lower yield of ATP per consumed oxygen compared with CHO and will be one significant factor. Combustion of fatty acids may also be limited by the rate of acetyl-CoA formation where one or several links in the chain may limit the process (fuel transport from the fat depots into the muscle fiber; transport of FFA into mitochondria; rate of b-oxidation). In addition, it has long been recognized that CHO availability may be necessary for optimal function of aerobic energy transduction: ‘fat burns in the glow of carbohydrates’ (Albert Szent-Györgyi). The basis for this may be that the function of the tricarboxylic acid (TCA)
Chapter . cycle depends on pyruvate-dependent anaplerosis (expansion of TCA cycle intermediates). This hypothesis is supported by the finding that (i) prolonged exercise results in glycogen depletion and reduced levels of TCA cycle intermediates [] and (ii) TCA cycle intermediates remained low in McArdle patients where glycogen utilization is blocked []. However, the hypothesis that the level of TCA cycle intermediates may limit maximal TCA cycle flux has recently been questioned []. During prolonged one-legged knee extension exercise it was shown that TCA cycle intermediates decreased but that TCA cycle flux was maintained and PCr increased, and this was considered inconsistent with the hypothesis []. The CHO stores limit the amount of energy that can be produced by CHO oxidation. Cycling or running at intensities of between and % of V˙2 max can normally proceed for – h before exhaustion and coincide with depletion of the glycogen store in the working muscle. During exercise at low intensities the energy demand is low and can be met by fat oxidation. Since fat is present abundantly the capacity of fat oxidation is very large and metabolic factors will not limit exercise duration.
Influence of muscle mass on power and capacity of whole-body energy production The power of anaerobic energy production appears to be limited by the activities of key enzymes such as myosin ATPase, creatine kinase and PFK. On a wholebody level an increased working muscle mass will result in a proportional increase in the total enzyme activities and therefore an increased anaerobic energy production ability. However, aerobic power is largely limited by cardiac output and will not therefore be influenced by the working muscle mass. The capacity of both aerobic and anaerobic energy production is limited by intrinsic muscular factors such as amount of glycogen, amount of PCr, and the volume available to distribute inhibitory metabolic end-products. An increased working muscle mass will increase the total available amount of glycogen and PCr and will therefore increase the amount of energy that can be produced by these processes. An increased working muscle mass, achieved either by training-induced hypertrophy or by increased recruitment of fasttwitch muscle fibers, will therefore be of advantage
during high-intensity exercise, since both power and capacity of anaerobic processes increase. However, during endurance running an increased muscle mass will be of disadvantage since energy expenditure will increase due to the increase in body weight. The difference in body composition between sprinters and endurance runners is an obvious sign of this basic concept.
Energetics during exercise Estimated whole-body ATP turnover increases from about . mol ATP/min at rest to – mol ATP/min during running. The ATP turnover during m running is times higher than that during marathon running, whereas ATP turnover during the m is only % higher than that during a marathon. The difference in energy demand is reflected by a large difference in the energetic processes used. A mixture of the described energetic processes is normally used but the relative contribution varies considerably. The intensity of exercise is an important factor in determining the relative recruitment of the energy processes. Another factor is the time taken to activate an energetic process. PCr breakdown is instantaneous and is therefore considered to buffer the ATP level both temporally and spatially within the cell. Therefore the first few seconds of exercise always involve PCr utilization. Although most reports demonstrate that glycolysis contributes to ATP generation from the onset of exercise there appears to be a lag of a couple of seconds before maximum rate of glycolysis is achieved []. Aerobic processes reach maximal power (V˙2 max) after – min. The delayed onset of aerobic metabolism is the basis for the incurred O2 deficit during steady-state exercise. In addition to exercise intensity and duration of exercise other factors such as availability of oxygen and fuels, environmental factors and hormonal changes will modify the extent to which the energetic processes are recruited. In Fig. .. the ATP turnover and the estimated contribution of various energetic processes during different running events are shown. The figure does not discriminate between different phases of the exercise (onset of exercise, middle of exercise and spurt) during which both ATP turnover and recruitment will differ from the average values shown. The energetic challenge during exercise will be dif-
Metabolism during Exercise ferent during different running distances. Over m the time is too short for recruitment of aerobic processes and the muscles rely almost solely on anaerobic processes, which also have the high power required to meet the energy demand. At the end of m running, muscle PCr will be reduced to about % of the initial level [] and will reduce the power of this energy process. Muscle lactate will accumulate and reach about % of maximal values [] and muscle pH will decrease. Energetic power will for these reasons be reduced and this may explain why speed often decreases at the end of m. Over m, the required power exceeds that of the aerobic processes and the duration is too short to reach maximal rates of oxidative energy production. The capacity of the anaerobic processes is insufficient to cover the whole energy demand during m. The challenge is to maximize the aerobic contribution but to avoid too high a lactate concentration early in the race, which could otherwise impair energetic processes and reduce mechanical efficiency. This metabolic strategy is achieved by a rapid acceleration of speed (which will accelerate oxidative energy release), submaximal running during the middle of the race and a maximal spurt. When the distance is completed the whole energetic capacity of both PCr breakdown and glycolysis should have been used. Normally, the speed decreases at the end of the distance and this is probably related to a reduced power of anaerobic energy release. Over m, oxidative processes are sufficient to cover the energy requirements. During the race utilization of aerobic processes should be maximized without accumulation of inhibiting amounts of lactate. The high power of anaerobic processes should be saved for the spurt. At the end of the race muscle lactate levels will be high and PCr depleted but due to the high total energy expenditure the relative contribution of anaerobic processes will be low (about %). During the marathon CHO stores are insufficient to cover the energy demand and at the same time the power of FFA oxidation is insufficient. The strategy is to: (i) maximize the CHO stores prior to exercise by CHO loading; (ii) avoid lactate formation since this would rapidly deplete the CHO stores; and (iii) optimize oxidation of FFA. Ideally the glycogen stores should be depleted at the end of the race.
Muscle fatigue and metabolism The cause of muscle fatigue (i.e. inability to maintain a defined exercise intensity) is considered to be multifactorial. The classic hypothesis is that muscle fatigue is caused by failure of the energetic processes to generate ATP at a sufficient rate. The evidence for this hypothesis is that interventions which increase the power (i.e. aerobic training, hyperoxia, blood doping) or capacity (i.e. CHO loading, creatine supplementation, glucose supplementation) of the energetic processes result in increased performance and delayed onset of fatigue. Similarly, factors that impair the energetic processes (i.e. depletion of muscle glycogen, intracellular acidosis, hypoxic conditions, reduced muscle blood flow) have a negative influence on performance. The evidence is, however, circ*mstantial and a direct cause and effect relationship remains to be established. It has been argued that since muscle ATP remains almost unchanged during exhaustive exercise it is unlikely that energetic failure is a cause of fatigue. This line of argument may, however, be too simplistic since temporal and spatial gradients of adenine nucleotides may exist in the contracting muscle. Furthermore, the mechanism may be related to increases in the products of ATP hydrolysis (i.e. ADP, AMP or Pi) rather than to decreases in ATP per se. A small decrease in ATP will cause large relative increases in ADP and AMP, due to much lower concentrations of these compounds. Muscle fatigue is generally associated with increased catabolism of adenine nucleotides, which signifies a condition of energetic stress []. This lends further support to the hypothesis that muscle fatigue under many conditions is caused by energetic deficiency. Decrease in PCr is another hallmark of energetic deficiency and is paralleled by a similar increase in Pi. There is evidence that increases in Pi will interfere with the contraction process and it is considered to be one of the major factors for the decrease in force []. Metabolic factors are likely to play an important role in fatigue and performance during exercise but there is no doubt that conditions exist where fatigue cannot be explained by metabolic changes. Considering the diversity and complexity of exercise this is to be expected.
Chapter . Energy expenditure and metabolism Energy expenditure during exercise Energy expenditure during exercise varies over a large range. From a basal metabolic rate (BMR) of approximately – kJ/h in men and – kJ/h in women energy expenditure may increase to – kJ/h during heavy exercise. Assuming a mechanical efficiency of around %, this permits kJ/h of work to be performed []. During a -s bout of exercise more than kJ of work may be performed by a highly trained athlete and during a -min bout kJ []. The total energy expenditure (TEE) of an adult person averages – kJ/ h. Individuals with physically very demanding occupations may reach values of – kJ/ h. The TEE is made up of three components: the BMR, the dietaryinduced thermogenesis (DIT) and the activitydependent energy expenditure (Table ..). The BMR is normally the largest component of TEE, averaging – kJ/ h in men and – kJ/ h in women. The DIT, which is defined as the extra energy consumption resulting from a meal, normally accounts for one tenth of the TEE. DIT is largest after a protein meal, where it amounts to –% of the energy contained in the meal, but considerably smaller for meals containing carbohydrates (–%) and fat (–%) []. The remaining part of the TEE is the activity-dependent energy expenditure (AEE), which can be calculated based on the . and . kJ of energy released for each liter of oxygen consumed during fat and carbohydrate oxidation, respectively (for further discussion, see below). When the oxygen uptake is unknown, different approximations are often used to assess the activity-dependent energy consumption, e.g. quiet sitting corresponding to an energy consumption of about . ¥ BMR, office work .– . ¥ BMR, standing . ¥ BMR, cycling – ¥ BMR and various sports activities of the order of – ¥ BMR (Table ..) []. The energy cost of running is independent of running speed and of the order of kJ/km/kg body weight. For walking at a pace of .– km/h, the corresponding figure is kJ/km/kg: body weight []. This means, for example, that the energy content of g fat ( kJ) for a -kg person covers the energy demand of running approximately km or
Table .. Energy expenditure in adult men and women, given as the total energy expenditure/ h as a multiple of BMR (equal to the physical activity level, PAL). Data from []. BMR = basal metabolic rate (kJ/24 h) DIT = diet-induced thermogenesis (kJ/24 h) AEE = activity-induced energy expenditure (kJ/24 h) TEE = total energy expenditure = BMR + DIT + AEE PAL = physical activity level (includes DIT) = TEE/BMR BMR
18–29 years
30–39 years
40–64 years
Males Females
7500 6200
8200 6000
7000 5800
PAL over 24 h with different living conditions Chair- or bedbound Seated work, low leisure time activity Seated work with moving around, low leisure time activity Standing work, low leisure time activity Strenuous leisure time activity (30–60 min, ≥ 4 times/week) Strenuous work or high activity in leisure time
1.2 1.4–1.5 1.6–1.7 1.8–1.9* +0.3† 2.0–2.4‡
* For example, 8 h sleeping (0.95), 4 h sitting (1.2), 12 h walking around (2.5). † Up to a maximal value of 2.0. ‡ 2.4 is considered to be the highest PAL that can be tolerated other than for short periods of e.g. very intensive training.
walking km. It is evident that complex nervous and hormonal regulation is required in order to control the utilization of the different energy substrates during exercise with large variations in energy demand.
Exercise metabolism Exercise metabolism is focused on the utilization of biologic energy in order to perform work. Biologic energy is found in the oxidizable substrates in the body, namely glucose, free fatty acids and amino acids, and also lactate and glycerol (and under some circ*mstances ethanol and ketone bodies). In addition to aerobic oxidation, energy is released during the anaerobic degradation of glycogen to lactate. This is the major energy source in some cells and tissues devoid of mitochondria, such as the red blood cells and the kidney tubules, and also in skeletal muscle during short-term, high-intensity exercise. An important issue in metabolic regulation at rest and during exercise is that,
Metabolism during Exercise under non-starving conditions, the central nervous system (as well as the red blood cells and the kidney tubules) is limited to the use of glucose as the sole energy substrate. The supply of glucose to these tissues is therefore highly prioritized. The skeletal muscle cells store energy in the form of glycogen, triglycerides, ATP and phosphocreatine (PCr). Biologic energy can also be delivered to the muscle in the form of bloodborne energy substrates directly originating from the alimentary tract following a meal or, between meals, in the form of blood-borne substrates released from the storage organs, mainly the liver and the adipose tissue. In the previous part of this chapter, a detailed description was given of the biochemical pathways involved in these processes. The energy expenditure during exercise originates from aerobic and anaerobic biochemical processes. The energy expenditure originating from the aerobic combustion of nutrients can be determined with great precision by measuring the oxygen uptake of an individual. Each liter of oxygen consumed corresponds to the release of .–. kJ of energy, depending on the relative proportions of carbohydrates or fat being oxidized. These proportions can be determined from the respiratory quotient (RQ, the ratio between the amount of CO2 exhaled and the amount of O2 taken up). The energy expenditure originating from the anaerobic processes, i.e. glycogen degradation to lactic acid and breakdown of PCr and ATP, can, on the other hand, only be roughly estimated (e.g. based on measurement of the total work performed with subtraction of the aerobic energy delivery). While maximal aerobic power can reach kJ/min in endurance ath-
letes, athletes in events of – min duration can reach a maximal total anaerobic energy release of kJ. For an untrained person, aerobic power may reach kJ/min and maximal total anaerobic energy release kJ, the former value being limited by the capacity of the heart to eject oxygenated blood into the arterial system and the latter by the total muscle mass that can be recruited in the specific exercise []. During maximal work, anaerobic processes dominate when exercise durations are less than approximately min, with longer exercise durations aerobic processes will yield the majority of the energy delivery.
Energy sources at rest and during exercise Energy sources at rest At rest, under postabsorptive conditions, fatty acids constitute the primary energy source, accounting for approximately % of energy requirements, leaving about % for carbohydrates and proteins, respectively. Postabsorptive conditions are said to be present when no nutrients are entering the blood from the intestinal tract. The energy liberated per gram of nutrient combusted is kJ for carbohydrates and proteins and kJ for fat. Therefore, the demand for fat combustion at rest can be covered by the adipose tissue liberating g of fatty acids per hour, of which . g is taken up by the liver and g by skeletal muscle. The carbohydrates are provided by the liver, which releases . g/h of glucose, of which . g is derived from glycogenolysis and g from gluconeogenesis. This covers mainly the g/h of glucose which is used
Table .. Typical changes in energy source (g/h) when an individual exercises at successively higher intensity (postabsorptive state) [,].
Glucose, from liver store Glucose, from liver glucose neoformation Glucose, from muscle store Fat, from adipose tissue or muscle
Rest
Exercise 100 W
Exercise 200 W
Exercise 250 W
4.5 3 – 5
16 4 40–45 18
25 5 100 26
40 5 150 22
Values are given in g/h and refer to the postabsorptive state. Exercise metabolism during the absorptive state will vary with meal composition and the time following the meal. Generally, however, more energy will be derived from the blood (glucose, fatty acids, triglycerides) and less from the substrate stores in skeletal muscle and adipose tissue.
Chapter . by the central nervous system and the red blood cells. Liver glycogenolysis is made possible by the liver store of glycogen (about g in the fed state), whereas substrates for gluconeogenesis are lactate, glycerol and amino acids taken up by the liver from the blood. The amino acids used for gluconeogenesis derive mainly from net proteolysis in skeletal muscle, which releases around . g amino acids/h. The latter also constitute an important energy substrate for the intestines and the liver []. Absorptive conditions prevail for several hours following each meal, with most nutrients being taken up by the body during the first – h. If it is assumed that the main absorption phase takes place during the first . hours following each meal, with three meals a day, absorptive conditions will prevail for . h/ h, whereas the body during the remaining . h per day is closer to a postabsorptive state. In the absorptive state, the metabolic situation is different in that now carbohydrate oxidation dominates, normally covering three-quarters of total substrate oxidation, while the substrate stores of the body are refilled rather than used. If kJ/ h is covered by three meals of kJ each, containing % carbohydrates, % fat and % protein, g glucose, g fatty acids and g amino acids will be made available to the body during the absorptive period after each meal. Due to the shift from predominantly fat to predominantly carbohydrate oxidation during this period, around g of the g of carbohydrates taken up by the body will be oxidized, whereas the remaining g will be used to refill the liver glycogen store ( g) and the glycogen store in skeletal muscles (– g during nonglycogen-depleted conditions) []. The g of fatty acids from each meal enters the blood in the form of a special lipoprotein, the chylomicron. The chylomicron triglycerides (TGs) are degraded by the enzyme lipoprotein lipase (LPL), which is localized in capillary endothelial cells in most organs of the body, but with especially high levels in adipose tissue, myocardium and skeletal muscles. The fate of the enzymeliberated fatty acids is mainly storage in adipose tissue, but also uptake in liver and skeletal muscle []. In muscle tissue the fatty acids are oxidized and/or used for the restoration of muscle TG stores reduced by exercise []. In the liver, the chylomicron remnants are taken up and fatty acids resynthesized to triglycerides, which are incorporated into very low density lipopro-
tein, exported and finally also stored in adipose tissue. The g amino acids from each meal are added to the – g of amino acids being formed per h mainly from the degradation of protein stores of skeletal muscle and liver. Of these amino acids, – g are used for synthesis and approximately g are used for oxidation in the intestines and the liver [].
Energy sources during exercise in the postabsorptive state During exercise, the energy consumption may be increased by -fold. The primary factor determining whether carbohydrates or fat are preferentially used during exercise is the exercise intensity, the proportion of energy derived from carbohydrates growing progressively larger with increasing intensity. At a moderate exercise level of W, demanding an oxygen uptake of around . L/min, equalling an energy expenditure of kJ/h, the proportions might typically change to % carbohydrates and % fat. In this situation, the demand for carbohydrates ( g glucose/h, i.e. kJ) is met by glycogenolysis (around – g/h) and glucose uptake (around g/h), whereas the demand for fat is met by lipolysis in adipose tissue and muscle, supplying g fatty acids (i.e. kJ). Under normal circ*mstances, protein is not an important metabolic fuel during exercise, and it is considered unlikely that, even during prolonged exercise, protein oxidation can cover more than % of the energy demand of the exercising body []. In spite of this, activation of protein metabolism is an integral part of the acute metabolic response of the body to exercise []. To roughly estimate the RQ during exercise and therefore the relative demand for carbohydrates and fat, Dill and coworkers used an equation, empirically derived from their data: Respiratory quotient during exercise = . + . · oxygen uptake in L/min []. Although obviously not generally applicable, the equation can be used here to illustrate the increasing demand for carbohydrates at increasing exercise intensities. When the exercise intensity is increased to W (oxygen uptake = . L/min), this formula indicates an RQ value of . (indicating % carbohydrate and % fat oxidation). This corresponds to a combustion of g carbohydrates and g fatty acids.
Metabolism during Exercise Similarly, exercise at W can be calculated to demand combustion of g carbohydrates and g fatty acids. It is therefore evident that fat combustion will level off with increasing exercise intensities, when simultaneously carbohydrate oxidation, as well as hepatic and muscular glycogenolysis and muscle glucose uptake, increases exponentially (above the ‘lactate threshold’). When exercise is prolonged, fat combustion increases. This change is most likely secondary to a continuing depletion of the body’s carbohydrate stores. During prolonged exercise at % of V˙2 max in overnight fasted untrained subjects, plasma free fatty acids contributed to % of the fuel demand during the fourth hour of exercise compared to only % during the first hour []. Asmussen and Christensen describe two subjects being able to work at intensities demanding oxygen uptakes of . and . L/min (– W) for h []. During the first hour, the subjects combusted g carbohydrates and g fatty acids; during the third hour the corresponding figures were g carbohydrates and g fatty acids. Endogenous glycogen is the dominant fuel during the initial period of moderate to severe exercise, and during sustained exercise at work rates corresponding to –% of V˙2 max, fatigue coincides with the depletion of muscle glycogen [,]. With the continuous depletion of endogenous glycogen, the utilization of plasma-derived glucose increases and has, during prolonged exercise, been reported to cover up to –% of the estimated carbohydrate oxidation by muscle []. The increased glucose uptake by skeletal muscle during heavy exercise must be balanced by a glucose release from the liver of the same magnitude. Because there are only limited possibilities for increasing gluconeogenesis in liver (from to g/h [], mainly secondary to increased availability of glycerol due to the increased lipolysis in adipose tissue), the majority of the increased glucose output from the liver has to be derived from glycogenolysis. With liver glycogenolytic rates of g/h during heavy and g/h during very heavy exercise, the liver glycogen supply of around g will be rapidly depleted. However, fatigue due to hypoglycemia can be postponed by the ingestion of glucose. Although it may be difficult to ingest large amounts of glucose during exercise, it has been reported that as much as g/h of ingested glucose may be taken up by the body [] during heavy exer-
cise of long duration. It has been observed that the total amount of carbohydrate used during a marathon race was higher than could be accounted for by the endogenous glycogen stores in the working muscles and the liver. From this, it was concluded that glycogen reserves in inactive muscle and other tissues must also have been mobilized []. Glycogenolysis with net lactate release from inactive muscle has been demonstrated during exercise []. Relatively little is known about endogenous triglycerides as a potential source of energy for the contracting muscle, but it seems likely to be an important fuel during exercise. During . h of cycle ergometer exercise to exhaustion, it was found that the decrease in thigh muscle triglyceride concentration averaged % []. The authors calculated that % of total oxidized fatty acids originated from endogenous triglycerides, whereas % came from plasma-derived free fatty acids, and that the energy contribution of endogenous triglycerides was % of that of glycogen. During the Swedish -h Wasa ski race, it was calculated that the decrease in muscle triglycerides corresponded to twice as much energy as the decrease in muscle glycogen []. See also the data by Hurley et al. [], which are discussed in the section on training below.
Energy sources during exercise in the absorptive state When exercise is performed in the absorptive state, less energy will be derived from the substrate stores in skeletal muscle and adipose tissue, and more from glucose, fatty acids and triglycerides in blood, although plasma free fatty acids will be less important as an energy fuel than in the postabsorptive state []. In an experimental study, metabolism during min of forearm exercise after an overnight fast was compared with the same exercise h following a meal []. In the postabsorptive state, the exercise was fueled by glucose uptake from blood (%) and by intramuscular depots (%). Following the meal, the contribution to exercise metabolism from plasma glucose was similar to that in the postabsorptive state, but the muscular uptake of plasma triglycerides was markedly increased and, if oxidized, could cover around % of the energy demand. This indicates that, following a meal, the contribution of plasma triglycerides to exercise metabolism may be considerably higher than previously realized. Due to the high blood flow during exercise,
Chapter . arteriovenous differences for VLDL-triglycerides (VLDL-TG) are very difficult to detect accurately, but it has been estimated that, if oxidized, plasma triacylglycerol could cover half of muscle triacylglycerol oxidation during exercise []. However, their slow turnover argues against VLDL-TG as an important fuel for the working muscle. It is likely that muscle lipoprotein lipase may be more active towards chylomicron-TG than VLDL-TG [] and the idea that chylomicron-TG may serve as a fuel for the exercising muscle is further suggested by the fact that postprandial lipidemia is diminished during and after exercise []. There is evidence that physical training, by increasing skeletal muscle lipoprotein lipase activity, while reducing that of adipose tissue, causes a redirection of circulating lipid from storage in adipose tissue to oxidation in muscle.
Energy sources during exercise in the trained state One factor counteracting the low fat combustion at high exercise intensities is the effect of training. It has been convincingly shown that, at a certain exercise intensity, a trained individual uses more fat than an untrained individual. This effect is quite strong and occurs after relatively short periods of training. One group of subjects was studied after and days of training for h daily at a moderately high exercise intensity (% of the pretraining V˙2 max) []. Following days of training, the total fat oxidation at this intensity had increased by % and after days of training, the increase was as high as %. The oxidation of carbohydrates during the exercise bout showed the opposite pattern. It is therefore obvious that a good physical fitness level makes it much easier to maintain a high degree of fat combustion during intense exercise []. The source of the increased fat usage during exercise in endurance-trained subjects has been debated, however, since the plasma levels of free fatty acids during exercise are often lower than in untrained individuals []. This is likely to be secondary to the lower sympathoadrenal activation after training [] which, unopposed, would lead to decreased lipolysis of not only adipose tissue, but also intramuscular triglycerides. When male subjects exercised at the same absolute intensity (% of the pretraining V˙2 max)
before and after a -week programme of endurance training, plasma free fatty acid and glycerol concentrations were found to be lower in the trained than in the untrained state []. In spite of this, the respiratory exchange ratio was reduced after training, indicating a greater reliance on fat oxidation. Muscle triglyceride utilization was found to be twice as great and muscle glycogen utilization to be % lower after, as opposed to before, training. It was concluded that the greater utilization of fat in the trained than in the untrained state was fueled by increased lipolysis of intramuscular triglycerides. This conclusion was supported by a study showing a lower turnover of plasma free fatty acids in the trained state []. In fact, Jansson and Kaijser [] also concluded that the reduced reliance on carbohydrate metabolism in their trained, as compared to their untrained, individuals would have been covered by intramuscular triglycerides. They based this conclusion on the finding of no difference between trained and untrained individuals in the ratio of plasma free fatty acid extraction to O2 extraction by the working legs. It is known that increased fat oxidation with training is a local effect since after one-leg training it occurs in the trained leg only [,]. Underlying this training response is an increased mitochondrial density and an increased content of mitochondrial enzymes in aerobically trained muscle, accompanied by increases in the enzymes involved in activation, transfer into the mitochondria and b-oxidation of fatty acids [–]. Holloszy and coworkers have formulated a hypothetical biochemical mechanism whereby a large concentration of mitochondrial oxidative enzymes in trained muscle would lead to a greater reliance on fat metabolism, a lower rate of lactate formation and sparing of muscle glycogen during exercise []. These adaptations in trained skeletal muscle would, at a given exercise intensity, permit the rate of fatty acid oxidation to be higher in the trained than in the untrained muscle, even in the presence of a lower intracellular fatty acid concentration in the trained state.
Exercise and weight regulation Effect of exercise on body weight Weight balance implies that food intake equals food oxidation and most probably also that the oxidation
Metabolism during Exercise of carbohydrates, fat and protein equals the intake of these nutrients. It has therefore been concluded that the quotient between the intake of carbohydrates and fat (described as the food quotient, FQ, i.e. the ratio of carbon dioxide produced to oxygen utilized for the oxidation of the food) over the long term must equal the average RQ over h (RQ- h) for the individual to maintain weight balance [,]. Most individuals are in weight balance, where their weight only fluctuates by –%. If unusually little food is taken in on a particular day, the RQ will be lowered due to inhibition of glucose oxidation, and fat oxidation will be increased to cover the negative energy balance. Conversely, if more food than usual is taken in during one day, carbohydrate oxidation will be increased (and fat consumption passively decreased to achieve energy balance that day) []. Thus, if the intake decreases it will be covered by stored fat; thereafter all of the lost fat is replenished due to an increased carbohydrate oxidation with high intakes. There seems to be no direct regulatory mechanism whereby fat oxidation is increased with a higher fat intake. However if, over the long term, fat intake is increased, fat oxidation must also be increased in order to achieve weight balance. This may be achieved by expansion of the adipose tissue mass, which increases fat oxidation more than carbohydrate oxidation. However, an increase in h fat oxidation (i.e. decrease in RQ- h) may also be achieved by exercise []. Therefore, exercise allows weight maintenance to be achieved with less body fat in physically active individuals, where exercise substitutes for an enlarged fat mass in bringing about rates of fat oxidation corresponding with fat intake. This is one conceivable mechanism by which regular exercise tends to keep the fat depots down []. In a meta-analysis by Ballor and Keesey [] based on scientific studies, it was reported that training reduces the fat mass on average by . kg per week, and to the same extent in men and women.
Hormonal mechanisms at rest and during exercise Hormonal regulation of resting metabolism At rest, insulin and glucagon are the major hormones regulating whether energy fuels are liberated from the storage sites or, conversely, channelled for storage. In
the postabsorptive state, the insulin/glucagon concentration ratio is around , which allows a normal hepatic release of glucose into the blood. Following a carbohydrate-containing meal insulin increases substantially, which in concert with a slight decrease in glucagon concentration causes the insulin/glucagon ratio to increase by more than -fold. This increase is necessary in order to direct glucose for storage in skeletal muscle and liver. With a carbohydratepoor meal, the rise in insulin will be small, whereas plasma glucagon concentration clearly increases. The resulting decrease in the insulin/glucagon ratio serves to maintain a sufficient hepatic release of glucose in order to cover the needs of the central nervous system and erythrocytes in spite of a carbohydrate-poor meal [] (Fig. ..). Insulin stimulates glycogen synthesis in the liver and also promotes liver glucose uptake, but only at an elevated portal vein glucose concentration. Glycogen synthesis in the liver is also directly stimulated by increased vagal nerve activity. Glucagon, on the other hand, stimulates hepatic glycogenolysis as well as lipolysis in adipose tissue. In addition, glucagon stimulates the liver capacity for gluconeogenesis. The effect of glucagon on adipose tissue lipolysis is, however, secondary to the more powerful stimulation by the sympathetic nervous system, cortisol and growth hormone. Several other factors may stimulate hepatic glycogenolysis, including a- and b-adrenergic stimulation and vasoactive intestinal polypeptide, whereas hepatic gluconeogenesis is stimulated by increased precursor (lactate, pyruvate, amino acids, glycerol) availability, secondary to skeletal muscle glycolysis, skeletal muscle proteolysis and adipose tissue lipolysis. During exercise all these processes are stimulated, as well as hepatic extraction of these precursors and gluconeogenetic efficiency [].
Hormonal changes with exercise During exercise, several hormonal systems are activated and increases are seen in plasma concentrations of adrenaline/noradrenaline (epinephrine/ norepinephrine), adrenocorticotrophic hormone (ACTH), cortisol, b-endorphin, growth hormone, renin, testosterone, thyroid hormone and several gastrointestinal hormones (Fig. ..). Arterial levels of glucagon are unchanged or only marginally increased
Chapter . Liver
Insulin/glucagon = low (epinephrine)
Insulin/glucagon = high
Glucose
Muscle
Contraction Insulin
Availability Fatty acids Insulin Norepinephrine
Plasma–cytoplasmic gradient
Glycogen Contraction Epinephrine Norepinephrine Pyruvate Lactate
Adipose tissue
Fig. .. Schematic illustration of the quantitatively most important hormonal mechanisms in the regulation of carbohydrate and fatty acid metabolism at rest and during exercise. Mechanisms important during exercise are in bold. A low insulin/glucagon ratio is around , a high ratio may be or higher [,,,–].
by exercise, whereas insulin is decreased []. The decrease in plasma insulin concentration can be quite marked during exercise (< % of values at rest) and is thought to be mediated by an increased activity in sympathetic nerves and by small decreases in the blood glucose concentration during exercise. The latter fact explains why the insulin decrease may be attenuated, and even reversed, by voluntary intake of glucose solutions during exercise. Both insulin and glucagon exert a large part of their effect on the liver and this effect will be underestimated based on hormone concentrations in peripheral arteries, because concentrations in the portal vein, which is the relevant concentration for the liver, are considerably higher. Therefore, it is likely that, although peripheral levels may stay unchanged, the glucagon concentration in the portal vein is increased by exercise []. The catecholamines in plasma increase with exercise intensity in an exponential manner. The source of circulating epinephrine is the adrenal medulla and the
increase with exercise reflects an increased (sympathetic) nerve stimulation of this organ. Norepinephrine also originates to some extent from the adrenal medulla, but the increased norepinephrine concentration in arterial plasma is mainly considered to reflect overflow from postsynaptic sympathetic nerve endings mainly in the heart, but also in the liver and the adipose tissue. The mechanism behind the large sympathetic activation with exercise is not clear, but one important variable is likely to be a decrease in the portal glucose concentration. The two hormones differ in that the plasma concentration of norepinephrine starts to increase at lower rates of exercise and also increases more steeply with increased exercise intensity. At high exercise intensities, or long exercise durations, these hormones may be increased by –-fold. Following exercise, norepinephrine often remains increased for several hours, whereas plasma concentrations of epinephrine return to basal levels within minutes [,].
Metabolism during Exercise Hormonal regulation of carbohydrate metabolism during exercise Changes in insulin and glucagon have been reported to account for practically all of the increase in hepatic glucose output with exercise [,]. It is believed that the decrease in insulin concentration with exercise makes the liver more sensitive to the stimulation by glucagon. Sympathetic nervous stimulation seems to have no role in stimulating hepatic glucose output during exercise in humans, whereas epinephrine has a stimulating effect, additional to that of glucagon, during prolonged exercise, when epinephrine levels are at their highest. In addition, cortisol has an indirect effect on hepatic gluconeogenesis, by increasing the enzymatic potential for this pathway. The catecholamines are important in ‘sensitizing’ skeletal muscle glycogenolysis to the stimulating effect of contraction. With exercise leading to hypoglycemia, the compensatory increase in hepatic glucose output is mainly triggered by epinephrine [].
Hormonal regulation of fat metabolism during exercise The mobilization of free fatty acids from the adipose tissue during exercise is stimulated by catecholamines, mainly norepinephrine synthetized from sympathetic nerves, and inhibited by insulin. In adipose tissue, degradation of triglycerides into glycerol and free fatty acids is to some degree balanced by reesterification of fatty acids, using acyl-CoA and glycolysis-derived glycerol--phosphate. This reesterification has been found to be % of the lipolytic rate at rest, but only % during exercise, a decrease that makes more free fatty acids available to the working muscle during exercise [,].
Effect of training on the hormonal response to exercise In trained individuals, the hormonal responses to exercise are generally decreased. This is true for the increases in norepinephrine, epinephrine, growth hormone, ACTH and glucagon, as well as for the decrease in insulin. This adaptation is especially marked with regard to the sympathoadrenal activation with exercise and occurs rapidly, within the first weeks of training []. The mechanism behind this change is not fully established, but hormonal activation secondary to
other stressful stimuli, e.g. hypoxia or hypoglycemia is in fact increased in the trained state and it is well known that the secretory capacity of the adrenal medulla is increased by endurance training: ‘sports adrenal medulla’ []. Trained individuals display lower insulin concentrations in plasma, during both basal and glucose-stimulated conditions, secondary to a decreased pancreatic insulin secretory rate [] and an increased peripheral insulin sensitivity []. Training augments the lipolytic capacity of the adipocyte, which serves to maintain a sufficient lipolytic rate in a trained individual, in spite of a reduced sympathetic activation during exercise at a given intensity []. Endurance training also increases the oxidative capacity of the liver as well as the hepatic capacity for gluconeogenesis, although the glucose demand during exercise is clearly decreased in the trained state, as discussed above. This decreased demand is sensed by the body and as little as days of endurance training has been shown to decrease the hepatic glucose output during h of exercise by as much as % [].
Summary During exercise, energy consumption may be increased by -fold. The primary factor determining whether carbohydrates or fat are preferentially used during exercise is the exercise intensity, the proportion of energy derived from carbohydrates growing progressively larger with increasing intensity. When exercise is performed in the absorptive state, less energy will be derived from the substrate stores in skeletal muscle and adipose tissue, and more from glucose, fatty acids and triglycerides in blood. A high level of physical fitness results in a higher degree of fat combustion during intense exercise. In addition, regular exercise allows weight maintenance to be achieved with less body fat in physically active individuals. Changes in insulin and glucagon have been reported to account for practically all of the increase in hepatic glucose output with exercise. The mobilization of free fatty acids from adipose tissue during exercise is stimulated by catecholamines, mainly norepinephrine synthesized from sympathetic nerves, and inhibited by insulin. Hydrolysis of ATP is the immediate energy source for practically all energy-requiring processes in the cell. The ultimate process of ATP formation is oxida-
Chapter . tive phosphorylation during which different substrates are oxidized with oxygen in the mitochondrion. In addition, regeneration of ATP can also occur through anaerobic processes (breakdown of PCr, glycolysis from glycogen and ADP fusion). There are two inherent limits to the energetic processes: the maximum rate (power) and the amount of ATP (capacity) that can be produced. Factors such as muscle mass and fiber type composition, training status and nutritional factors are important determinants of the individual profile of power and capacity. Several lines of evidence suggest that oxidation of fatty acids cannot proceed at the same rate as for carbohydrate oxidation. On a whole-body level an increased working muscle mass will result in a proportional increase in the capacity for anaerobic energy production. In contrast, during two-legged exercise, aerobic power is largely limited by cardiac output and not limited by the working muscle mass.
Multiple choice questions What is the body’s demand for fatty acids in the postabsorptive state (at rest, VO2 = . L/min): a . g/h b g/h c g/h d g/h e g/h. The hepatic glucose output is of the order of . g/h at rest and – g/h during heavy exercise. This is covered by the liver glycogen store of approximately g and by the synthesis of new glucose in the liver (gluconeogenesis). What is the maximal capacity of the liver for gluconeogenesis during exercise: a g/h b g/h c g/h d g/h e g/h. Which of the following hormones are considered to be the most important in the control of hepatic glucose output during exercise: a epinephrine b cortisol c glucagon d insulin e norepinephrine.
Breakdown of phosphocreatine in skeletal muscle causes: a pH decrease b buffering of protons c pH increase d release of inorganic phosphate e ADP fusion. Oxidation of fatty acids cannot proceed at the same rate as for carbohydrate oxidation. This can be explained by: a lower oxygen demand b high rate of acetyl-CoA formation c low b-oxidation capacity d low TCA cycle capacity e low carnitine-palmityl transferase capacity.
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Chapter 1.3 Skeletal Muscle: Physiology, Training and Repair After Injury MICHAEL KJ ÆR, HA NNU KA LI MO & BENGT SALTI N
Classical reference
Introduction
Gollnick PD, Armstrong RB, Saltin B, Saubert CW, Sembrowich WL, Shepherd RE. Effect of training on enzyme activity and fiber composition of human skeletal muscle. J Appl Physiol ; : –. This reference was the first to report an enhancing effect of endurance training on muscle oxidative enzymes and fiber types in humans. Individuals trained aerobically for months performing h bicycling, days a week at % (in the early stage) to –% V˙2 max (at the late stage). A significant increase was found in peak pulmonary oxygen uptake rate and this was accompanied by a marked increase in oxidative and glycolytic enzymes (Table ..). Fiber type distribution of type I (ST) and type II (FT) was not altered significantly by training, but in this study no further subdivision into types IIa or IIb was performed. The study demonstrated a marked ability in skeletal muscle to adapt to physical training with regard to metabolic activity.
Table ..
Oxygen uptake · (V O2max) (L/min) Oxidative enzyme (SDH) (mmol/g) Glycolytic enzyme (PFK) (mmol/g)
Before
After
3.81
4.40
13%
4.65
9.10
95%
28.5
59.0
Improvement
117%
PFK, phosphofructokinase; SDH, succinate dehydrogenase.
Skeletal muscle is composed of two main components: specialized contracting cells, myofibers, and a connective tissue framework formed by fibroblasts. Myofibers are long ribbon-shaped cells of various subtypes with different functional properties. They are surrounded by a distinct basal lamina. Each myofiber is ensheathed by a thin layer of collagenous connective tissue named endomysium. A group of myofibers (from a few tens to a couple of hundred) are bound together by another connective tissue sheath named perimysium and form bundles or fascicles of myofibers. Finally a variable number of bundles are ensheathed by a strong epimysium, which forms the bounding fascia for individual muscles and which continues at the ends of muscles into tendons by which the muscles are attached to the surrounding connective tissue. In addition, motor nerve branches penetrate into the muscle and ultimately divide into axon terminals to innervate each individual myofiber. Sensory nerve fibers enter muscle spindles and convey information about the contraction state of the muscle. Nutrients for the active metabolism of muscle are supplied by an abundant vascular network branching into a rich capillary network around individual myofibers. The structural organization of human skeletal muscle and its contractile capacity ensure limb stabilization and weight bearing over joints, and allow for active movement of the body[,]. Around % of total body weight is accounted for by skeletal muscle in an adult human. Skeletal muscle has an amazing ability to adapt to varying workloads, whether increased due to regular physical training, or decreased due to inactivity during injury or disease [].
Chapter . Presumptive myoblasts
Morphology Muscle cells are derived from mesodermal cells in the somites, which migrate from the parasagittal region into the future sites of individual muscles. These myogenic precursor cells differentiate into myoblasts and begin to synthesize muscle-specific proteins. Important regulators of this process of myogenic differentiation are muscle-specific transcription factors of the myoD family (e.g. MyoD, myogenin and Myf-) [a]. Myoblasts fuse into multinuclear myotubes, which form a basal lamina around themselves and begin to synthesize proteins of the contractile apparatus, which will occupy most of the sarcoplasm. Finally, the nuclei move to the periphery of these elongated cells which then display the morphology of fully differentiated myofibers [] (Fig. ..). It is of great importance that some of the myogenic precursor cells do not differentiate, but become localized between the plasma membrane and basal lamina of the myofibers as so-called satellite cells. These serve as reserve cells and are recruited when growth and/or regeneration after injury of myofibers is needed, controlled by mitogenic factors released during growth or upon muscle cell injury []. Early in development the motor nerves migrate from the anterior horn cells in the spinal cord to regions where muscle tissue is under formation; this migration is dominated by a high degree of specificity although the details are not fully known. When the developed myofiber and axon terminals meet, acetylcholine receptors spread along the sarcolemma are aggregated into the region of the nerve contact and develop further into the motor endplate or neuromuscular junction (NMJ). In fetal life, axons from several motoneurons can form NMJs on a single myofiber, but later on only one single NMJ remains on each muscle fiber, while the other NMJs undergo degeneration after birth []. One motoneuron and the myofibers innervated by its axon terminals form a motor unit, in which myofibers are contracted simultaneously. The number of myofibers which each motoneuron innervates varies considerably depending on the accuracy of movement required. In muscles performing coarse movements like the quadriceps femoris, the number of myofibers per motoneuron is up to , whereas in
Proliferation Clonal distribution Myogenic transcription factor synthesis
Myoblasts
Fusion
Myotubes
Mature muscle cell: Innervation Nuclear migration Myofibrillar synthesis Histochemical differentiation ACh receptor redistribution
Fig. .. Embryonic development and maturation of skeletal muscle cell. Lines illustrate myofibrils, sarcolemma and basal membrane. Nuclei are located intracellularly. Satellite cells are not depicted, but are located outside the sarcolemma and within the basal lamina.
ocular muscles the number is only about per motoneuron. All muscle fibers within a certain motor unit are of the same fiber type (for the properties of different types of fibers, see below). How this differentiation occurs is only partly understood. In mature myofibers, the firing pattern of the innervating motoneuron is traditionally considered to play an important role in fiber type determination []. It has been demonstrated that cross-innervation of skeletal muscle (i.e. motoneuron axons from a motor unit containing slow contracting muscle fibers transposed to motor units
Skeletal Muscle with fast fibers or vice versa) leads to a change in the fiber type characteristics towards the innervating nerve type. On the other hand, in human fetal muscle fiber types have not yet reached a differentiation level that allows classical fiber type classification. However, more recent molecular biological techniques have demonstrated that even in fetal muscle different types of myoblasts and myotubes exist and thus it is likely that myofibers have already begun their differentiation into fiber types by this stage. These studies demonstrate that during muscle development a selective initial innervation of muscle fibers from specific axons does occur. It is possible that fiber type-specific transmembrane proteins in the sarcolemma can direct axons from spinal motoneurons to muscle cells predisposed to become fast or slow type fibers []. Mature muscle cells, which are specialized in the production of force and movement, account for more than % of skeletal muscle volume. Muscle cells are elongated and ribbon-shaped, i.e. myofibers, with a diameter of – mm and a variable length of up to mm. Myofibers are multinucleated due to their formation by fusion of myoblasts, the nuclei of which persist in the mature myofibers and become distributed subsarcolemmally along the whole fiber length. Although this indicates that a high degree of internuclear signaling is needed to allow hom*ogenous cell development, experiments have indicated that muscle cell adaptations to, for example, mechanical loading can vary along the length of the muscle cell. These findings suggest that the individual myonuclei have a certain degree of autonomy. The cytoplasm of skeletal myofibers, sarcoplasm, contains — as in other eukaryotic cells — the normal set of organelles but in unusually large numbers reflecting the function of the myofiber as a contractile cell. Most of the sarcoplasm is occupied by cytoskeletal proteins organized into regular sarcomeric structures, which extend the whole length of myofibers and which are composed of the two main contractile filaments myosin and actin and their binding and regulatory proteins (for details see []). The number of ribosomes, the key organelle of protein synthesis, is relatively low compared with the large amount of proteins present in myofibers, which suggests low turnover rates for many muscle proteins. On the other hand, because muscle cells primarily produce proteins which are used locally,
rough endoplasmic reticulum is also a minor component of the sarcoplasm. As the mitochondria are responsible for the major (aerobic) part of energy production in myofibers, they contain the enzymes needed for oxidation of substrates and production of ATP. Because active myofibers consume large amounts of energy mitochondria are numerous, although their size and number can vary substantially during the adaptation of a muscle cell to an altered loading pattern, e.g. at the onset of physical training. Mitochondria can transform from single oval organelles into an almost reticular network along the capillaries in physically very well trained individuals. This contributes to an optimal usage of the delivered oxygen in relation to energy production. In extreme situations in highly oxidative fibers the mitochondria can account for more than % of the total cell volume []. In addition to the aerobic metabolism of substrates, the cytoplasm contains enzymes necessary for the anaerobic formation of ATP from glycogen. Glycogen is stored in abundance in the muscle cell, primarily between myofibrils and adjacent to the sarcoplasmic reticulum []. In addition, small lipid droplets are present in sarcoplasm, most abundantly in fiber types with a high oxidative capacity. Different regions of the sarcomere are named according to their appearance under the microscope. The region that contains myosin is called the A-band (anisotropic appearance in light display) whereas the actin region is called the I-band (isotropic). The region of the A-band where no actin–myosin overlap is present is called the H-band (‘helle’ means ‘light’ in German), the thin band, which divides the I-band into two parts, is called the Z-band (‘zwischen’ means ‘in between’ in German), and the small band dividing the A-band into two is called the M-band. The sarcomere length is defined as the distance from one Z-band to the next, and serially connected sarcomeres comprise the myofibrils of the muscle, which are arranged in parallel to form the muscle fiber [,] (Fig. ..). The architecture of the muscle is important for the development of force and for flexibility, in that the muscle force is proportional to the physiologic crosssectional area of the muscle fibers, whereas the contraction velocity of the muscle is proportional to the muscle length. A more exact description of the
Chapter . Epimysium
Skeletal muscle
Single muscle fiber Nuclei Perimysium
Integrin Fibronectin Merosin
Capillary
Satellite cell
Sarcolemma Basal lamina
alin ulin, T
, Vinc
Nuclei
Actin
Dystrophin
Myosin thick filament Actin thin filament (+troponin, tropomyosin)
Endomysium Type IV collagen Titin Nebulin
Myofibril
Mitochondrion Desmin
Z-line
M-line H-zone A-band
Z-line
I-band
Fig. .. Schematic representation of a muscle cell with its cellular structures. Actin and myosin filaments are depicted in detail to illustrate the basis for the contraction process.
relationship between the cross-sectional area and force development requires consideration of the muscle fiber angle compared to the axis for force development (pennation angle). It is evident that fibers that run in the direction of contraction contribute maximal force
to the movement, whereas fibers that are at an angle to the work direction will perform a smaller force. However, it has to be taken into account that by angling of the fibers, more fibers are placed within the same muscle bulk, and a larger physiologic cross-sectional area is
Skeletal Muscle thereby reached. This means, for example, that the quadriceps and foot plantar flexors have a high physiologic cross-sectional area, with short fibers, and are thereby well suited for large development of force, whereas the hamstring and dorsal flexors of the foot with long muscle fibers and a smaller cross-sectional area are more suited for large movements and ranges of motion. In addition muscles with high pennation angles often experience smaller increases in intramuscular pressure than other muscles (Fig. ..). Apart from connecting the muscle to bone, tendon structures are important as energy absorbers, improve the functional movement range of the muscle–tendon complex, and are of importance for the release of elastic energy in explosive movements [,]. In skeletal musculature up to % of the total content is collagen tissue, and although studies have demonstrated increased turnover of collagen in response to training, the relative amount or even the total content of collagen does not seem to be influenced. The connective tissue in muscle displays passive resistance to stretching, and human models for evaluation of tendon stiffness and stretch-related energy absorption as well as viscoelastic stress relaxation during the static phase have been developed. Repeated stretching of human ham-
FL ML
ML FL
Fig. .. Muscle architecture in the lower limb. Whereas dorsiflexors (tibialis anterior) have a high fiber length (FL) to muscle length (ML) ratio and thus are suited for high excursions and velocity, plantar flexors (triceps surae) favor large force production due to their low FL : ML ratio.
string muscles results in a shortlived decrease in tissue stiffness. Furthermore, daily stretching exercises over several weeks leads to no change in biomechanical tissue characteristics, but results in an increased range of movement, most likely due to an increased pain tolerance, whereas strength training increases the passive stiffness of the muscle–tendon unit. The load-bearing structures in skeletal muscle during passive stretch are not well defined, and the force transmission is more complicated than previously thought. In addition to the obvious force transmission that occurs in series of muscle–tendon structures, elements of the cytoskeleton are thought to mediate a substantial amount of force transduction in the lateral direction. In support of such a role, individual muscle fibers have been shown not to equal the length of the whole muscle.
Proteins and their function Muscle proteins can be separated into sarcomeric/ myofibrillar, mitochondrial and cytosolic proteins (Table ..). The endosarcomeric proteins are dominated by actin-associated (including both actin and troponin and tropomyosin), myosin heavy chain (MHC) and myosin light chain proteins. These form the two types of contractile filaments. Myosin is an asymmetric molecule with a long twisted root at one end and a more circular arrangement at the other end, and each myosin molecule consists of two heavy and four light chains. Myosin proteins are arranged antiparallel and the molecules are rotated approximately degrees to each other. This results in the characteristic feather-like structure, with parts of the heavy chains sticking out at the ends. It is at this location that the actin binding regions are found, and the myosin heavy chains (MHC) are used for characterization either with immunohistochemistry or via in situ hybridization. Actin filaments are thinner than myosin and constructed of actin monomers arranged in an a-helix. Because of this arrangement, a longitudinal cleavage will occur in the filament, in which the regulating protein tropomyosin is located. In addition, the protein troponin is arranged along the actin filament and is responsible for the initiation of the contraction process. Actin and myosin work together during the contraction process, and the filaments are regularly arranged, allowing for some overlap between
Chapter . Table .. Proteins, enzymes and growth/transcription factors in skeletal muscle with tonic stimulation or endurance training. Gene Sarcomeric contractile proteins Myosin heavy chains IIb to IIx to IIa to I I to IIa to IIx to IIb Myosin light chains Fast to slow isoforms Actin Troponin subunit TnT,TnI,TnC Fast to slow isoforms
Protein
mRNA
+ –
+ –
+ ?
+ ?
+
+
Sarcomeric contractile-associated proteins Myosin-associated (titin, myomesin, creatine kinase) Actin-associated (nebulin, tropomodulin, actinin) Z-line-associated (paranemin, synemin, plectin) Exosarcomeric cytoskeletal proteins Intermediate filaments (desmin, skelemin, vimentin) Cytoskeletal anchor proteins (ankyrin, desmin, dystrophin, integrins, syntrophin, talin, vinculin) Mitochondrial proteins and enzymes TCA cycle enzymes (CS, SDH, MDH) Respiratory chain nuclear-encoded (cyt-c, NADH/cyt-c) mitochondrial-encoded (cyt-ox III, cyt-b) Mitochondrial membrane phospholipid (cardiolipin)
+
+
+
+ +
+/–
Cytosolic proteins and enzymes Glycolytic enzymes (HKII, PFK, LDH) Glycogen metabolism (phosphorylase, GS) Fatty acid metabolism (HAD, CAT) Amino acid metabolism (aminotransferase) Myoglobin Fatty acid binding protein Parvalalbumin Sarcoplasmic reticulum Ca2+-ATPase (fast to slow isoform)
+/– –? + + + + + +/–
Surface receptors, enzymes and transporters N-cadherin Acetylcholine receptor Ciliary neurotrophic factor receptor Beta-adrenergic receptor Adenylate cyclase Insulin-sensitive glucose transporter (GLUT-4)
–/+ + + + + +
Transcription factors and peptide growth factors Early response genes (c-fos, c-jun, egr-1) Myogenic growth factors (MyoD, myogenin) Fibroblast growth factors
+ + +
+/–
+ + + + +/–
+ + + + +
cyt-ox III, cytochrome oxidase III; CAT, carnitine acyltransferase; CS, citrate synthase; cyt-b, cytochrome-b; cyt-c, cytochrome-c; GS, glycogen synthase; HAD, b-hydroxyacyl coA dehydrogenase; HKII, hexokinase II; LDH, lactate dehydrogenase; MDH, malate dehydrogenase; NADH/cyt-c, nicotinamide adenine dinucleotide (reduced)/cytochrome-c ratio; PFK, phosphofructokinase; SDH, succinate dehydrogenase.
Skeletal Muscle structures, in order for actin and myosin to form crossbridges and create a contraction [–]. A short contraction — a twitch — is initiated via stimuli from motoric centers via myelinated amotoneurons to the motoric endplate, which ultimately leads to muscle contraction — altogether called exitation–contraction coupling []. When the action potential reaches the neuromuscular junction, local calcium channels are opened, enabling potassiumassociated initiation of fusion of acetylcholine-filled vesicles with the presynaptic junction cleft, triggering release of transmitter molecules. Other membranerelated proteins such as synapsin and synaptophysin also stimulate vesicle transport and transmitter release. When acetylcholine binds to the receptor on the sarcoplasmic reticulum, several processes are initiated, that all lead to a release of calcium from the sarcoplasmic reticulum, which binds to troponin and results in a cyclic interaction between actin and myosin leading to muscle contraction. The degree of muscle contraction is controlled by the number of motor units activated, and in addition to this the stimulation frequency is modulated and afferent signals from tendon and muscle modify the motoric activity, so that the desired amount of force is achieved []. The activation of a muscle fiber via propagation of the action potential does not occur exclusively on the fiber surface, but also across the fiber due to the t-tubuli system. Subsequent activation occurs via recently identified dehydropyridine receptors, which upon activation produce a transmitter substance which enables the sarcoplasmic reticulum system to release Ca2+. In addition to the contractile myofibrillar proteins, sarcomeric and exosarcomeric muscle proteins exist, including cytoskeletal proteins either as intermediate filaments or as cytoskeletal anchor proteins, which are believed to play an important role in force transmission. Models in which gene expression for some of these proteins is missing will often display decreased muscle function. Eccentric movements exert high loading forces on the muscle tissue compared with concentric contractions and it is generally accepted that this leads to muscle injury, soreness and elevated serum enzyme levels. Using eccentric exercise on a motor-driven ergometer in humans or eccentric exercise models in animals, it was demonstrated that ultrastructural abnormalities within
the myofibrils occurred. These included broadening, smearing or even total disruption of Z-discs, and disorganization of the adjacent A-bands [] (Fig. ..). There is growing evidence that the cytoskeletal protein titin is involved in these ultrastructural changes. Titin is a long elastic molecule which connects M-bands to Z-bands and plays an important stabilizing role for the contractile machinery of skeletal muscle as it is responsible for returning extended sarcomeres to their original length. Another cytoskeletal protein which is damaged by eccentric exercise is desmin, which is responsible for keeping myofibrils in register by connecting neighboring myofibrils at their Z-bands. It has been shown that after only a few minutes of loading desmin immunolabeling is lost in many muscle fibers — preferentially type II fibers. The relative role of cytoskeletal proteins in force transmission during muscle contraction is still debated but dystrophin, titin and desmin are three major proteins that have all been shown to be important (Fig. ..). The time pattern of morphological changes following eccentric exercise showed that in addition to the loss of desmin staining, fibronectin positive cells (indicative of sarcolemmal disruption) were demonstrated after a few hours. After days some fibers had developed extreme sizes and abnormal shapes and were often invaded by inflammatory cells. In some cases also fibers expressing fetal myosin were found as a sign of regeneration, i.e. the injury had activated satellite cells and these had produced ‘new sarcoplasm’ where embryonic myosin isoforms were expressed [,]. Eccentric loading leads to a reduced capacity of the muscle to perform tetanic contraction, and the muscle strength can be reduced by more than % after damaging exercise. The lowest value is obtained either immediately or – days after exercise, and the muscle gradually recovers strength over – days []. Interestingly, this decrease in force is not related to pain as electrically stimulated contraction is also reduced. Furthermore it has been demonstrated that initial force reduction and especially recovery time is markedly reduced after training or even a few accustomizing bouts of exercise. The fact that some studies demonstrate a further loss in force for up to days after exercise indicates that contraction triggers events that further decrease muscle performance. Muscle
Chapter . shortening and thus reduction in the range of motion can also accompany eccentric exercise, most likely related to abnormally high levels of Ca2+ in the sarcoplasma, and may be complicated by increased water content. In addition to this, the eccentric exercise results in delayed-onset muscle soreness (DOMS) which reaches a maximum – days after exercise, and is described as a dull, aching pain combined with tenderness and stiffness. The tenderness is frequently localized in the region of the distal myotendinous junction, but can also be generalized throughout the muscle. Although there is an inflammatory response with macrophage accumulation and prostaglandin release, and thus sensitizing type III and IV pain afferents, the true explanation for DOMS remains undiscovered. Mitochondrial proteins are crucial for oxidative capacity of the muscle (see Chapter .) and whereas in endurance training gene expression and protein formation for the different enzymes roughly corresponds to the number of mitochondria, during muscle hypertrophy in response to resistance training the relative content of mitochondrial enzymes either remains constant or decreases. Studies have indicated that tonic contractile activity stimulates expression of protein-coding genes, and interestingly, several mitochondrial complexes require a coordinated expression of genes within both the nuclear and mitochondrial compartments. Cytosolic proteins are important not only for anaerobic fuel combustion but also for transportation of oxygen and the contraction process. Physical activity is shown to increase gene expression for enzymes involved in both lipid and amino acid metabolism. Glycolytic enzyme gene expression is shown to decrease in animal models, whereas enzyme activity can be shown to increase in human models. GLUT- exists both in the cytosol and located in the surface membrane and rises with contraction, and likewise gene expression for several surface receptors increases with activity. Myogenic transcription factors that are important during development and regeneration have also been shown to be activated in relation to mechanical loading of muscle. Using gene expression and protein formation as markers for adaptive responses to loading, it is important to note that transcription and translational
processes are influenced by several factors (Fig. ..). Firstly, an increase in protein synthesis may be due to and preceded by an increase in mRNA levels. However, it has to be noted that mRNA is subject to degradation as well as processing. Secondly, if the translational efficiency increases, protein formation can increase disproportionately to changes in mRNA. Whereas the levels of mRNA and protein can be determined for several of the factors discussed, the detailed transcriptional processes prior to mRNA formation, and especially the translational steps involved, have only been described to a minor degree for enzymes, proteins and other factors involved in adaptive responses to exercise. The messengers and signal transduction pathways involved in exercise are complex. Changes in intracellular Ca2+ concentration activate or repress signaling pathways for a variety of cellular responses. Changes in energy charges or phosphorylation potential may initiate changes in gene expression, and — though less well investigated — the redox state may also prove important in this process. Mechanical stretch is well known to cause a hypertrophic response in cardiac muscle, mediated via autocrine and paracrine effects of peptide hormones. In myotubes stretch is found to change Na+/K+-ATPase
DNA Transcription RNA processing
mRNA
Degradation
RNA stability
Translation Protein processing, transport, stability
PROTEIN
Degradation
Fig. .. Schematic representation of protein synthesis to illustrate events occurring in skeletal muscle and steps at which gene expression can be controlled.
Skeletal Muscle and phospholipase activity and activate growth factors, but MHC slow isoforms have also been shown to be induced by stretching. During force development under isometric conditions, the maximal force is dependent upon the sarcomere length, so that optimal force is achieved when optimal contact and thus overlap between actin and myosin is reached (length–tension relationship) []. In addition, a relationship between magnitude of force and contraction speed exists (force–velocity relationship) (Fig. ..). When the muscle is activated to overcome a resistance smaller that its maximal tetanic force, the muscle will shorten under the occurrence of a concentric contraction. The relationship between force and velocity follows a steep rectangular hyperbolic curve, indicat-
% of maximal force
(a)
100
Plateau
75 Descending limb
50 25 1.0
Ascending
1.5
2.0 2.5 3.0 Sarcomere length (mm)
3.5
(b) % of maximal isometric force
200 160
Lengthening
120 80
Shortening
40 0 –0.8
ing that force decreases markedly with increasing velocity []. This is related to the force by which cross-bridges between actin and myosin can be coupled and uncoupled. The higher the velocity in a contraction, the more myosin heads are in a state in which they are not tightly bound to actin, and thus cannot contribute to the development of large muscle force. The speed in which a certain force can be developed is trainable, and this may have great importance in rehabilitation and in patients with reduced muscle force, since it is not only the maximal force that an individual can produce which is crucial, but also the speed at which a certain force can be achieved. The higher the contraction speed, the more myosin heads will not reach an actin and thus will not develop the required force. Muscle contractions that result in shortening of the muscle are concentric, whereas contractions of muscle accompanied by lengthening are eccentric in nature. The magnitude of external resistance to movement vs. the development of torque produced by a muscle will determine whether there is a change in velocity during the movement and thus whether there is going to be a positive acceleration (speed increase) or a negative acceleration (deceleration or braking of the movement) independently of whether the contraction is concentric or eccentric. Interestingly, it can be debated whether isometric muscle contraction in fact is in accordance with the definition that no change in muscle length has occurred. As isometric or static contraction is normally defined by lack of change in external movement (e.g. over a joint), the fact that connective tissue of tendons is elastic will allow for a shortening of the muscle, and thus a concentric contraction, in the absence of any detectable external movement. Eccentric exercise is not only an important part of normal locomotion, but attracts special attention as this work mode results in the most dramatic changes in muscle with regard to factors such as absorption of power, both in relation to training and with injury.
Fiber types –0.4 0.0 0.4 Relative shortening velocity
0.8
Fig. .. Relationship between (a) sarcomere length and contraction force and (b) force–velocity relationship during different types of muscular contractions.
Within the individual motor units muscle fibers with specific characteristics exist with regard to contractile, histochemical and metabolic activity. Furthermore, muscle fibers from a given motor unit are known to be located over a relatively large area of the cross-
Chapter . sectional area of the muscle (up to %), indicating that within a given small muscle region all fibers represented in the muscle will be present. Two main categories of motor unit exist, one of which possesses a relatively slow timewise development of maximal force (slow twitch) and the other a fast development of maximal force (fast twitch) [a, ,] (Fig. ..). With the use of histochemical characterization of skeletal musculature, determining myofibrillar ATPase activity and incubating at varying pH levels, three main fiber types were originally described: type I, type IIa and type IIb (now known to be identical to myosin heavy chain classification IIx, which will be used in the rest of this chapter). These are distinctly different from each other with regard to contractility, morphology and metabolic characteristics. Type I fibers are slow contracting, are more red in appearance, and are well equipped for oxidative metabolism, with regard to both enzyme and substrate content. In contrast type II fibers are fast contracting and more white in colour and contain more glycolytic enzymes and fewer oxidative enzymes than type I fibers [–]. Motor unit type FF Histochemical profile FG
More recent techniques have allowed refinement of our characterization of muscle fibers and determination of the myosin heavy chain (MHC) isoforms has allowed the demonstration of type I b-slow, type IIa and type IIx as well as several muscle fibers coexpressing two or all three of these isoforms []. The MHCIIb isoform has been demonstrated in species other than humans, and for practical purposes the MHC type IIx is equivalent to the ATPase-stained type IIb fiber (Fig. ..). During physical activity, activation of the different muscle fibers is known to depend on the intensity and duration of the work. Intense short-lasting activities involve mainly the type IIx fibers, whereas lowintensity prolonged exercise primarily activates type I fibers and type II fibers are first involved at a later time point when type I fibers have depleted their carbohydrate stores. The distribution of fiber types varies between individual muscles in both the upper and lower extremities, and some muscles are dominated by slowtwitch type I fibers (e.g. the soleus) whereas others possess up to % fast-twitch type II fibers (e.g. the
FR
S
FOG
SO
la afferents
IA EPSP Motoneuron
AcATPase
Ox
50
gm
40 30 Twitch response
20 10 0 0 100% 0 0
100ms Fatigue curves 2
4
6
0 100% 0 0
100ms
2
4
6 60
Time (min)
0 100% 0 0
100
2
4
200ms
6 60
Fig. .. Three types of muscle fibers representative of separate motor units in the cat. The different motor units are characterized by recruitment pattern, metabolism, twitch characteristics and fatiguability. FF, fast-fatiguable; FR, fast-resistible; S, slow, FG, fastglycolytic; FOG, fast-oxidativeglycolytic; SO, slow-oxidative.
Skeletal Muscle
Table .. Contraction speed (in sarcomere length units per second) of single fibers from human muscle with varying degrees of slow vs. fast fibers (Harridge, personal communication).
I/IIa IIa/IIx IIa
I
MHC
Histochemistry
I
20
IIa
40
60
IIx
IIb
80
100
Type I Type I/IIa Type IIa Type IIa/IIx Type IIx
Soleus
Vastus lateralis
Triceps brachii
0.27 – 1.25 – –
0.29 0.67 1.10 1.83 2.24
0.27 0.64 1.20 1.73 2.31
% Fig. .. Comparison of the fiber type composition in sedentary individuals determined by single-fiber analysis of myosin heavy chain (MHC) composition and myofibrillar ATPase histochemistry in biceps brachii muscle.
triceps brachii). Within a single muscle the relative distribution of the fiber types can vary, but probably not by more than –% between regions. The interindividual variation in muscle fiber type distribution is primarily genetically determined, and studies of monoand dizygotic twins have shown a close to similar fiber type distribution in monozygotic (r2 around .), but not in dizygotic twins. Furthermore, a certain fiber type (e.g. type I) from human musculature displays similar contractile patterns independent of the anatomic position (Table ..). This indicates that the characteristics of a human muscle are dependent on the relative contribution of the different fiber types rather than on variations in characteristics within a certain muscle fiber type. Although this thight correlation exists for isolated muscle fibers it cannot be extrapolated to whole muscle. However, use of the muscle plays a major role. It has been shown that the specific tension of the muscle fiber is reduced after, say, days of bedrest. Surprisingly, a reduction in specific tension has also been demonstrated after monotonous use of the muscle at a low intensity, as occurs in extreme endurance training.
Muscle fiber plasticity The plasticity of muscle can in general be classified according to the ability to change either (i) the quantity (i.e. hypertrophy) or (ii) the type of protein (i.e. isoform or phenotype) of the different cellular compo-
nents of the muscle cell. The muscle cell may respond to loading by increasing the cross-sectional area with no change in the proportion of the different muscle proteins and their expression, and will in this case increase its maximal force but maintain its other inherent functional properties such as contractile speed or endurance []. If on the other hand the training results in altered expression in the type of protein (e.g. altered expression of MHC isoforms of the myofibrils) the muscle may also change its intrinsic contractile properties. In real life, responses to training may often be a combination of a change in the amount of protein and the type of protein isoform it expresses. A change in isoforms of proteins means in this situation a slight variation in the amino acid composition, whereby structure, function or enzymatic properties are influenced [,,]. To allow for muscle plasticity to occur, both the protein turnover and the protein synthesis rate have to be taken into account, and the protein half-life will be the important determinant of the time needed to achieve an alteration in muscle plasticity. Whereas some proteins have a relatively long half-life and therefore turnover time, others have a short half-life and thus allow a more rapid adaptation in response to training (e.g. days for glycolytic enzymes). Evidently, a rapid adaptation requires not only a short half-life for the protein but also a high protein synthesis rate in order to allow for synthesis to match or even surpass protein degradation. Furthermore, the time frame for muscle adaptation to training will be fully dependent on the different steps of gene expression, and pretranslational, translational and post-translational regulation often occurs at different time intervals dependent
Chapter . Table .. Muscle fiber characteristics into functional units (based on myosin heavy chain isoforms). Properties
I
IIa
IIx
Myofibrillar ATPase SR Ca2+-ATPase Glycolytic enzymes ATP buffering enzymes High-energy phosphate levels Oxidative enzymes Blood flow Fatiguability Contractile speed
Low Low Moderately high Moderately high High High High Low Slow
Moderately high Moderately high Moderately high Moderately high High High High Moderate Moderately fast
High High High Moderately high Very high Moderately high Moderately high Moderate Fast
on the stimulus and the protein involved (Table ..). The mechanisms behind mechanical loading resulting in altered gene expression and thus altered protein content are not clear. Several potential messengers generated within contracting skeletal myofibers are illustrated in Table ... The acetylcholine released from the motor nerve binding to its receptor, and the subsequent release of Ca2+ from the SR and resulting myofiber contraction can either itself or by generating other intracellular messengers activate signals for altered gene expression in response to mechanical loading. These additional messengers can either be linked to receptor-linked pathways or stretch-dependent pathways, or be a part of the metabolic changes associated with the contraction. What has been shown so far is that resistance training decreases the Ca2+ concentration needed to elicit % of maximal tension, decreases MHC IIx gene expression, and increases contractile proteins in parallel, all of which together allows greater absolute workloads to be moved [,]. Furthermore, serum response element of the skeletal a-actin promoter has been identified as part of the mechanotransduction pathway involved in enhancing actin gene transcription, which results in muscle enlargement (Table ..). Endurance training, on the other hand, increases and decreases the maximal shortening velocity of individual slow and fast fibers, respectively, both changes contributing to improved endurance performance. Expression of several genes is increased with training, and a complex interaction with and between modulators such as nerves,
cytokines, autocrine/paracrine substances, hormones, temperature, circulatory changes and fluid shifts within muscle takes place and is far from understood in relation to training of skeletal muscle [,]. With the use of immunohistochemical and molecular biological techniques for determination of MHC isoforms and thus characterization of fiber types, it has been demonstrated that endurance training can cause a fiber type shift from type IIx to IIa. Although animal studies using long-term low-frequency electrical stimulation of muscle have been able to demonstrate a fiber type shift from II to I, it is more questionable to what degree such a shift can occur in human skeletal musculature in relation to training. It is most likely that such a transformation can occur in humans, as is indicated by findings from long-term electrical stimulation of paralyzed muscle and observations on translocated muscle used for cardiomyoplasty, but obviously extremely long-term loading is required. Thus, it must still be concluded that a high relative content of type I fibers in an endurance athlete is due to genetic rather than training-induced factors. Termination of training or inactivity rapidly reverses the described training-induced changes in skeletal muscle. Loss of enzymes occurs most rapidly, followed by loss in muscle mass and finally a shift in muscle fiber type towards IIx. At extreme degrees of long-term inactivation (e.g. in spinal cord patients) a complete fiber type shift occurs from type I and IIa to type IIx. Inactivity leads to a loss in muscle mass initially due to both increased degradation and decreased synthesis of myofibrillar protein, followed by a period dominated by increased degradation, and only after days of
Skeletal Muscle inactivity is a new and lower steady-state level for protein turnover reached. The degree of muscle atrophy with inactivity depends upon the relative reduction in activity []. Thus, antigravity muscles undergo a more pronounced degree of atrophy than other muscles. If muscle is rehabilitated after inactivity the morphology and characteristics of the muscle can be restored relatively fast in comparison with other structures like tendon and bone []. Endurance training markedly improves oxidative mitochondrial enzyme content and activity, which is important for both fatty acid oxidation, the TCA cycle and the respiratory chain. Values for oxidative enzyme content of – times normal as well as reticulumformed mitochondria can be obtained in elite endurance athletes [,–]. Whereas maximal training effects of type I fibers can be obtained with low and moderate workloads, a somewhat higher training intensity is required to obtain training adaptation of type II fibers (e.g. interval training). Whereas oxidative enzyme level can alter with training independent of fiber type specific myofibrillar isoforms, the fiber type composition in the individual muscle is of major importance for the content of glycolytic enzymes. The time course for adaptation of metabolic enzymes is shorter than for phenotypic changes of skeletal muscle [,]. Physical loading of muscle can be achieved either by passive stretching or by development of voluntary or electrically induced muscle force. Depending upon which loading the muscle is subjected to, an adaptation will occur in the form of either increased muscle mass, increased metabolic capacity or alteration in fiber types. In order to differentiate between different types of training they are mainly categorized into either endurance (low resistance, many repetitions) or resistance (high load, few repetitions) training or combinations of the two, which is typically what is seen within different sports events. Changes in muscle force are in general achieved with workloads that exceed –% of the maximal strength expressed either as maximal voluntary contraction (MVC) in isometric exercise or the performance of one maximal bout of dynamic contraction ( RM = repetition of maximum). In addition, the determination of maximal force developed at a certain angle-speed is used during isokinetic exercise. Although this latter form of contraction does not
fully reproduce the force produced during normal movements, it often correlates with maximal movement performed during functional activities and sports. The connection between the number of repetitions (in dynamic work) or holding time (in static work) and the relative workload varies extensively from muscle to muscle dependent upon the fiber type composition, in that a larger number of type I fibers will shift the curve to the right. For more practical reasons the curve can be used to conclude that a resistance that can be performed dynamically – times before fatigue develops or a static resistance that can be maintained for less than a minute corresponds to around % relative workload. Whereas changes in the nervous activation of the musculature can improve the performance of the muscle, changes in the muscle tissue force are primarily due to a muscle fiberhypertrophy. Although occasional reports have suggested that strength training can cause hyperplasia, the increase in muscle force is due to an increased muscle cross-sectional area (Fig. ..). In addition to this it has to be acknowledged that determination of anatomical cross-sectional area in many muscles may underestimate the increase in physiologic cross-sectional area due to the altered pennation angle of the muscle fibers after a training period (see Chapter . for details). Furthermore, it has been demonstrated that contractile proteins (e.g. myosin light chains) may also alter composition and thus contribute to the fact that training can result in increased contractility force of single muscle fibers in excess of what can be explained by fiberhypertrophy. By determination of maximal muscle force and electromyography the relative contribution in general of fiber hypertrophy and increased neural activation of the muscle can be determined. This principle is used for estimation of maximal contraction force in patients who cannot develop maximal voluntary force due to fatigue or pain. Short-lasting electrical contractions (twitches) on top of voluntary activation can be used for estimation of the true maximal muscle force in an individual. By stimulation at different degrees of voluntary contraction it is possible to estimate the maximal muscle strength, and, for example in elderly individuals, a marked portion of the interindividual variability in maximal voluntary strength can in fact be ascribed to variation in ability to contract the muscle voluntarily.
Chapter . (a) Progress Most training studies
Most serious strength trainers
(Steroids)
Strength
Neural adaptation Hypertrophy
Activation
Time
(b) Neural factors A IEMG
At the onset of strength training, the dominant factor in strength improvement is an increased neural activation, which causes activation of more motor units and thereby recruitment of more muscle fibers. In addition to this, a more synchronized recruitment of motor units occurs. The neural improvement with training is most pronounced in the first – weeks of a training period, and interestingly, this effect is evident also in the contralateral extremity, whereas no crossover effect is observed with regard to structural muscle tissue adaptation []. Muscle fiber hypertrophy is first evident and measurable after – weeks, but data indicate that rates of transcription and formation of contractile proteins begin increasing within days into a training period. Muscle strength can be improved markedly over a short period of time (around % per day within the first – weeks). With static training the development of maximal force seems to play a more important role than the number of repetitions for the training effect achieved. Similarly, in dynamic exercise the most pronounced effects are evident with resistance training programs containing six or fewer repetitions per training series prior to fatigue (Table ..). These findings obviously have to be matched to the initial capacity of the individual prior to training, and thus the realistic possibilities of carrying out high-intensity training. Interestingly, muscle strength training can be carried out even at an advanced age, and it is quantitative rather than qualitative differences that are characteristic of the training responses seen in elderly as compared to young individuals. In general it is believed that the cross-sectional area of type I muscles can improve ~% with training whereas type II fibers enlarge by % of their initial area. More and more evidence points towards the satellite cells being involved in providing genetic material for myofibrillar protein formation and thus the development of hypertrophy. If training is carried out with low resistance but with a high number of repetitions, no marked strength improvement will be found, whereas muscle endurance will be improved markedly. Muscle strength training decreases mitochondrial and capillary density in the muscle due to a marked increase in the amount of contractile proteins. Furthermore, whereas strength training will not influence concentrations of glycolytic
Hypertrophy B
No change in activation
Increased
Force
Force
Before training After training Fig. .. (a) Response of muscle force to intensive training. (b) The difference in neural improvement or muscle hypertrophy.
enzymes and only slightly increases the amount of enzymes catalysing energy-rich phosphate compounds, muscle endurance training will markedly increase the capillary density, the number of mitochondria and the amount of glycolytic enzymes. The training effects are specific, and depend on the type of training program, and the transfer value is limited. This concept is important in rehabilitation, where movement patterns and contraction types should be tailored specifically to the functional aim.
Skeletal Muscle
Table .. Improvements in performance following weeks of dynamic or isometric training in humans. Muscle endurance training (% improvement) Testing Static (60%, 5 s, 10–150/day, 35 days)
Dynamic (60%, 10–150/day, 35 days)
Static force Static endurance Dynamic force Dynamic endurance
0 0 29 630–5040
4–11 84–122 2–6 41–92
Strength training (% improvement) Type of training Program
Static force
Dynamic force
Static Dynamic
100%, 5 s,¥ 20, 45 days 50–80%, 6 ¥ 10, 30 days
35 0
0 370
Skeletal muscle injuries can be divided into two basic types. In a less severe in situ necrosis type of injury only the myofibers are damaged, whereas the basal lamina and the mysial sheaths are not breached. In its mildest form such an injury occurs in eccentric exercise and more extensive in situ necrosis can be caused for example by ischemia as seen in compartment syndrome or after injection of local anesthetic (e.g. bupivacaine). Repair after in situ necrosis can be virtually complete. In a shearing type of injury not only are the myofibers breached but their connective tissue sheaths and intramuscular blood vessels are also torn to a variable extent. Healing after a shearing injury is complicated by the scar formation and complete restoration of the muscle is usually not possible [,]. Following muscle damage several proteins are released into serum. One of the most commonly used markers of muscle injury is creatine kinase (CK) which is generally detectable – days post injury and can remain elevated for – days after prolonged strenuous exercise. Most of the measured CK is caused by the muscle-specific isoenzyme CK-MM. Carbonic anhydrase III (CA-III) and myoglobin (Mb) are more specific to muscle than total CK is, and the profile differs. CA-III is present in type I fibers only and Mb peaks immediately after long-distance running, making them suitable for markers of acute events. It must be acknowledged that a large variability exists with regard to interindividual differences in responses of
100 Maximum tetanic tension (% control)
Injury and repair
80 60 40
Sham operated Lengthening Isometric Shortening
20 0 0
5
10
15
20
25
30
35
Time after stimulation (days) Fig. .. Decline in performance in the recovery phase after isometric, dynamic contraction and lengthening contraction.
these muscle damage markers, and that only an indicative relationship between degree of muscle damage and serum markers can be demonstrated. The exact mechanism behind the cascade of changes associated with eccentric exercise is not clear, but free oxygen radicals and inflammatory processes are suggested to play a role. Two major hypotheses have been proposed to explain damage to skeletal muscle associated especially with eccentric exercise. The first emphasizes metabolic overload, where the ATP demand surpasses the production, leading to a vicious cycle of Ca2+ overloading of the cell and further
Chapter . decrease in ATP production. Intracellular calcium activates phospholipase which in turn is involved in a subsequent breakdown of the cell membrane — explaining the fiber necrosis occurring days later — and causes an activation of the arachidonic acid cascade and the production of prostaglandins. The other hypothesis stresses mechanical factors as a cause of exercise-induced muscle damage, pointing out the relatively low metabolic cost but the high mechanical strain per muscle fiber during eccentric exercise. In support of the latter, mechanical disruption of the sarcolemma has been demonstrated immediately after exercise. It has been found that training of a specific muscle group diminishes the structural changes, strength reduction and clinical manifestations associated with eccentric exercise (Fig. ..). With regard to the cause of muscle injury in eccentric exercise, more recent data have suggested that the decline in force after eccentric contraction is related more to the magnitude of muscle strain than to the stress imposed upon the fibers. Putting this finding into perspective, it is likely that strain results in muscle fiber membrane disruption and subsequent proteolysis or conformational changes of the cytoskeletal network. A candidate could be the calcium-activated protease calpain which uses desmin as a substrate, and is activated by increased intracellular Ca2+ concentration. It can be hypothesized that muscle fiber strain increases calcium influx and intracellular Ca2+ via stretch-activated channels or disruption of t-tubuli or sarcoplasmic reticulum. In more extensive in situ necrosis type of injuries, as in the compartment syndrome, the myofibers become necrotized within their intact basal lamina over a variable length, in the most severe cases the entire length of the myofiber. Both the basal lamina and the connective tissue framework of different mysial sheath remain intact. The satellite cells are remarkably resistant to different types of injury, including ischemia, and they become activated after the insult has subsided and the regeneration process has been initiated. The basal lamina provides the scaffold within which the regeneration can proceed without major disturbing effects. The production of new myofiber to replace the necrotized part follows in general the same sequence as the formation of skeletal muscle during development (see above). The myoblasts fuse into myotubes which are also able to fuse with the surviving parts of the injured
myofiber and thereby restitution of the entire myofibers and bridging over the entire necrotized segment may occur [,,]. A shearing type of muscle injury may be caused by a strain, contusion, laceration or incision, in which myofibers together with their basal membrane, and their mysial sheaths are ruptured to a variable degree, and thus the functional continuity of the tendon– muscle–tendon complexes is disrupted. In these injuries the spontaneous contraction of the transected myofibers results in the formation of a gap between the stumps of the ruptured fibers, which forms the central zone (CZ) of the injury (Fig. ..). Due to the rich vascularization of skeletal muscle, hemorrhage from the torn vessels fills up the gap and this hematoma is later replaced by a connective tissue scar. The injury breaches the plasma membrane of the myofibers and thus exposes sarcoplasm to the extracellular space, initiating necrosis in the injured myofibers inside the preserved though ruptured original basal lamina. The extension of the necrosis along the ruptured myofiber must be halted to prevent destruction of the entire fiber. This is implemented by condensation of cytoskeletal material, which forms a so-called contraction band at a distance of approximately – mm from the rupture. This band acts as a barrier in the protection of which a demarcation membrane, i.e. a new plasma membrane, is formed and thereby the integrity of the myofiber, though divided into two parts, is restored. The necrotized part will be regenerated, i.e. it forms the regeneration zone (RZ) of the injury, which is delineated from the survival zone (SZ), where myofibers survive with certain reactive changes [,]. Blood-derived inflammatory cells gain immediate access to the injury site and substances released from the necrotized area serve as chemoattractants for further extravasation of inflammatory cells. Polymorphonuclear leukocytes of the acute phase are soon followed by monocytes, which are transformed into macrophages and begin to phagocytose the necrotic debris both in the RZ within the original basal lamina cylinders and in the CZ. The regeneration pattern after shearing muscle injury follows a remarkably uniform scheme. Satellite cells become activated by mitogenic factors derived from the necrotic tissue and by growth factors secreted
Skeletal Muscle
(1)
Rupture + necrosis + phagocytes
(2)
Proliferation of myoblasts
(3)
Late attachment to the scar Fig. .. Responses to a laceration trauma in rat muscle. See text for further explanation.
by macrophages. Experimental studies have suggested that sarcolemmal contact exerts a preventive effect upon satellite cell proliferation. This could explain why only the damaged parts of a fiber with injured sarcolemma respond with regeneration. On the other hand, it has been suggested that satellite cells from the surviving part are also recruited to the RZ. Several growth factors, including insulin-like growth factor I (IGF-I), transforming growth factor b (TGF-b) and basic fibroblast growth factor (bFGF), affect regeneration by either stimulation or inhibition of proliferation, and differentiation of satellite cells depending on the stage of regeneration. For example, bFGF response is coupled to plasma membrane wounding and occurs early in the regeneration, whereas IGF-
released from the satellite cell itself is thought to stimulate differentiation, which is followed by TGF-b-mediated inhibition of the differentiation process. However, it has to be acknowledged that most data on the involvement of growth factors in the regeneration process after muscle injury, derive from in vitro experiments, while results in humans are still almost non-existent. The activated satellite cells begin to proliferate at about h post injury within the preserved basal lamina in the RZ. The satellite cells differentiate into myoblasts. This is associated — in not only developing but also regenerating muscle — with expression of myogenic transcription factors of the myoD gene family (MyoD, myogenin, Myf, Myf), which determine
Chapter . the differentiation of the precursor cells along the myogenic lineage by inducing the production of muscle-specific proteins. Myoblasts fuse with each other into multinucleated myotubes. The regenerated muscle cells fill the original basal lamina cylinder of the RZ by approximately day , whereafter they extend out of the opening of this basal lamina into the connective tissue of CZ (see below). Proximally the myotubes fuse with the preserved myofibers of the SZ. The regenerating myofibers gradually acquire their mature form with bundles of myofilaments which become organized into regular sarcomeres thereby giving the myofiber its cross-striated appearance. Furthermore, myonuclei assume their normal subsarcolemmal localization [,]. The early phase of the regeneration process after shearing injury up until about day is almost identical to that seen after in situ necrosis, because it occurs within the basal lamina scaffold. Thereafter, the ends of the regenerating fibers need to enter the connective tissue scar of CZ. This creates a situation in which regeneration of the injured myofibers and formation of the connective scar tissue between the stumps are two simultaneous processes which are at the same time dependent upon but also at odds with each other. On the one hand, the scar is needed to keep the stumps together and it provides the connective tissue with which the ends of the regenerating myofibers can reestablish the firm myofiber to extracellular matrix (ECM) attachment. On the other hand, if the connective tissue scar formation between the stumps is excessive it may impede regeneration of myofibers and reinnervation of the so-called abjunctional stumps (see below). Within the first day after muscle injury the hematoma between the ruptured myofibers is invaded by inflammatory cells including phagocytes which begin disposal of the blood clot. Blood-derived fibrin and fibronectin cross link to form a primary matrix, which acts as a scaffold and anchorage site for the invading fibroblasts and gives the initial strength to the scar to withstand the forces applied on it. Fibroblasts begin to synthesize both proteins and proteoglycans of the ECM. Fibronectin, collagen type III and tenascin are among the first ECM proteins to be expressed, followed later by production of type I collagen which remains elevated for several weeks. Parallel to the
deposition of ECM proteins, the tensile strength of the scar increases. Biomechanical tests have shown that upon pulling, regenerating muscle ruptures at the scar between the stumps until day . Thereafter the scar is stronger than the muscle tissue and the rupture occurs within myofibers close to their ends, at the site where the rupture most often occurs also in healthy muscle. The ends of the regenerating fibers attempt to pierce through the scar tissue from day onwards and maintain a growth cone appearance until about day –. During this active growth period the regenerating fibers reinforce their integrin-mediated adhesion to the ECM (Fig. ..) on their lateral surfaces in both the intact (SZ) and the regenerating (RZ) parts of the myofibers. This lateral adhesion reduces movements of the stumps and the pull on the still fragile scar, and thus apparently reduces the risk of rerupture. Furthermore, lateral adhesion allows for the use of the injured muscle before complete healing has been achieved. Interestingly, reinforcement of lateral adhesion does not occur if muscle is immobilized after injury, indicating that signals of mechanical stress must be transduced from the surrounding ECM to induce this reinforcement. On the other hand, integrins appear to transduce signals of mechanical stress, which affect the synthesis of ECM proteins in the connective tissue cells, thereby regulating the composition of the surrounding ECM. It is likely that integrintransduced signals are essential also in regulating various cellular functions in regenerating myofibers. Thus, the increased expression of integrins is more important for enhanced signal transduction in the drastically altered mechanical stress situation in ruptured myofibers than for adhesion as such. These molecular findings support the importance of early mobilization during rehabilitation after muscle injuries. Around day new myotendinous junctions are formed at the end of regenerating myofibers with clustering of integrin- and dystrophin-associated molecules. Having re-established firm terminal adhesion, myofibers no longer require reinforced lateral adhesion, and integrin and vinculin on the lateral sarcolemma decrease whereas immunoreactivity for dystrophin-associated molecules increases. Thus, these two complexes of adhesion molecules seem to have complementary roles in myofiber–ECM
Skeletal Muscle adhesion. Gradually the imposed scar diminishes in size, bringing the stumps closer to each other, and finally myofibers become interlaced. However, full fusion of the stumps does not occur, as indicated from high levels of integrins, for up to months after the injury. Thus it appears that injuries resulting in the division of a muscle into two halves will result in persisting interposed scar tissue in the muscle. The volume of the interposed scar also appears to have significance for reinnervation, and the myogenically denervated abjunctional stumps are reinnervated by axons sprouting from nerves in the adjunctional stumps on the contralateral side of the scar. These thin axons are able to pierce through the scar and induce formation of new neuromuscular junctions on the abjunctional stumps. If the interposed scar is too dense or voluminous the sprouts may be unable to penetrate through it and the abjunctional stumps remain denervated, undergo neurogenic atrophy and are replaced by connective tissue. The processes occurring during regeneration are influenced by mobilization. As an example, adhesion protein complexes have been shown to respond after just a single bout of exercise with regard to transcription and mRNA formation, whereas the protein synthesis rate increases after repetitive exercise bouts only [,,]. Muscle ruptures due to a sports injury can also be complicated by rupture of intramuscular nerve branches, which leaves parts of the muscle denervated. Because in such an injury the nerve itself is damaged, the denervation and consequent atrophy of myofibers is neurogenic. In shearing injury parts of the ruptured myofibers may also become myogenically denervated. This occurs because each myofiber is innervated at a single neuromuscular junction located within the middle third of the myofiber, and the transection of the fiber often leaves the neuromuscular junction on one of the muscle fiber stumps. Finally, it has been shown that myoblasts grown in a non-moving culture system proliferated with random orientation, whereas cells which were cyclically lengthened and shortened became aligned and synthesized more protein []. This indicates that mechanical stress or at least strain has a pronounced effect on the myoblast maturation process, and demonstrates the importance of lengthening–shortening activity in rehabilitation after injury.
Summary Skeletal muscle represents a unique tissue with multinuclear cells and a variety of proteins responsible for mechanical function and energy supply, allowing stability and active movement. Muscle possesses an enormous ability to adapt to various types of mechanical loading and training. Increased loading results in enhanced protein turnover and in a higher net synthesis of both myofibrillar and mitochondrial components, and hypertrophy of the individual muscle cell occurs. Furthermore, muscle fiber types can alter with mechanical loading, favoring a more oxidative fiber type. Conversely, inactivity causes rapid loss of muscle tissue and oxidative capacity in a reversible fashion. Muscle fibers depend on cytoskeletal and extracellular matrix proteins present within and around muscle fibers in order to optimally transmit force, and overloading can result in both cytoskeletal damage and muscle cell rupture damage. Satellite cells play an important role in regeneration of muscle tissue, under the influence of mechanical stretching and active loading. Complex cellular and molecular regulation lies behind the response of muscle proteins to changes in contractile activity, and responses are modulated by factors as nerves, growth factors, hormones, temperature, circulation and fluid shifts. Such signaling pathways are just beginning to be identified.
Multiple choice questions Prolonged endurance training results in increased oxidative capacity of the muscle and in: a a fiber type shift from type I to type II b no shift at all c a fiber type shift from type IIb/IIx to type IIa d a fiber type shift from type II to type I. The primary function of the satellite cells involves: a synthesis of oxidative enzymes b connection of motor nerves to the sarcolemma c acting as a reservoir for formation of myoblasts and myofibrillar structure in injury and supplying genetic material for myofibrillar protein formation in strength training d formation of extracellular matrix proteins. Tropomyosin is important for: a enabling motoneuron excitation b blocking of calcium uptake by the mitochondria
Chapter . c inhibition of actin and myosin interaction d stimulation of cross-bridge shortening. Resistance training results in the following adaptation(s) in skeletal muscle: a hyperplasia and hypertrophy b increased levels of oxidative enzymes and hypertrophy c hypertrophy d fiber type I formation and hypertrophy.
References Lieber RL, Leonard ME, Brown-Maupin CG. Effects of muscle contraction on the load-strain properties of frog aponeurosis and tendon. Cell Tissues Organs ; : –. Trestik CL, Lieber RL. Relationship between Achilles tendon mechanical properties and gastrocnemius muscle function. J Biomechan Eng ; : –. Saltin B, Gollnick PD. Skeletal muscle adaptability. significance for metabolism and performance. In: Peachey LD, ed. Handbook of Physiology. Bethesda: American Physiological Society, : –. Jansen JKS, Fladby T. The perinatal reorganization of the innervation of skeletal muscle in mammals. Prog Neurobiol ; : –. Bischoff R. Interaction between satellite cells and skeletal muscle fibers. Development ; : –. Milner-Brown HS, Stein RB, Yemm R. The contractile properties of human motor units during voluntary isometric contractions. J Physiol ; : –. Miller JB, Stockdale FE. Developmental origins of skeletal muscle fibers; clonal analysis of myogenic cell lineages based on expression of fast and slow myosin heavy chains. Proc Natl Acad Sci ; : –. Kirkwood SP, Munn EA, Brooks GA. Mitochondrial reticulum in limb skeletal muscle. Am J Physiol ; : C–C. Hultman E. Physiological role of muscle glycogen in man, with special reference to exercise. Circulation Res ; : –. Huxley AF, Niedergerke R. Structural changes in muscle during contraction. Interference microscopy of living muscle fibers. Nature ; : –. a Edgerton VR, Smith JL, Simpson DR. Muscle fibre type populations of human leg muscles. Histochem J ; : –. Huxley HE, Hanson J. Changes in the cross-striations of muscle during contraction and stretch, and their structural interpretation. Nature ; : –. a Eftimie E, Brenner HR, Buonanno A. Myogenin and MyoD join a family of skeletal muscle genes regulated by electrical activity. Proc Natl Acad Sci ; : –.
Dominguez R, Freyson Y, Trybus KM, Cohen C. Evidence that myosin neck bending is taking place during muscular contraction. Cell ; : –. Hill AV. The heat of shortening and the dynamic constants of muscle. Proc Royal Soc London ; : –. Friden J, Sjöström M, Ekblom B. Myofibrillar changes following intense eccentric exercise in man. Int J Sports Med ; : –. Kääriäinen M, Kääriäinen J, Järvinen TLN, Sievänen H, Kalimo H, Järvinen M. Correlation between biomechanical and structural changes during the regeneration after laceration injury of skeletal muscle. J Orth Res ; : – . Kääriäinen M, Kääriäinen J, Järvinen TLN, Nissinen L, Heino J, Järvinen M, Kalimo H. Integrin and dystrophin associated adhesion protein complexes during regeneration of shearing type muscle injury. Neuromusc Disord ; : –. McCully KK, Faulkner JA. Injury to skeletal muscle fibers of mice following lengthening contractions. J Appl Physiol ; : –. Gordon AM, Huxley AF, Julian FJ. The variation in isometric tension with sarcomere length in vertebrate muscle fibers. J Physiol ; : –. Katz B. The relation between force and speed in muscular contractions. J Physiol ; : –. Bodine SC, Roy RR, Eldred E, Edgerton VR. Maximal force as a function of anatomical features of motor units in the cat tibialis anterior. J Neurophysiol ; : –. Burke RE. Motor unit types of cat triceps surae muscle. J Physiol ; : –. Buchthal F, Schmalbruch H. Spectrum of contraction times of different fibre bundles in the brachial biceps and triceps muscle of man. Nature ; : –. Peter JB, Barnard RJ, Edgerton VR, Gillespie CA, Stempel KE. Metabolic profiles on three fiber types of skeletal muscle in guinea pigs and rabbits. Biochemistry ; : –. Thompson WJ, Sutton LA, Riley DA. Fibre type composition of single motor units during synapse elimination in neonatal rat soleus muscle. Nature ; : –. Schiaffino S, Gorza L, Sartore S, Saggin L, Ausoni S, Vianello M, Gundersen K, Lomö T. Three myosin heavy chains isoforms in type skeletal muscle fibres. J Musc Res Cell Motil ; : –. Chahine KG, Baracchini E, Goldman D. Coupling muscle electrical activity to gene expression via cAMP-dependent second messenger system. J Biol Chem ; : – . Baldwin KM, Klinkerfuss GH, Terjung RL, Mole PA, Holloszy JO. Respiratory capacity of white, red and intermediate muscle, adaptive response to exercise. Am J Physiol ; : –. Salmons S, Henriksson J. The adaptive response of skeletal muscle to increased use. Muscle Nerve ; : –.
Skeletal Muscle Booth FW, Baldwin KM. Muscle plasticity: energy demand and supply processes. In: Rowell LB, Shepherd JT, eds. Handbook of Physiology, Section . Oxford: American Physiological Society, : –. Williams RS, Neufer PD. Regulation of gene expression in skeletal muscle by contractile activity. In: Rowell LB, Shepherd JT, eds. Handbook of Physiology, Section . Oxford: American Physiological Society, : –. Williams P, Goldspink G. Change in sarcomere length and physiological properties in immobilized muscle. J Anat ; : –. Thomason DB, Herrick RE, Surdyka D, Baldwin KM. Time course of soleus muscle myosin expression during hindlimb suspension and recovery. J Appl Physiol ; : –. Gollnick PD, Armstrong R, Saubert C, Piehl K, Saltin B. Enzyme activity and fiber composition in skeletal muscle of untrained and trained men. J Appl Physiol ; : –. Gollnick PD, Armstrong RB, Saltin B, Saubert CW, Sembrowich WL, Shepherd RE. Effect of training on enzyme activity and fiber composition of human skeletal muscle. J Appl Physiol ; : –.
Henriksson J, Reitman J. Time course of changes in human skeletal muscle succinate dehydrogenase and cytochrome oxidase activities and maximal oxygen uptake with physical activity and inactivity. Acta Physiol Scand ; : –. Henriksson J. Training induced adaptation of skeletal muscle and metabolism during submaximal exercise. J Physiol ; : –. Moritani T, Devries HA. Neural factors versus hypertrophy in the time course of muscle strength gain. Am J Phys Med ; : –. Hurme T, Kalimo H, Sandberg M, Lehto M, Vuorio E. Localization of type I and III collagen and fibronectin production in injured gastrocnemius muscle. Lab Invest ; : –. Hurme T, Kalimo H. Adhesion in skeletal muscle during regeneration. Muscle Nerve ; : –. Henry MD, Campbell KP. A role for dystroglycan in basem*nt membrane assembly. Cell ; : –. Vandenburg HH. Dynamic mechanical orientation of skeletal myofibers in vitro. Dev Biol ; : –.
Chapter 1.4 Neuromuscular Aspects of Exercise — Adaptive Responses Evoked by Strength Training PER AAGAA RD & A LF THORSTE NSSON
Ikai M, Steinhaus AH. Some factors modifying the expression of human strength. J Appl Physiol ; : –. Heavy-resistance strength training generally results in both neural and muscular adaptations. Muscle hypertrophy was already recognized in the late s and has since then been extensively documented at wholemuscle, muscle-fiber and muscle subcellular levels. About the same time it was observed that substantial gains in muscle strength could occur without any detectable changes in the muscle itself, particularly in the early stages of the training regime. (Recent methodologic developments have, however, demonstrated early changes to occur in RNA translation and transcription.) The logical conclusion was that the improvements in strength had to be accounted for by neural adaptations. This assumption required there to be a margin, or force reserve, in the muscle that would not be accessible with a normal maximal voluntary effort due to neural inhibitory mechanisms. Another assumption would be that these mechanisms could be overcome, disinhibited, by adaptations in the nervous system occurring as a result of strength training. Ikai and Steinhaus reported one of the first convincing demonstrations of the existence of such a muscular reserve of force inherent to the muscle, and thus the presence of inhibitory mechanisms. They showed that the static strength of the arm flexor muscles could be substantially increased above that voluntarily achiev-
able ‘by a loud noise, by the subject’s own outcry, by certain pharmacologic agents, and by hypnosis’. In Fig. .. (original figure) the strength output during repeated maximal voluntary efforts, is shown with and without a preceding gunshot or shout. Similar effects on strength were seen with the other interventions. The authors conclude that all their observations ‘support the thesis that the expression of human strength is generally limited by psychologically induced inhibitions’ and that the interventions decreased these inhibitions. They also emphasize the large variation between subjects in response to the interventions. They particularly point out one subject who showed no increase in strength under hypnosis. This subject was an ‘experienced weight-lifter’ and the interpretaBlank Shot Shout Blank control
90 80 LBS
Classical reference
70 60
5
10
15
20
25
30
Time (min) Fig. .. Strength output, expressed in pounds (LBS), measured by Ikai & Steinhaus during repeated static contractions of the arm flexors [].
Neuromuscular Aspects of Exercise tion was that ‘he was able, probably because of long training, to approximate his physiological limit in the waking state’, thus suggesting a trainability of this neural phenomenon. The existence of a margin for improvement in strength by neural adaptations has since been convincingly demonstrated by other methods, such as electrical stimulation applied directly onto the muscle or to the nerve supplying it. By similar means, a smaller margin has been noted in trained athletes. In addition to the accumulation of indirect evidence for neural adaptations, particularly in the initial phase of a training program, more direct evidence for such adaptations has also emerged. Perhaps the most thoughtprovoking evidence has been obtained in experiments where the contractions have been only intended, and no activation of the muscles has actually occurred, as verified by electromyographic recordings[a]. Still, significant improvements in strength were seen (the hypothenar muscles of the hand were investigated) of a magnitude similar to that obtained with conventional ‘effortful’ contractions. The authors conclude: ‘These force gains appear to result from practice effects on central motor programming or planning’. Strength gains were also detected for the corresponding muscles of the opposite hand. Such transfer of training effects, presumably of neural origin, has been frequently documented in the literature. Obviously, these findings have interesting implications for rehabilitative training of unilateral neuromuscular injuries.
Introduction The assessment of maximal muscle strength For more than seven decades the contractile strength of human skeletal muscle in vivo has been evaluated by use of various types of dynamometers. Early mechanical devices allowed muscle contraction strength to be determined during isometric (static) contraction conditions. In addition, in vivo mechanical muscle performance was assessed in dynamic contractions using sophisticated flywheel methodology [,]. With the evolution of motor-driven dynamometers it became possible to obtain maximal muscle strength during concentric (shortening) and eccentric (lengthening) muscle contractions. Both isokinetic and non-
isokinetic dynamometers have been used to evaluate the dynamic strength properties of human muscle in vivo. While the isokinetic dynamometer is designed to keep joint angular velocity constant, non-isokinetic dynamometers allow acceleration and speed to vary freely throughout the movement. Non-isokinetic dynamometers have been used mainly to examine the strength capacity of the elbow flexors [,] and knee extensors [–]. These muscles have also been extensively investigated by use of isokinetic dynamometry [–] in addition to a large number of other human skeletal muscles [,]. The descriptive and clinical relevance of assessing maximal muscle strength by use of isokinetic dynamometry may not seem obvious at first hand. Even though the term ‘isokinetic’ denotes that joint angular velocity is kept constant (which may itself not always be true) [], this does not imply that any constancy should exist for the linear velocity of muscle shortening or lengthening. Furthermore, due to the variation in muscle lever arm length(s) throughout the range of joint movement, the recorded moment may not resemble the actual contractile force generated by the muscle []. In addition, neuromuscular activation may be reduced under certain loading conditions (e.g. eccentric contractions) and a coactivation of antagonist muscles can also occur. This applies to isokinetic dynamometry as well as to all other types of strength measurements. In result, inconsistent and conflicting moment– velocity relationships may be found in the literature with marked differences observed between studies and muscles examined [] as well as between subject groups of different training status []. Nevertheless, isokinetic dynamometry does appear useful for evaluating the expression of maximal voluntary muscle strength in vivo. Firstly, joint angular velocity and movement range can be reproduced with reasonable accuracy. In the experimental set-up this means that multiple trials can be performed and compared successively until reaching a given selection criterion. Secondly, the fact that joint movements are accurately reproduced ensures that the change in muscle strength induced by specific interventions (training, detraining) can be evaluated in a reliable way. Thus, it is important to recognize that a change in maximal isokinetic strength may be a valid indication of the underlying change in maximal muscle force, as for a given
Chapter . subject the relation between joint angular velocity and muscle contraction velocity or between the measured muscle moment and the underlying muscle force is not likely to change. Thirdly, and perhaps most importantly, modern isokinetic dynamometers allow for a standardized and well-controlled evaluation of maximal eccentric muscle strength. This aspect of in vivo muscle function deserves special attention as it not only appears to comprise unique mechanisms of neuromuscular activation and inhibition but also involves factors of importance for dynamic joint stability and stiffness. A hyperbolic relationship exists between the contractile force and velocity of shortening of isolated muscle in vitro [,] (Fig. ..). Similar hyperbolic force–velocity relationships may be observed during in vivo contraction of human skeletal muscle [,,]. However, force–velocity relations that were clearly non-hyperbolic have been reported as well [,,]. Beyond any doubt the quadriceps femoris has been most extensively used to investigate the maximal contractile strength (moment of force) generated by human skeletal muscle, in vivo. The appearance of isokinetic (i.e. constant velocity) dynamometers has allowed maximal dynamic muscle strength to be obtained during standardized and easily reproducible experimental conditions (see above). While some studies obtained the peak moment of force (‘torque’) exerted within the total range of movement [–] others have recorded the moment of force at a specific knee joint angle [,,] or performed both types
of measurements [,–]. Concentric isokinetic quadriceps peak moment occurs at gradually more extended knee joint positions with increasing joint angular velocity [,,]. Accordingly, the corresponding moment–velocity relationship consists of moment values obtained at different parts of the quadriceps length–tension curve. Nevertheless, the moment– velocity pattern based on angle-specific moment appears to deviate most markedly from a hyperbolic curvature at least when obtained in untrained subjects, as reflected by a levelling-off (‘plateauing’) of moment at low angular velocities [,,,,,,–] (see Fig. ..). A similar plateauing of moment of force during slow concentric contraction has been reported for other muscle groups than the quadriceps, e.g. the arm flexors [,]. Interestingly, maximal arm flexor and extensor moments plateaued in subjects of low maximal muscle strength, whereas no plateauing could be demonstrated in subjects of high strength [] suggesting that this phenomenon can be modulated by strength training. This plateauing in slow concentric muscle strength has previously been hypothesized to arise from a force inhibiting neural mechanism, reducing the level of neural efferent motor drive [,]. Maximal eccentric contraction strength is equal to or up to about % higher than maximal isometric strength when recorded in the human quadriceps muscle, in vivo [,,–]. In contrast, maximal eccentric contraction force is –% greater than
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Fig. .. Maximal concentric and eccentric quadriceps muscle strength obtained as isokinetic peak moment (triangles) and angle-specifc moment generated at ° knee joint angle (squares) before and after weeks of (a) heavy resisitance strength training; and (b) low-resistance, high-velocity strength training using concentric contraction alone. Closed and open symbols denote pre- and post-training values, respectively. Adapted from [].
isometric or slow concentric force when obtained in isolated muscle preparations [,] (see Fig. ..). Reduced levels of neuromuscular activation are one likely reason for this apparent deficit in maximal eccentric muscle strength, in vivo. Consistent findings of a marked increase in maximal eccentric muscle strength following heavy-resistance strength training strongly suggest this mechanism of suppressed neural activation to be modifiable with training.
Changes in maximal muscle strength in response to strength training The influence of strength training on the maximal contraction strength of human muscle in vivo has been extensively investigated for the concentric part of the moment–velocity curve [,,,,,,]. Also, data exist for the training-induced change in maximal eccentric muscle strength [,–]. Following concentric strength training, maximal muscle strength and power have been reported to increase at the specific velocity employed during training
[,,,,]. These and similar observations have been taken to indicate a specificity of training velocity and training load. However, it is questionable whether a generalized concept of training specificity should exist, since muscle strength has been reported to increase also at velocities lower than the actual velocity of training [,,,] as well as at higher velocity [,,]. The conflicting findings of specific as well as non-specific training adaptations probably arise, at least partly, due to a varying influence of learning []. While training and data collection have often been performed on the same dynamometer, other studies have emphasized the use of different training and measuring devices. The latter approach is intended to reduce the influence of learning, in order to obtain a more valid measure of the neuromuscular adaptations induced by strength training. The levelling-off (plateauing) in muscle strength observed during slow concentric contraction has been reported to disappear in response to heavy-resistance strength training [,] (see Fig. ..). These findings point to the existence of a neural force-inhibiting mechanism, which can be modulated by training. Interestingly, strength training using lower loads and higher speeds appears to have no effect [] (see Fig. ..), suggesting that heavy training loads should be employed when intending to remove this forceinhibiting mechanism. Marked increases in maximal eccentric muscle strength have been observed following heavyresistance strength training [,–,–]. Eccentric or coupled concentric–eccentric training seems to evoke greater strength gains than concentric training alone [,–,]. Importantly, maximal eccentric strength appears to remain unchanged after lowresistance strength training [,] (see Fig. ..). Thus, the exertion of very large muscle forces during training is probably a major prerequisite for any change in maximal eccentric muscle strength to take place.
Neuromuscular adaptations evoked by strength training The adaptive changes observed in the neuromuscular system in response to specific types of strength training may be differentiated into neural and muscular factors. Thus, it is well known that changes in contractile properties, i.e. increases in maximal contraction force
Chapter . and power as well as in the maximal rate of force development, can occur not only due to alterations in muscle morphology [] but also as a result of changes in the nervous system [,]. Neural adaptation mechanisms may involve changes in motoneuron recruitment and/or rate coding, more synchronized motoneuron firing patterns within the muscle itself as well as between muscle synergists, changes in spinal motoneuron excitability, and altered coactivation of antagonist muscles [–]. Early evidence, indicating neural mechanisms to play a significant role, was based on the findings that muscle strength increased more than could be accounted for by increases in muscle size alone [] and that strength gains were observed with no detectable muscle hypertrophy [,–]. More direct evidence has been provided with the use of electromyography (EMG), although inherent methodologic limitations may exist with the recording of surface EMG during voluntary muscle contraction. To overcome these problems, measurements of evoked spinal responses (H-reflex, V-wave) can be used to examine various aspects of neural adaptation evoked by strength training. In terms of muscle morphology, single muscle fiber area and whole-muscle area and volume have been demonstrated to increase following prolonged regimes of strength training []. In addition, based on the refinement of various in vivo muscle imaging techniques (MRI, ultrasonography), recent evidence suggests that muscle architecture in terms of muscle fiber pennation angle may also be altered, in turn contributing to the increase in physiologic muscle fiber area and contractile force generation with strength training []. The evaluation of muscle myosin heavy chain (MHC) content by use of electrophoretic analysis or immunochemical methods has provided a sensitive measure of the change in myosin isoform composition evoked by strength training. The emergence and evolvement of these methods have allowed an intensified focus on the change in muscle fiber composition induced by strength training and its impact on mechanical muscle performance. During static as well as dynamic contraction conditions, active muscle stiffness is determined by the total number of attached acto-myosin cross-bridges [] while also being strongly influenced by the pattern of neural activation []. Thus, the increase in muscle
size and/or neural innervation observed following strength training, in turn causing more cross-bridges to be attached during contraction, will have a strong positive effect on the ability to achieve high levels of muscle stiffness. In functional terms this effect would be beneficial over the whole movement spectrum, from athletes performing rapid and forceful movements to elderly individuals compensating for unexpected postural perturbations. The present chapter presents the involvement of various mechanisms and aspects of importance for the neuromuscular adaptation to strength training.
Adaptive changes in neural drive evaluated by electromyography EMG signal amplitude The electromyography (EMG) signal is constituted by the composite sum of all the muscle fiber action potentials present within the pick-up volume of the recording electrode(s). At the same time, this overall interference signal is modified by a multitude of intracellular and extracellular factors, which all exert a significant influence on the pattern of spatial and temporal summation of the single action potentials [,]. Acceptable test–retest reliability has been demonstrated for the EMG amplitude and power frequency obtained by use of surface electrodes []. Data based on intraclass correlation (ICC) analysis indicate that most of the variance in assessing reliability is among subjects rather than between days or trials []. For the human quadriceps femoris muscle, acceptable reproducibility was observed for the EMG recorded during static as well as dynamic contraction, including isokinetic knee extension [,,,]. Thus, with proper recording conditions and validated signal processing techniques, the surface electromyogram appears to be a useful tool for both clinical evaluation and research []. From a physiologic perspective the EMG signal can be seen as a complex combination of (i) motor unit recruitment, (ii) variation in firing frequency (rate coding), and (iii) synchronization between firing patterns of individual motoneurons []. EMG recording (Figs .. and ..) has been widely used to quantify the neural changes evoked by strength training. A majority of studies has demonstrated increased EMG
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signal amplitude after strength training, indicating a rise in the neural efferent drive to the muscle fibers [,,,,–,,,]. Importantly, neural drive has been found to increase not only in previously untrained subjects but also in highly trained strength athletes []. Thus, EMG increased when strength athletes used heavy training loads (above % of maximum), but decreased when training was performed at lower loads (–% of maximum) []. These findings suggest that heavy training loads should be used when seeking optimal neural enhancement. It is important to notice that the increase in surface EMG amplitude observed following strength training does not provide any conclusive evidence per se of the differential change in motoneuron recruitment, firing frequency or synchronization. In addition, it has not always been possible to demonstrate increases in EMG with strength training [–]. It should be recognized
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Fig. .. (a) Raw tracings of isokinetic knee joint moment and electromyography (EMG) signals obtained in an untrained male subject during maximal concentric (left) and eccentric (right) contraction of the quadriceps femoris muscle. (b) Maximal concentric and eccentric quadriceps muscle strength (left) and vastus lateralis EMG (right) measured in untrained male subjects and displayed as a function of knee joint angle and joint angular velocity. Negative and positive velocities denote eccentric and concentric muscle contraction, respectively [].
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therefore that electrode positions as well as skin and muscle tissue properties (i.e. subcutaneous fat layer, muscle fiber pennation angle, etc.) may vary from one recording session to another despite careful measuring procedures. Moreover, the compound surface EMG signal can constitute a summation of several thousand action potentials, causing a significant portion of the signal to be inherently stochastic []. Consequently, the sensitivity of the EMG signal as a measure of training effects depends highly on the EMG processing routines used, i.e. sampling rate, filtering algorithms, cut-off frequencies, etc. However, many of the problems inherent with surface EMG can be reduced or even eliminated by use of more sophisticated EMG techniques (recording of intramuscular EMG using indwelling needle or wire electrodes, H-reflex and Vwave measurements, evoked cortical potentials, etc.) as described elsewhere in this chapter.
Chapter . Motoneuron firing frequency
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Two basic questions can be raised: is motoneuron firing frequency influenced by strength training; and if that is the case, what is the functional significance? To address the latter question first, motor unit discharge rates have been recorded at much higher frequencies than needed to achieve full tetanic fusion in force. Thus, transient firing frequencies of – Hz were reported in brief bursts of activity during maximal voluntary contraction of human muscles in vivo [–]. Muscle innervation frequency influences not only the magnitude of contractile tension but also the rate of tension rise (i.e. rate of force development: RFD = Dforce/Dtime), as observed for whole muscle in situ [], single muscle fibers [,] and human muscle in vivo [–]. When individual motor units were examined in the neonatal rat [] it was noticed that RFD continued to increase at stimulation rates higher than the stimulation rate at which maximum tetanic tension was achieved [] (Fig...). Similar findings have been reported for whole-muscle preparations []. Corresponding results have been obtained for human musculature in vivo, as stimulation rates of Hz were able to produce greater RFD, but not a greater peak isometric force, than Hz stimulation rates []. Thus, the appearance of very high (i.e. supramaximal) firing frequencies likely serves to increase maximal RFD rather than increasing maximal contraction force per se [,] thereby causing a significant rise in contractile force in the initial phase of contraction (– ms). Importantly, at the onset of contraction the occurrence of discharge doublets in the firing pattern of single motoneurons (interspike interval < – ms, firing frequency >– Hz) cause a marked increase in contractile force and/or RFD [,,]. Thus, muscle force was markedly increased by addition of an extra discharge pulse (‘doublet’) as demonstrated during constant frequency stimulation of single motor units and whole isolated muscle [,] as well as in intact human muscle []. This phenomenon has been referred to as the catchlike property of skeletal muscle [–]. Interestingly, the occurrence of discharge doublets in the firing pattern of individual motor units was found to increase six-fold (from .% to .%) following ballistic resistance training [] (see Training for ‘explosive’ muscle strength, Fig. .. below).
Stimulation rate RG > PO
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Time (ms) Fig. .. Single force–time curves recorded in isolated motor units in the rat soleus muscle using an innervation frequency that elicited maximal tetanic fusion and maximal contraction force (PO) compared to when even greater (i.e. supramaximal) innervation frequencies were used (RG) which also elicited maximal tetanic fusion, however at an elevated rate of force development. Adapted from [].
The maximal firing frequency of human muscle in vivo has been examined by use of intramuscular EMG recording techniques, which allow the firing pattern of single motor units to be identified. Based on such techniques, the maximal firing frequency obtained in the rectus femoris muscle during maximal voluntary contraction (MVC) was % greater in trained elderly weight lifters compared to agematched untrained individuals []. Furthermore, using a longitudinal study design maximal firing frequency has been found to increase after strength training of selected hand muscles [] and leg muscles (vastus lateralis [], tibialis anterior []). Following weeks of ballistic-type resistance training Van Cutsem and coworkers reported a dramatic rise in the firing frequency of single motor units recorded in the tibialis muscle at the onset of maximal, forceful contraction. Mean firing frequencies of ., . and . Hz were observed in the first three interspike intervals, respectively, which increased to ., . and . Hz following the period of training [] (Fig. ..). Interestingly, training-induced increases in maximal motoneuron firing frequency appear to occur in both young and elderly individuals. Although elderly subjects initially demonstrated a lower maximal discharge rate than young subjects, no difference could be observed after strength training [,]. These data
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show that maximal motoneuron firing frequency can be increased in response to strength training, and that this adaptation may overrule the age-related decline in maximal discharge rate. As depicted from the S-shaped relationship between firing frequency and contraction force [], an increase in maximal firing frequency can result in a relatively greater increase in surface EMG amplitude compared to the corresponding increase in maximal contractile force []. In consequence, traininginduced increases in EMG may exceed the increase in maximal muscle strength [,], although this is not always a consistent finding [,]. Obviously, such disproportionate changes in EMG and force with training do not provide any conclusive evidence for an increase in motoneuron firing frequency, as similar effects would be caused by more synchronized patterns of motoneuron firing (see below).
Motoneuron synchronization Synchronization in the firing patterns of different motoneurons has been examined by use of EMG crosscorrelation analysis techniques, to quantify the degree of temporal association between the discharge signals []. Based on such techniques, studies have shown
that the synchronization of motoneuron firing can be altered by learning [], which suggests that changes in synchronization may also occur as an adaptive response to strength training. Even though an increased incidence of synchronization between the firing patterns of different motor units within the muscle may occur with strength training [], the advantage of such intramuscular synchronization, if any, remains unsolved []. Studies using artificial nerve stimulation have shown that at submaximal contraction intensity, muscle force is greater with asynchronous than synchronous stimulation [,]. In addition, RFD in brief maximal contractions was higher during voluntary (i.e. asynchronous) contractions as compared to evoked tetanic (i.e. synchronous) contractions []. However, synchronous stimulation may not adequately mimic in vivo muscle contraction, where the occurrence of discharge doublets at the onset of contraction may yield a marked increase in RFD (see above). Milner-Brown and coworkers [] found that the discharge patterns of single motor units were more synchronized to the overall interference signal recorded by surface EMG following weeks of strength training. As derived from single motor unit recording, observations of more synchronized firing patterns in weight lifters compared to skill-trained and untrained individuals [] support the notion that motor unit synchronization can be altered by strength training. Moreover, a longitudinal increase in synchronization between synergistic muscle pairs has been observed following ballistic strength training [], suggesting that intermuscular synchronization may also change as an adaptive response to strength training. An increase in motor unit synchronization induced by training is likely to result in a disproportionate increase in EMG amplitude, due to increased superposition of action potentials whose amplitudes are in phase and reduced summation of out-of-phase action potentials. Consequently, the peak-to-peak amplitude of the compound EMG signal is increased along with a decrease in median power frequency (MPF) [,a].
Motoneuron properties, evoked reflex responses Only a few studies have employed measurements of evoked spinal motoneuron responses to examine
Chapter . STIM SPINAL CORD Sensory 1a Muscle spindle Presynaptic Motor INHIBITION a MUSCLE Postsynaptic H
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spinal and supraspinal mechanisms of importance for the training-induced change in maximal muscle strength. The Hoffmann (H) reflex [,] may be useful for the assessment of motoneuron excitability in vivo, although also reflecting the degree of presynaptic inhibition present for the Ia afferent synapses [,]. When the peripheral nerve is electrically stimulated, the H-reflex amplitude is seen to increase and then gradually decrease with rise in stimulation intensity, to become completely suppressed at stimulation intensities, which elicit a maximal M-response (Fig. ..). This suppression in H-reflex amplitude at maximum stimulation intensity occurs due to an increased collision between (i) antidromic nerve impulses in the motor axon (i.e. action potentials propagating backwards towards the spinal cord) and (ii) ortodromic nerve impulses caused by the Ia afferent reflex volley (i.e. action potentials propagating from the spinal cord to the muscle fibers). When the peripheral nerve is maximally stimulated during ongoing voluntary muscle contraction, the H-reflex response reappears (now denoted a V-wave) since the antidromic impulses are removed (‘cleared’) as a result of collision with efferent nerve impulses generated by the voluntary effort [,] (Fig. ..a). Thus, an increased descending motor drive causes more motoneuron axons to be cleared for passage of the evoked reflex response, which is directly reflected by an increase in V-wave amplitude []. At the same time, any increase in spinal motoneuron excitability and/or enhanced Ia synaptic
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Fig. .. (a) Raw EMG signal (sampling frequency kHz) showing maximal M-wave and V-wave responses evoked in the soleus muscle by supramaximal stimulation of the tibial nerve during maximal isometric muscle contraction. (b) Mean V-wave and H-reflex amplitudes, obtained pre- and post- weeks of heavy-resistance strength training. The increases observed in Vwave and H-reflex amplitudes suggest an enhanced descending motor drive and/or increased excitability of spinal motoneurons and/or decreased Ia afferent presynaptic inhibition following the period of strength training [].
Neuromuscular Aspects of Exercise transmission efficiency would contribute to the increase in V-wave amplitude as well. Thus, V-wave and H-reflex measurements may be used to quantify the overall change in central descending motor drive, spinal motoneuron excitability and/or presynaptic inhibition induced by strength training [,–, ]. It is noticeable that the potential problem of invariant recording conditions with repeated measurements of surface EMG is eliminated with this particular type of evoked EMG recording, as the H-reflex and V-wave amplitude are both expressed relative to the peak-to-peak amplitude of the maximal Mresponse (Mmax) recorded during supramaximal stimulation of the motor nerve. Somewhat surprisingly, the H-reflex amplitude recorded in the soleus muscle during resting conditions (determined as Hmax/Mmax) was higher in endurance athletes than in power and sprint athletes [,a,b]. However, it could not be excluded that this finding occurred as a result of differences in muscle fiber composition between the two subject groups, since at low stimulation intensities the Ia afferent volley mainly excites the smaller motoneurons in the spinal cord which typically innervate the population of slow-twitch type I muscle fibers. In addition, it may be difficult to interpret differences in Hmax/Mmax between subject groups unless the shape of the H–M recruitment curve is identical in the groups examined. Otherwise the H-reflex would be elicited at different relative stimulation intensities, thereby evoking different amounts of antidromic clearing which would cause the H-reflex amplitude to differ. Although more time consuming, the H-reflex can alternatively be recorded using a stimulation intensity that evokes an M-response of a fixed percentage of the maximal direct M-response (e.g. % Mmax) [,,]. Ballet dancers demonstrate lower H-reflex amplitudes in the soleus muscle than physical education students, presumably due to increased presynaptic inhibition in the dancers []. In contrast, Mynark and Koceja [] observed no difference in soleus Hreflex amplitude between trained dancers and controls during standing or prone rest. However, H-reflex gain (ratio of H-reflex to background EMG) was lower in the dancers during isometric contractions at , and % MVC performed in a standing position, suggesting that the gating of spinal excitatory and in-
hibitory pathways can be modulated to adapt to the contraction-related demands placed upon the system during standing posture []. As previously described, the V-wave can be evoked when supramaximal H-reflex stimulation is superimposed onto maximal voluntary muscle contraction. Due to the supramaximal level of nerve stimulation, which excites all Ia afferent axons in the peripheral nerve, the V-wave response comprises all the spinal motoneurons, including the largest type II motor units. V-wave amplitudes recorded in the hand and lower limb muscles of sprinters and weight lifters were elevated relative to untrained control subjects [,,]. Using a longitudinal study design an ~% increase in V-wave amplitude was observed (recorded as V1/Mmax) following – weeks of strength training [], indicating an enhanced neural drive in descending corticospinal pathways, elevated motoneuron excitability and/or alterations in presynaptic inhibition. Recent results have verified these findings, demonstrating a % increase in V-wave amplitude (V1/Mmax) in response to weeks of heavyresistance strength training [] (Fig. ..). Likewise, the H-reflex amplitude recorded during maximal contraction was found to increase after the period of training []. Interestingly, it appears difficult to elicit adaptive V-wave changes in certain hand muscles []. This finding suggests that the range of neural adaptation may differ between muscles involved in grasping tasks and muscles responsible for propulsive force generation, respectively. Collectively, the data based on measurement of evoked V-wave and H-reflex responses strongly support the notion that neural adaptation can occur both at spinal and supraspinal levels, involving increased motoneuron excitability (and/or changes in presynaptic Ia afferent inhibition) and enhanced central descending motor drive.
Eccentric muscle contraction It has been suggested that eccentric muscle contractions require unique activation strategies by the nervous system []. Indications of a preferential activation of high-threshold motor units have been demonstrated during eccentric muscle contraction of submaximal intensity [,], which was suggested to originate from an increased presynaptic inhibition
Chapter . of Ia afferents synapsing onto the low-threshold motoneurons [,]. Measurements based on the H-reflex technique (see above) have shown that the modulation of spinal motoneuron excitability and/or presynaptic inhibition may differ between eccentric and concentric contractions of submaximal intensity []. Unique and distinct motor patterns could also exist during maximal eccentric contraction. Thus, raw EMG tracings obtained in the quadriceps femoris muscle demonstrate large EMG spikes dispersed by short interspike periods of low or absent EMG activity (Fig. ..). However, EMG mean or median power frequency (MPF) does not seem to differ between maximal concentric and eccentric quadriceps contractions [,,]. More than anything, these contrasting findings probably reflect the insensitivity of surface EMG spectral analysis for detection of subtle changes in motoneuron recruitment. Thus, the possibility exists that even if type II motor units were selectively activated during eccentric contraction, the corresponding increase in MPF due to their high firing frequency could be masked by a relative increase in synchronization as the result of their large unit size (i.e. many muscle fibers being innervated by the same motoneuron) and the appearance of temporal ‘on–off ’ activation patterns, both causing MPF to decrease. In consequence, recording of muscle EMG by use of intramuscular wire or needle electrodes could perhaps clarify this point, as it may allow the recruitment and firing pattern of single motor units to be identified. However, even when employing intramuscular techniques, it is difficult to discriminate signals from individual motor units during contractions of high intensity. Another experimental approach has been taken by use of muscle biopsy sampling, which demonstrated a clear pattern of selective glycogen depletion for histochemically stained type IIb fibers obtained in the vastus lateralis muscle acutely following bouts of maximal eccentric cycle sprint []. Although this finding suggests the presence of selective type II muscle fiber recruitment, it could also, at least in part, be explained by a greater glycogen breakdown rate in the type II fibers compared to type I fibers. Electrical transcutaneous stimulation of passive vs. active muscles has also been used to address the issue of neural activation during eccentric muscle contraction. For the quadriceps femoris and triceps surae muscles
eccentric contraction strength was higher than isometric strength during contractions evoked by electrical stimulation, but not during maximal voluntary muscle contractions [,,,] (Fig. ..). Moreover, with artificial activation the normalized moment– velocity relationship of human muscle in situ appears to have a more similar shape to that of isolated muscle in vitro, during both eccentric and concentric contractions [,,] (Fig. ..). Quadriceps muscle strength is elevated during eccentric but not concentric contractions when electrical transcutaneous stimulation is superimposed onto maximal voluntary contractions [,] (see Fig. ..). Interestingly, this evoked increase in eccentric contraction strength is seen only in sedentary subjects and not in strengthtrained athletes [], suggesting that the apparent deficit in eccentric muscle strength disappears as an adaptive response to strength training. More direct evidence exists to suggest that neuromuscular activation is in fact suppressed during eccentric contraction, as the EMG recorded in the quadriceps femoris muscle during maximal eccentric contraction was markedly less than that of maximal concentric contraction, particularly at high speeds [,,,,–] (Fig. ..). Hence, a neural regulatory mechanism that limits the recruitment and/or discharge rate of motor units during maximal voluntary eccentric muscle contraction has been proposed [,,,]. The precise mechanisms responsible for such an inhibition in motoneuron activation during eccentric contraction are not known. Although evidence of a preferential recruitment of type II motor units and derecruitment of type I units has been reported for submaximal eccentric muscle contraction in vivo [,], this could not be verified for maximal eccentric contraction as examined by surface EMG spectral analysis (MPF) [,–]. Unfortunately, no data are available on the recruitment and firing pattern of single motor units during maximal eccentric contraction. Recent results suggest that the apparent suppression in motoneuron activation during maximal eccentric contraction may be partly or fully removed following intense regimes of heavy-resistance strength training []. Thus, maximal eccentric muscle strength was seen to increase in parallel with a partial (lateral and medial vastii) or complete (rectus femoris)
Neuromuscular Aspects of Exercise
Torque
1.25 0.75 0.25 Vastus medialis
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360
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90 45 45 90 Velocity (°/s)
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Fig. .. Maximal muscle strength (isokinetic moment of force) and EMG-velocity relationships determined during maximal voluntary eccentric and concentric contraction of the quadriceps femoris muscle. A significant suppression in quadriceps EMG was observed during slow concentric as well as in slow and fast eccentric contraction compared to fast concentric contraction. Data from [].
removal of suppressed EMG signal amplitudes following weeks of strength training, which involved multiple exercise types (squat and leg press and knee extension) using heavy external loads (– RM) [] (Fig. ..). On the other hand, quadriceps EMG remained suppressed during maximal eccentric contraction, with no signs of a partial removal, when strength training was performed using a single type of exercise (i.e. maximal isokinetic knee extension) for a moderate period of time ( weeks) []. Based on these findings, the possibility exists that the removal of neural inhibition during maximal eccentric muscle contraction requires heavy-resistance strength training
regimes of long duration and/or a large total work load (number of exercises · number of sets · kg or Nm lifted or exerted in each set). The finding of a rapid and selective decrease in eccentric but not concentric muscle strength following days of detraining in highly trained strength athletes [] further emphasizes the important effect of strength training not only for achieving but also for retaining optimal neural activation patterns during maximal eccentric muscle contraction. The specific mechanisms responsible for the adaptation in motoneuron activation during eccentric contraction are so far unidentified. During maximal voluntary muscle contraction afferent motor output is regulated not only via central descending pathways but also through sensory reflex pathways, including group Ib afferents from Golgi organs and group Ia and group II afferents from muscle spindles. Thus, the apparent suppression in motoneuron activation during maximal eccentric muscle contraction may be caused by inhibitory feedback from sensory group I and II afferents. Sensory Ib afferents from Golgi organs located in the muscle–tendon unit converge onto the entire motoneuron pool together with Ia and group II afferents from muscle spindles []. The Golgi Ib afferents excite inhibitory interneurons in the spinal cord, which in turn are influenced by higher central nervous system (CNS) centers through descending corticospinal pathways [,] (see Fig. .. below). It is possible that the removal of motoneuron inhibition, and the resulting increase in maximal eccentric muscle strength observed following heavy-resistance strength training, appears as a result of reduced inhibitory interneuron activity mediated via central descending pathways. Alternatively, reduced presynaptic inhibition of the Ia afferent inflow from muscle spindles would be expected to augment the excitatory spinal inflow during eccentric contraction as well. Significant increases in maximal eccentric muscle strength have been reported following heavyresistance strength training [,,–,–], whereas training using low resistance and faster speeds does not seem to have any effect [,] (Fig. ..). Generally, greater gains in eccentric strength have been observed following eccentric or coupled eccentric–concentric training as compared to concentric training [,–,] although not always a
Chapter . Maximal contractile muscle strength
(a)
Strength
After strength training
Quadriceps Moment of force
Before strength training
Eccentric Fast
Concentric Slow
Neuromuscular activation
(b)
Knee angular velocity
Fast
Slow
EMG
After strength training RF
Quadriceps EMG
VL, VM
Before strength training Eccentric Fast
Concentric Slow
Slow
Fast
consistent finding [,]. Also, it should be recognized that concentric heavy-resistance strength training might elicit substantial gains in maximal eccentric [,,,] and coupled eccentric–concentric [] muscle strength. Eccentric strength training may evoke specific adaptive changes in the nervous system. Thus, recordings of surface EMG have demonstrated neural activation to dominantly increase in eccentric contraction conditions following eccentric training, while neural activation during concentric contraction mainly increased following concentric training [–]. These findings of training-specific neural adaptations are not surprising, given the fact that all training and strength evaluation tests were carried out in the same dynamometer [–]. Nonetheless, neural activation during maximal eccentric contraction also increased when different test and training devices were used [] (Fig. ..). In addition, neural contralateral effects, so-called crosseducation [], may be more pronounced with eccentric training, as indicated by a greater relative increase in strength reported for the non-trained limb following eccentric compared to concentric single-limb training []. A similar trend was reported by Seger & Thorstensson [] who also found contraction type
Knee angular velocity
Fig. .. (a) Heavy resistance strength training has consistently been shown to result in a significant increase in maximal eccentric and slow concentric strength of the quadriceps femoris muscle (VL, VM, RF). (b) Following months of heavy resistance training the suppression of motoneuron activation was fully (RF) or partially (VL, VM) removed, in parallel with a marked increase in maximal eccentric muscle strength. Data from [].
and speed specificity in the transfer of strength gain from the trained to the contralateral, untrained, leg after both eccentric and concentric training.
Bilateral strength deficit Motoneuron activation and force generation may be significantly reduced in maximal bilateral compared to unilateral muscle contraction. Thus, less EMG and strength have been recorded from each limb during simultaneous contraction of the muscles in both limbs than measured during single limb contractions [–] although not present in all studies []. Interestingly, strength training involving bilateral muscle contractions appears to reduce or fully abolish the bilateral strength deficit []. Since the bilateral deficit in EMG and force can be observed in both maximal isometric and rapid dynamic contractions [], it has been suggested that the mechanism may act at higher centers involved in programming of the movement []. During volitional muscle contraction EEG potentials, defined as movement-related cortical potentials (MRCPs), generated by neural circuits involved in motor preparation and initiation can be obtained from the left (C) and right (C) motor cortex areas []. In
Neuromuscular Aspects of Exercise
0.15 EMG 0.075 (mV) 0 –500 Force 350 175 (N) 0 –500
Fig. .. Averaged movementrelated cortical potentials recorded from the left and right motor cortex area (C and C) and rectified EMG and isometric handgrip force obtained during maximal unilateral (UL) and bilateral (BL) contractions of right and left hand muscles in right-handed subjects. Data from [].
L C3 C4 0
250
Force 350 175 (N) 0 –500
maximal unilateral muscle contraction, MRCP amplitudes were significantly greater on the contralateral hemisphere [,] (Fig. ..). This contralateral asymmetry of large cortical MRCPs disappeared during maximal bilateral contractions, in which symmetric and MRCPs were observed at both hemispheres (Fig. ..). The bilateral deficit in force and EMG associated with reduced MRCPs suggests the involvement of an interhemispheric inhibition mediated by commissural nerve fibers in the corpus callosum []. Thus, the removal of the bilateral strength deficit, as observed following bilateral strength training, could be the result of adaptive changes in interhemispheric inhibition.
Antagonist muscle coactivation Coactivation of antagonist muscles is involved in many types of joint movements [,]. Antagonist muscle coactivation could be important for several reasons: to protect ligaments at the end-range of joint motion [,], to ensure a hom*ogeneous distribution of compression forces over the articular surfaces of the joint [], and to increase joint stiffness thereby providing protection against external impact forces as well as enhancing the stiffness of the entire limb []. In addition, maximal antagonist muscle strength may play an important role in the execution of fast, ballistic
500 UL R
R
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–10 (µV)
C4 0 250 Time (ms) UL
0.15 EMG 0.075 (mV) 0 –500
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limb movements. Thus, high eccentric antagonist strength allows for a shortened phase of limb deceleration, thereby increasing the time available for limb acceleration, with a resulting rise in maximal movement velocity []. Coactivation is elevated during either of two states: when uncertainty exists in the required task, or during anticipation of compensatory muscle forces []. During maximal coactivation, the monosynaptic excitatory pathway (Ia) as well as the disynaptic reciprocal inhibitory pathway (Ib) are exposed to spinal inhibition via descending supraspinal pathways [,]. The increase in muscle and joint stiffness mainly results from a direct activation from the CNS with the cerebellum playing an important role in switching from reciprocal activation to coactivation [,]. It is not well known whether strength training per se may induce altered patterns of antagonist coactivation. Intuitively, a decrease in antagonist coactivation would seem desirable, as this would cause net joint moment (agonist joint moment minus antagonist joint moment) to increase. However, as implied above a decrease antagonist muscle coactivation may not be optimal for the integrity of the joint. Antagonist coactivation has been reported to decrease [a,], increase [] or remain unchanged [,,a,a,,,,
Chapter . ] in response to strength training. Häkkinen and coworkers [a] found that coactivation of the lateral hamstring muscle during maximal isometric contraction of the quadriceps femoris was elevated in old subjects ( years) compared to middle-aged subjects ( years). However, after months of heavy resistance-training coactivation decreased in the old subjects to reach a level similar to that recorded for the middle-aged subjects, which in turn did not change during the course of training [a]. Given that antagonist coactivation is markedly elevated when uncertainty exists in the motor task, subjects may occasionally demonstrate very high levels of coactivation during the initial round of experiments. This may, at least in part, explain the decrease in antagonist coactivation that has been observed with training. To minimize this potential problem, conditioning tests could be conducted prior to the round of actual pretraining testing. Interestingly, a differential change in antagonist motor pattern in terms of a selective decrease in medial (semitendinosus) but unchanged lateral (biceps femoris) hamstring EMG activity was observed in maximal isolated knee extension in response to weeks of heavy-resistance training, involving isolated knee extension and squat exercises []. This adaptation indicates an important aspect of motor reprogramming, as it potentially counteracts excessive internal tibia rotation which otherwise may give rise to elevated stress forces in the anterior cruciate ligament (ACL) during active knee extension [,]. To obtain a valid measure of antagonist muscle coactivation it is crucial to ensure that the antagonist EMG signal is not contaminated by the EMG activity of adjacent agonist muscles, as a result of EMG crosstalk between electrode pairs [,]. The amount of cross-talk between two given EMG signals can be quantified by use of cross-correlation analysis [,]. Using a wide range of time phase shifts (i.e. from t = to t = ± ms) and long record lengths (> data points), the peak cross-correlation coefficient raised to the second power, Rxy(t)2, may be taken to represent the percentage cross-talk between electrode sites []. Based on this methodology low levels of EMG cross-talk (–%) were demonstrated between adjacent quadriceps (agonist) and hamstring (antagonist) muscles in maximal isolated knee extension [], although substantially higher values have
also been reported []. Importantly, the level of cross-talk will depend strictly on the specific measuring set-up used, with electrode size and distance between electrodes being the most critical factors. The above findings therefore indicate that it may be possible, with careful experimental procedures, to minimize the magnitude of EMG cross-talk between antagonist and agonist muscles.
Neural inhibitory mechanisms Numerous pathways in the nervous system could be responsible for exerting an inhibitory synaptic drive onto the spinal pool of a-motoneurons. As an important feature, these pathways allow for an integration of spinal and supraspinal inputs. It appears therefore that changes in the spinal neural circuitry induced by training, including alterations in synaptic gating, may emerge as a result of adaptive changes at both spinal and supraspinal levels. Consequently, considerable plasticity can be expected for the neural adaptation to specific types of activity and training. For example, inhibition of various inhibitory pathways as a result of strength training would yield an increase in the net excitatory drive to the motoneuron pool.
Ib afferent inflow from Golgi organs Negative feedback via force-sensing afferents from the Golgi organs arises through the action of inhibitory Ib interneurons, which project to the motoneurons that control the muscle fibers affecting the Golgi organ (Fig. ..). Golgi organs are primarily located within the muscle, at the site of muscle fiber attachment to the aponeurosis or other tendinous structures (> %), rather than at the actual tendon (< %) []. Golgi organs respond not only to large but also to small increments in force and the widespread distribution of Golgi organs allows each motor unit to be monitored by at least one to three Golgi organs []. Consequently, active and passive muscle forces can be accurately monitored in every portion of the muscle []. Importantly, the Ib inhibitory interneurons are influenced by descending corticospinal pathways (i.e. rubrospinal and reticulospinal tracts) [,] (see Fig. ..). Conversely, information from Golgi organs reaches the cerebellum and cerebral sensory cortex through dorsal spinocerebral tracts, suggesting that Ib afferent feedback contributes to conscious
Neuromuscular Aspects of Exercise (a)
Corticospinal
Joint
(b) Input
Skin
Rubrospinal Reticulospinal
Ia Fig. .. (a) Negative feedback via force-sensing neural Ib afferents from Golgi organs arises through the action of inhibitory neurons (Ib In) which project to a-motoneurons that, in turn, control the muscle fibres that affect the Golgi organs. (b) Ib interneurons not only inhibit motoneurons that innervate their parent muscles, but also motoneurons controlling many other muscles (Het a).From [].
Ib In Ib In
Ib
sensations of contractile and passive muscle stress []. It is also noticeable that various sensory cutaneous afferents and joint afferents converge onto the pool of inhibitory Ib interneurons, in turn facilitating Ib inhibitory effects (Fig. ..). Interestingly, this includes the posterior articular nerve (PAN) of the knee joint, which contains sensory axons from the ACL, posterior cruciate ligament (PCL) and joint capsule [,]. The facilitary inflow to the Ib inhibitory interneurons from skin and joint sensory afferents not only constitutes a safety mechanism, causing muscle force to be suppressed during joint injury; it probably also contributes to the (re)programming of motor patterns when adapting to specific types of training or when rehabilitating from joint or ligament injury. It should be noted, however, that recent experimental evidence obtained in animal preparations suggest that in certain situations (e.g. quiet standing, specific phases of locomotion) the Golgi organs may exert a common excitatory feedback drive onto the motoneurons of antigravity muscles crossing the same joint []. Thus, the Ib afferent pathway appears to be highly complex, and also in humans the possibility exists that reflex reversal mechanisms are functioning at different levels of the CNS to facilitate motor function during standing and locomotion. It is plausible that the removal of motoneuron suppression and the resulting increase in maximal eccentric muscle strength observed following heavy-
a
Ib In
Het a
a
Excitatory synapses (EPSPs) Inhibitory synapses (IPSPs)
resistance strength training (Fig. ..) is the result of a down-regulation in spinal Ib inhibitory interneuron activity (i.e. ‘disinhibition’) mediated via central descending pathways.
Renshaw inhibition In the spinal cord Renshaw cells may serve as a variable gain regulator at the motoneuronal level, controlling the relationship between synaptic input and efferent axonal output. Recurrent inhibition, by which the motoneuron exerts an autoinhibitory influence on itself, is mediated via Renshaw cells (Fig. ..). Recurrent Renshaw inhibition has been considered as a factor limiting motoneuron discharge frequency, and also to have a regulating influence on the reciprocal Ia inhibitory pathway [,]. Animal experiments have shown that Renshaw cells are submitted to several types of supraspinal control that can enhance as well as depress the recurrent pathway [,]. Thus, with facilitation of Renshaw cells the input–output relationship of the motoneuron becomes impaired, whereas inhibition of the Renshaw cells causes the input–output relationship to be enhanced (Fig. ..). As compared to tonic contractions, Renshaw cell activity appears to be more inhibited in maximal phasic contractions, resulting in a reduced level of recurrent inhibition []. This could indicate that ‘explosive’ types of heavy-resistance strength training, aimed at maximizing the contractile rate of force
Chapter . – +
(b)
Activity in descending fibers (n× f)in = input α Output = activity in motoneuronal pool (n× f)out ≈ force
Excitatory synapses (EPSPs) Inhibitory synapses (IPSPs)
(c) Output from motoneurons (n×f)out
(a)
Ia IN
(ii)
α
α
Inhibited Renshaw cells (i) Facilitated Renshaw cells
γ
RC Ia
Input to motoneurons (n× f)in
Fig. .. (a) Input and output connections of a-motoneurons and Renshaw cells, a specialized type of spinal interneuron. Excitatory and inhibitory synapses are shown. Note that the Renshaw cells themselves receive both excitatory and inhibitory synaptic inputs, from spinal as well as higher centers in the CNS. (b) Simplified diagram of input–output relations of a motoneuron pool involving two different situations: (i) with a facilitation of Renshaw cells, the efferent motoneuron output is diminished for a given neuronal input; (ii) conversely, the inhibition of Renshaw cells causes an overall disinhibition of the a-motoneuron pool, with a resulting rise in efferent motor output for a given synaptic input. The presence of recurrent inhibition provides a basis which allows the input–output relationship of the motoneuron pool to be dynamically modulated. (c) Concept of the motoneuron stage. Neurons constituting the efferent output are indicated by thick lines. RC, Renshaw cell; Ia IN, Ia inhibitory neuron. From [].
development, should be superior in evoking neural changes as compared to other types of strength training (i.e. low-resistance training, body building).
Adaptive changes in muscle morphology MHC isoform composition, fiber type conversion When a nerve impulse reaches the muscle fiber, the muscle membrane is depolarized and calcium is released to the interior of the cell from specialized intracellular organelles (sarcoplasmatic reticulum), in turn triggering a transient process of cyclic attachment and detachment of cross-bridges between actin and myosin molecules within the muscle fiber. As a result of this cross-bridge cycling, the actin and myosin filaments perform a sliding movement relative to each other while generating contractile force. In human skeletal muscle, the myosin molecule is constituted of three major types of polypeptide chains: the myosin heavy chain (MHC, molecular weight approx. kDa) and two distinct types of light myosin chains
(alkali, regulatory chain and DTBN chain, each approx. kDa) [,,]. Recent techniques, such as sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE), have identified distinctly different myosin isoforms within the single muscle fiber as well as in muscle hom*ogenate samples. Using SDS-PAGE three different MHC bands have been separated in adult human skeletal muscle, reflecting differences in molecular density. These bands correspond to the MHC-I, MHC-IIa and MHC-IIx isoforms [] (Fig. ..). The fiber type distribution determined by conventional myosin ATPase histochemistry relates closely to the MHC isoform content [–]. Although –% of the variance was accounted for (r2, r-values of .–. observed), the remaining –% reflects that the SDS-PAGE analysis provides a more sensitive and consistent picture of MHC coexpression, i.e. the presence of two or more MHC isoforms within the muscle fiber [,]. The term MHC-IIx has found increasing use to denote the fastest contracting MHC isoform found in human skeletal muscle, due to a consistent hom*ology
Neuromuscular Aspects of Exercise
MHC IIX MHC IIA MHC I
MHC IIX MHC IIA MHC I Fig. .. SDS-PAGE gel separations showing MHC bands from two subjects before and after days of heavy-resistance strength training followed by days of detraining. Densitometric scans are shown above each of the lanes. Data from [].
in genome expression between this fast human isoform and the MHC-IIx isoform in the rat [,]. Although the MHC-IIb encoding gene has been found in the human genome [,], evidence for its expression at the protein level is lacking []. It appears, however, that the MHC-IIb isoform is dominantly expressed in certain specialized muscles of the larynx and the eye [a]. The distribution into various distinct MHC isoforms, as well as its responsiveness to change with training, has significant implications for in vivo mechanical muscle function and the adaptation to given physiologic demands [,]. For example, a positive relationship has been found between the percentage of fast MHC-II isoforms determined by gel electrophoresis and the ability to produce high muscle force during fast concentric contraction [,]. Similar findings have been reported when assessing myosin composition by use of conventional myosin ATPase histochemistry [,,,]. In human skeletal muscle shifts in fast myosin iso-
form composition, i.e. MHC-IIa Æ IIx or MHC-IIx Æ IIa, appear to be readily evoked by training or detraining, respectively [,,,,–]. However, it remains a matter of controversy whether training within a realistic physiologic range can induce transformation between slow and fast myosin isoforms, i.e. MHC-I Æ II or MHC-II Æ I [,,]. The finding of an extremely large proportion of IIa and IIx fibers in the quadriceps muscle of long-term spinal cord-injured subjects (> % vs. % in agematched healthy subjects) led Andersen and coworkers to suggest that the expression of the MHC-IIx isoform represents a default setting, which is overruled with any chronic increase in muscle activity []. Interestingly, a marked decrease in MHC-IIx and corresponding increases in type IIa and type I MHC were observed in spinal cord-injured subjects after months of cycle training using functional electrical stimulation (FES) []. Not only endurance training but also resistance training appears to effectively suppress the expression
Chapter . of MHC-IIx. Thus, few muscle contractions performed against heavy external loads two or three times per week can reduce MHC-IIx almost completely, with a corresponding increase in MHC-IIa [,,–,,,]. This indicates that the total number of contractions or nerve impulses is not the only factor which influences the down-regulation of MHC-IIx with resistance training, as otherwise suggested with prolonged endurance training []. Rather, the magnitude of contractile force exerted by the muscle fibers appears to be a governing factor as well. Intense muscle contractions may lead to structural deformation of the sarcolemma and the cytoskeleton, thereby activating mechanosensitive or stretchsensitive signaling pathways affecting gene regulation of the nucleus []. Furthermore, exercise-induced changes in gene expression are accelerated by activation of gene-encoding transcription factors such as the myogenic regulatory factor family (MyoD, myogenin, Myf, MRF) []. The mechanical stress load exerted on the muscle fiber probably acts through similar intracellular pathways to switch off or down-regulate the MHC-IIx gene, while up-regulating the MHC-IIa gene. Also, exercise-induced activation of specific intracellular kinases, which controls the rate of RNA transcription/translation, thereby regulating protein synthesis rate, appears to be involved in the hypertrophic response to resistance training. For example, a strong positive relationship between the activation (i.e. phosphorylation) of pS6k, a -kDa S protein kinase, and the long-term increase in muscle mass with resistance training was recently reported in the rat, suggesting that this protein kinase plays an important role in the intracellular signaling cascade related to training-induced growth of skeletal muscle []. Data obtained in humans suggest that in the initial phase of resistance training (– weeks), the increased rate of myofibrillar protein synthesis is mediated mainly by a more efficient translation of mRNA []. On the other hand, the finding that intense bouts of resistance exercise can induce rapid changes in mRNA (– h) which precede changes in MHC content (– weeks) [a], indicate that resistance training may exert a strong and immediate modulatory effect on gene encoding as well. Similar findings have been reported following high-intensity endurance exercise []. In addition, the mismatch between the
expression of specific MHC isoforms and their respective mRNA isoforms observed with resistance training (and detraining) suggests that differentiated adaptive responses may exist for the pre- and posttranslational mechanisms related to gene expression [].
Muscle fiber size As a result of differences in spinal a-motoneuron cell soma size, the small low-threshold motor units are preferentially recruited in low-level isometric muscle contraction, whereas with increase in muscle force there is an additional and progressive recruitment of large high-threshold motor units, cf. ‘Henneman’s size principle’ []. Thus, heavy-resistance strength training will activate both low-threshold and highthreshold motor units, thereby involving slow type I as well as fast type II muscle fibers. Consequently, heavy-resistance strength training can induce significant alterations in muscle fiber morphology as manifested by an increase in type I and type II muscle fiber cross-sectional area [,,,] (Fig. ..). A majority of studies, however, have found a preferential or more pronounced hypertrophy of the type II muscle fibers [,,,,,–] (Fig. ..). Altogether these findings suggest that type II muscle fibers possess a greater adaptive capacity for hypertrophy compared to type I fibers. Muscle fiber hypertrophy occurs primarily due to an accumulation of contractile proteins (i.e. myosin and actin) as reflected by an increase in the size and number of myofibrils within the muscle cell, leaving the total number of muscle fibers basically unaltered []. Seen in this perspective, individuals genetically predisposed to have a large number of muscle fibers in a given muscle would appear to have the greatest potential for overall muscle hypertrophy in response to training. There is a possibility that neoformation of muscle fibers (hyperplasia) may occur as an effect of intensive resistance training, although for human skeletal muscle its existence remains questionable []. The muscle fiber hypertrophy induced by resistance training is often accompanied by an increase in the cross-sectional area or total volume of the muscle obtained by magnetic resonance imaging (MRI) or computed tomography (CT) scanning. Although at first hand a conflicting finding, disproportionate changes in
(a)
2
Muscle fiber CSA (mm )
(b)
2
Muscle fiber CSA (mm )
(c)
Fig. .. Muscle fiber cross-section from muscle biopsy samples obtained in the vastus lateralis and stained for myofibrillar ATPase after pre-incubation at pH . (a). (b-c) Muscle fiber cross-sectional area (CSA) with fiber types IIA and IIX collapsed, before and after weeks of heavy resistance strength training (n = ). Note the increase in type II muscle fiber with training. A trend towards increased type I fiber area was also observed with training [].
Chapter . MRI muscle cross-sectional area (CSA) and single muscle fiber CSA may occur with resistance training. Thus, mid-thigh quadriceps CSA as well as total quadriceps volume increased ~ %, whereas singlefiber CSA increased ~ % following weeks of resistance training [,,]. In studies using combined muscle biopsy sampling and muscle imaging (MRI, CT) the increase in muscle fiber CSA induced by resistance training generally appeared to exceed the increase in whole-muscle CSA [,–]. These findings are not explainable by an altered ratio of non-contractile to contractile tissue, which appears to remain unchanged with resistance training in animal models [] as well as in humans [,]. Rather, the disproportionate alteration in fiber CSA and whole-muscle CSA appears to be caused by training-induced alterations in muscle architecture. Thus, muscle fiber pennation angle may increase in response to prolonged heavy-resistance strength training, a change that allows physiologic muscle CSA (muscle fiber CSA) to increase more than anatomic muscle CSA (see ‘Changes in muscle architecture’, below). An upper limit seems to exist to the increase in muscle fiber size induced by resistance training []. Most likely this limit is closely linked to the genetic endowment of the individual. Because the myonuclei of adult muscle fibers are not capable of mitosis and therefore unable to divide, the nuclear/cytoplasmic ratio would approach zero with unlimited increase in muscle fiber size. Obviously, this would dilute the amount of mRNA in the cell, at some point causing net protein synthesis to cease. Interestingly, satellite cells may play an important role for the maintenance of a constant nuclear/cytoplasmic ratio during cellular hypertrophy. Satellite cells are located dormant under the muscle cell basal membrane. During normal muscle growth, satellite cells contribute nuclei to the muscle cell by proliferating, differentiating and fusing to existing myofibers [,]. The satellite cellderived myonuclei are no longer capable of dividing, but begin to produce muscle-specific proteins that add to the increase in myofiber size [,]. The proliferation and differentiation of satellite cells are stimulated by endogenous growth factors such as testosterone, insulin-like growth factor I (IGF-I),
growth hormone, insulin and interleukin- []. In addition, data exist which suggest that satellite cell activation may be enhanced by anabolic steroid use. Thus, high-level power lifters reporting several years of high-dose anabolic steroid usage (average years) demonstrated ~ % and ~ % elevated myonuclei number in their type IIa and I muscle fibers, respectively, together with a ~ % larger mean muscle fiber area compared to age-matched power lifters that did not use steroids []. Interestingly, type I muscle fibers have a lower nucleus/cytoplasm ratio than type II fibers []. Thus, the type I fibers would be expected to respond most markedly to anabolic steroid usage, as in fact supported by recent experimental evidence []. Opposite to that observed with resistance training, a reduction in muscle fiber CSA (atrophy) may be seen following intensive endurance training [,–]. From a muscle perfusion perspective this adaptation is very important, since it results in an elevated capillary to muscle fiber CSA ratio, which in turn facilitates O2 delivery and free fatty acid (FFA) uptake into the muscle cell due to the reduced diffusion distance. The elevated FFA uptake results in a reduced rate of glycogen breakdown to yield an enhanced endurance performance (prolonged time to exhaustion). Thus, regimes of concurrent strength and endurance training appear to involve stimuli for cellular hypertrophy as well as atrophy. As a functional consequence, no (or only minor) muscle fiber hypertrophy and no signs of a reduction in capillary density have been observed when strength and endurance training are combined [–]. With regard to muscle metabolism and endurance, it is noteworthy that the number of capillaries per fiber appears to either increase [,,] or remain unchanged [,] following prolonged (months) resistance training. Likewise, capillary density (cap/mm2) seems to remain unchanged [,,]. Thus, the capacity for capillary perfusion does not seem markedly impaired by resistance training, at least when performed for – weeks. On the other hand, previous findings of a reduced capillary density in experienced weight lifters and power lifters [] but not in body builders [] suggest that the specific type of resistance exercise could play an important role for this parameter.
Neuromuscular Aspects of Exercise Muscle cross-sectional area and volume
raphy to address the alteration in macroscopic muscle dimensions evoked by resistance training (Fig. ..). An accurate estimate of the total volume of a given muscle can be provided by the recording of successive axial MR images along the entire length of the limb.
During recent years there has been a progressively growing interest in the use of non-invasive imaging techniques such as magnetic resonance imaging (MRI), computed tomography (CT) and ultrasonog(b) (Lfemur3)
(a)
A (Lfemur2) (c)
Fig. .. (a) Coronal MRI scan of m. quadriceps femoris. (b) The relationship between quadriceps muscle CSA and total quadriceps volume. Pre- and post-training values are shown by closed and open symbols, respectively. (c) Axial MRI images of the thigh obtained at % femur length (proximal site) and % femur length (distal site) before and after weeks of heavy-resistance strength training. Data adapted from [ and ].
Chapter . The determination of muscle volume can be quite time consuming and costly in terms of time spent in the MR scanner. It is therefore interesting to note that in the quadriceps femoris muscle, which is the muscle that has been most frequently used to examine the effects of resistance training, a strong relationship can be found between muscle CSA obtained at % segment length and total muscle volume determined by recording of multiple axial images [] (Fig. ..b). Thus, training-induced changes in muscle volume may be well represented by changes in single-site CSA, at least when evaluating large subject groups. Anatomic muscle CSA obtained by use of MRI or CT has been reported to increase –% in response to prolonged heavy-resistance strength training [,,,a,,–,]. Corresponding increases have been found for total quadriceps volume [,,]. Using MRI some researchers have been able to identify the perimeter of the different quadriceps femoris muscles in successive axial images obtained along the length of the femur, to report differentiated hypertrophic response of each muscle compartment (i.e. vastus lateralis, medialis, intermedius and rectus femoris) following resistance training [,]. However, such differentiation is not always possible, since substantial fusion may exist between adjacent vastii. Based on cadaver data, of dissected quadriceps muscles showed fusion between the lateral and deep vastii at more than % of the entire length of the muscle []. In addition, axial MR scans typically show a lack of distinct fascial boundaries between the lateral and deep vastii (posterolaterally) and between the medial and deep vastii (anteromedially) when obtained proximally [] (Fig. ..c). Obviously, such fusion of adjacent muscle compartments will have important implications for the interpretation of MRI-based muscle CSA data. Resistance training involving eccentric alone or coupled eccentric–concentric muscle contractions seems to result in more pronounced morphologic changes than concentric training alone. Accelerated muscle hypertrophy was found after eccentric or coupled eccentric–concentric training compared to concentric training alone, as reflected by a greater increase in single muscle fiber CSA obtained by biopsy sampling [,,] although not confirmed by all studies [,]. Likewise, a greater increase in
anatomic muscle CSA obtained by use of MRI or anthropometric measures has been observed following eccentric strength training in most [,,] but not all studies []. Furthermore, muscle fiber area remained above pretraining values following detraining from eccentric but not concentric resistance training [], indicating that the hypertrophic response to eccentric training is more long lasting. The above disparities are likely to be related to differences in training duration between studies. With sufficient duration therefore, eccentric resistance training appears to be more effective for inducing muscle fiber hypertrophy and overall muscle growth than concentric training alone.
Muscle architecture Many, if not most, skeletal muscles are characterized by a pennate arrangement of the muscle fibers relative to their insertion at the aponeurosis or tendon. This allows physiologic muscle cross-sectional area (equivalent to the muscle fiber area perpendicular to the longitudinal axis of the individual muscle fibers) to greatly exceed the anatomic muscle cross-sectional area measured in a plane perpendicular to the longitudinal axis of the whole muscle. The maximal forcegenerating capacity of a given muscle is determined by its physiologic CSA, as this represents the maximal number of acto-myosin crossbridges that can be activated during contraction. For a given volume of muscle, physiologic CSA and thereby maximal contractile muscle force is progressively increased at more steep muscle fiber pennation angles, to reach an upper limit at a pennation angle of ° [,]. Consequently, pennate muscles are able to exert very large contractile force compared to non-pennate muscles. Muscle fiber pennation angle was previously estimated from dissection of cadaver specimens. However, more adequate and accurate measuring techniques have emerged, based on the appearance of highresolution ultrasonography techniques (Fig...). This has allowed fiber pennation angle to be measured at specific muscle lengths (joint angles) and at specific levels of muscle tension. Ultrasound imaging has been increasingly used to investigate the strain and stress forces generated in human tendon and aponeurosis in vivo [–]. In addition, ultrasonography
Neuromuscular Aspects of Exercise
Fig. .. Sagittal plane ultrasound image obtained in the relaxed quadriceps femoris muscle at % femur length. Muscle fiber pennation angle (qp) in vastus lateralis was measured as the angle between VL muscle fibre fascicles and the deep aponeurosis.
has been used to address the more chronic change in muscle fiber pennation angle induced by resistance training. Findings of steeper muscle fiber pennation angles and greater anatomic muscle CSA in the triceps brachii muscle of body builders compared to untrained subjects [] suggest that the muscle hypertrophy induced by resistance training could be associated with an increase in fiber pennation angle. This notion was confirmed by longitudinal data demonstrating a significant increase in muscle fiber pennation angle from .° to .° in the triceps brachii muscle following weeks of resistance training []. Likewise, an increase in fiber pennation angle from . to .° was reported for the vastus lateralis muscle after weeks of intense heavyresistance strength training []. In contrast, Rutherford and Jones found an unchanged fiber pennation angle in the lateral and medial vastii after weeks of resistance training, despite a % and % increase in anatomic CSA and maximal isometric strength, respectively []. These conflicting results were probably caused by differences in total training load, which differed by a factor of three. Thus, a change in muscle
architecture evoked by resistance training appears to require considerable effort and time. The training-induced increase in muscle fiber pennation angle was suggested to allow muscle fiber CSA and thereby maximal force-generating capacity to increase significantly more (%) than whole-muscle CSA and volume (%) []. Thus, the disproportionate change in macroscopic versus microscopic morphometry observed with strength training [,–] implies that muscle CSA or volume obtained by MRI or CT (i.e. reflecting changes in anatomic CSA) cannot replace the information obtained by measurements of single muscle fiber area in biopsy samples (i.e. reflecting changes in physiologic CSA), or vice versa. Clearly, the adaptation in muscle fiber pennation angle should be taken into account when examining training-induced changes in maximal muscle strength, in vivo.
Functional aspects Training for ‘explosive’ muscle strength ‘Explosive’ muscle strength can be defined as the rate of force development (RFD = Dforce/Dtime) exerted
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within the very initial phase of contraction (– ms) (Fig. ..). The ability to generate very steep increases in muscle force at the onset of contraction has important functional significance for the force and power generated during rapid, forceful movements. Thus, contraction times of – ms can be observed in many types of fast movement (e.g. sprint running, long jump take-off, karate, boxing). In contrast, it takes about – ms to reach maximal force in the human quadriceps femoris muscle [,] (Fig. ..). Consequently, contractile RFD is a major determinant of the maximal force and velocity that can be achieved in very fast movements. In isometric contraction conditions, RFD is determined by the level of neural activation (efferent motor drive), muscle size (muscle CSA and volume) and fiber type composition (MHC isoforms) while also influenced by the length–tension characteristics of the muscle. During dynamic contraction, the RFD will
also be influenced by the force–velocity characteristics of the muscle. Acutely, a rise in RFD is seen with increasing motoneuron firing frequency [] and overall neural drive. In terms of muscle morphology, a large CSA will also result in a large absolute RFD. Maximal cross-bridge cycle transition rate appears to be the major limiting factor for the maximal intrinsic RFD of mammalian muscle fiber []. Thus, a predominance of type II MHC isoforms results in a high RFD [], due to their elevated rate of cross-bridge cycling []. In consequence, the maximal muscle force that can be reached in situations of short contraction times (i.e. < ms) is positively related to the proportion of type II MHC []. Based on electromyography (EMG) recordings (Figs .. and ..a), efferent neural drive to the muscle fibers has been found to increase in response to strength training [,,,,a,–,a,,, ]. Because a ‘parallelism’ of the rate of EMG and force development may exist [], concurrent adaptations in neural drive and contractile RFD can be expected following resistance training. In line with these expectations, RFD and neural efferent drive have both been reported to increase in response to strength training [,,,a,,,] (Fig. ..). Interestingly, Schmidtbleicher and Buerhle [] found that ‘power training’ at lower loads and fast contraction velocities had no strong effect on these parameters. Duchateau and Hainaut [] used electrically evoked tetanic contractions to address changes in intrinsic muscle properties, and found that peak RFD was augmented to a greater extent by fast ballistic training than isometric training (% vs. %) in the adductor pollicis muscle. This latter finding suggests that not only heavy-resistance strength training but also maximal ballistic training using lower loads could have an important effect on the increase in RFD. Comparing dynamic and isometric ballistic training (i.e. at high RFD), Behm and Sale observed the increase in RFD to be similar with both these types of training regimes, during evoked as well as voluntary contraction conditions []. Thus, the involvement of an intended ballistic effort may be more important for inducing increases in RFD than the type of contraction actually performed. The marked increase observed in neural drive suggests that the increase in contractile RFD is mainly caused by neural adaptation. In particular the finding
Neuromuscular Aspects of Exercise 3500
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Fig. .. Changes in RFD and neural drive pre- and post- weeks heavy resistance training. Error bars denote SEM. (a) Rate of force moment of development during maximal isometric contraction of the quadriceps femoris muscle calculated in time intervals from the onset of contraction. (b) Neural drive calculated as the mean integrated EMG divided by integration time. (c) Neural drive quantified as the rate of EMG rise [].
of disproportionately large increases in EMG amplitude (–%) and rate of EMG rise (–%) compared to RFD (–%) and maximal muscle strength (%) (Fig. ..) suggests that an increase in motoneuron firing frequency may be responsible for the training-induced rise in contractile RFD []. This notion was further supported by the finding that RFD normalized to MVC, i.e. expressed as % MVC/s, increased in the initial phase of contraction (–/ MVC, corresponding to the initial – ms)
[]. Muscle fiber hypertrophy could also have contributed to the increase in RFD, as evidenced by an increase in type II muscle fiber CSA following training (%) []. Recently, Duchateau and colleagues reported increased contractile RFD together with an increase in firing frequency as well as a six-fold increased occurrence of ‘discharge doublets’ in the firing pattern of single motor units following ballistic-type resistance training [] (Fig. ..). This increased incidence of ‘discharge doublets’ may be particularly important for the training-induced increase in RFD, by taking increasing advantage of the catch-like property of skeletal muscle (See Adaptive changes in neural drive: motoneuron firing frequency). Collectively, the above findings suggest that the (see Adaptive changes in neural drive: motoneuron firing frequency) major stimulus for training-induced increases in RFD may reside in the high-frequency motor unit firing pattern associated with an intended ballistic movement []. For this purpose training probably should involve heavy-resistance strength training combined with a more ballistic type of training using somewhat lower loads. Based on the training experience accumulated in top-level track and field athletics and power lifting, the most optimal training stimulus perhaps can be achieved when heavy-resistance strength exercises executed in an ‘explosive’ manner (i.e. emphasis on acceleration of the load) are combined with specific ballistic-type exercises using lower loads. There is no doubt that the increase seen in contractile RFD is one of the single most important functional benefits associated with resistance training. Very fast movements are characterized by muscle contraction times of – ms, which is considerably less than the time it takes to reach maximal force (Fig. ..). Consequently, increases in RFD evoked by resistance training may greatly enhance the maximal force and velocity that can be achieved during very fast movements. In support of this notion, maximal muscle force and power were markedly elevated during very fast movement speeds following heavy-resistance strength training []. Likewise, the increase in contractile RFD likely is responsible for the increase in maximal unloaded movement speed reported following heavyresistance strength training []. It is important to notice that training-induced changes in contractile RFD will have important functional consequences,
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not only in athletes, but also in non-athletic subjects. For example, in the elderly individual, high muscular RFD may play an important role for the ability to rapidly regain postural balance and thereby avoid falls.
Training for optimal neural and morphologic adaptation From the findings presented in this chapter strength training appears effective for evoking significant adap-
tive changes within the nervous system as well as in the muscle itself (Fig. ..). Training with heavy loads (– RM) seems to emphasize various aspects of neural adaptation, in turn causing significant increases in contractile RFD [] and maximal eccentric strength []. The use of moderate to heavy training loads (– RM) may be more optimal for the development of muscle hypertrophy [] and may also prove more effective for inducing alterations in muscle
Neuromuscular Aspects of Exercise 6–12-RM loads ‘muscle volume training’
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Fig. .. Diagram summarizing neural and morphological effects evoked by resistance training. *≠ Muscle cross-sectional area (CSA); ≠ CSA type II muscle fibers (type II MHC isoforms). Changes in muscle architecture (≠ fiber pennation angle). ** ≠ Neural drive to muscle fibers (≠ iEMG); ≠ motoneuron excitability; Ø motoneuron inhibition.
architecture. It should be noted, however, that the adaptation evoked by resistance training involves a mixture of neural and morphologic mechanisms that often cannot be separated from each other. As described above, the increase in maximal muscle strength can be the result of changes in muscle size or muscle architecture (angle of fiber pennation), and/or of neural changes, i.e. enhanced efferent motor outflow to the muscle fibers. The increase in contractile RFD is caused by an increased neural drive, especially within the initial – ms of contraction. In addition, there may be a significant contribution from muscle fiber hypertrophy. The functional outcome is that movements can be performed more rapidly and that muscle force and power generated during fast movements will be enhanced. Eccentric muscle strength is increased mainly due to neural adaptation mechanisms, which likely include a reduced inhibition of the motoneurons during maximal eccentric contraction. However, muscle fiber hypertrophy will contribute as well. These adaptations cause muscle force and power to be enhanced in functional situations, such as during rapid limb acceleration and deceleration, and in forceful stretch–shortening cycle activities, e.g. jumping and sprinting. Moreover, an increase in the maximal eccentric strength of antagonist muscles has been suggested to be of importance for the magnitude of dynamic joint stabilization provided by antagonist coactivation [,,]. In consequence, the increase in eccentric antagonist muscle strength may be expected to result in a reduced incidence of joint injury. Another important aspect that is often overlooked, is that regular resistance training may allow the individual to tolerate better a higher intensity of training which, in turn, will improve performance.
Summary Strength training induces marked increases in maximal concentric, eccentric and isometric muscle strength as well as in the contractile rate of muscle force development. Adaptive changes occur both in the nervous system and within the muscle itself. Experimental data obtained by electromyography have indicated several mechanisms for neural adaptation, including increase in efferent motor drive, increased motor unit firing frequency, enhanced intramuscular and intermuscular motor unit synchronization, increased motoneuron excitability and decreased presynaptic inhibition of spinal a-motoneurons. Down-regulation of inhibitory pathways, at either the supraspinal or spinal level, e.g. of Ib Golgi afferents and Renshaw recurrent inhibition, may contribute to the increase in maximal muscle strength in response to heavy-resistance strength training, particularly during eccentric muscle contractions. Adaptations in muscle morphology include increase in muscle fiber crosssectional area (CSA), whole-muscle CSA and volume, and changes in muscle architecture in terms of an increased angle of muscle fiber pennation, as demonstrated by histochemical, magnetic resonance and ultrasonographic techniques, respectively. Using modern gel electrophoresis and antibody classification methods, effects of strength training have also been demonstrated at the subcellular level, e.g. as shifts in myosin heavy chain isoforms, mainly between MHC-IIa and IIx. The enhancement of neuromuscular function induced by strength training will have significant benefits for the performance and ability to endure intense training in most sports as well as for carrying out many activities in everyday life, not least in the elderly. Training with moderate to heavy loads
Chapter . and eccentric, concentric and isometric contractions, should be integral parts of preventive and rehabilitative training for muskuloskeletal injuries.
Multiple choice questions Which of the following statements about isokinetic strength measurements is correct? a ‘Isokinetic’ implies that the muscle contraction velocity is kept constant over the whole range of motion. b Under true isokinetic conditions the measured moment of force equals the net muscle strength produced around the joint investigated. c Since the muscle lever arm changes with joint angle over the range of motion, the muscle force has to change accordingly to keep the torque constant. d Under eccentric isokinetic measurements the dynamometer has to produce a torque that is lower than the net torque produced by the muscles. e During isokinetic strength measurement the joint angular velocity is constant over the entire range of motion. Which of the following neural adaptations is least likely to occur after heavy-resistance strength training? a Increased efferent drive from higher neural centers to the agonist motoneuron pool. b Increased firing frequency of agonist a-motoneurons. c Decreased presynaptic inhibition of Ia afferents onto hom*onymous motoneurons. d Increased activation from supraspinal centers onto the Renshaw cells innervating the agonist motoneurons. e Decreased inhibition from Ib afferents on agonist motoneurons. Which of the following muscular adaptations is the least likely to occur after heavy-resistance strength training? a A shift from myosin isoform MHC-IIx to MHCIIa. b A larger relative area of type II as compared to type I muscle fibers. c A higher number of capillaries per muscle fiber. d A larger angle of pennation. e An increased number of type IIb muscle fibers.
Which of the following statements about eccentric (lengthening) muscle contractions is false? a In eccentric muscle contractions the force produced per unit of muscle activation is larger than in concentric muscle contractions. b In eccentric muscle contractions the EMG required to produce a certain muscle force is lower than in concentric muscle contractions. c The effect of slow vs. fast movement velocity on maximal voluntary muscle strength is smaller in eccentric than in concentric muscle contractions. d Combining eccentric and concentric contractions in strength training gives a larger strength gain than concentric training alone. e The potential gain in maximal voluntary strength by disinhibition of inhibitory pathways is smaller in eccentric than in concentric muscle contractions. Which of the following statements about neural adaptations to strength training is false? a Training of each limb separately will decrease the difference in strength between summed unilateral and bilateral contractions, respectively (the so-called bilateral strength deficit). b Training of one limb can increase the strength of the other, so called cross-education. c Training with ballistic movements can lead to an increased occurrence of so-called discharge doublets, which, in turn, may lead to a higher rate of force development (RFD). d The intention and effort to develop force quickly during heavy-resistance strength training can lead to an increased ability to produce force at high speeds. e Strength training of agonist muscles does not necessarily result in a decreased coactivation of antagonist muscles.
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Chapter 1.5 Biomechanics of Locomotion ERIK B. SIMONSE N & PAAVO V. KOMI
Classical reference
Introduction
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Winter D. A. Biomechanics and Motor Control of Human Movement. New York: John Wiley & Sons, Inc., .
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Biomechanics is a scientific interdiscipline combining physics, anatomy and physiology. Within sports medicine biomechanics is useful for measuring loadings of anatomic structures in general and for evaluating function before and after some sort of intervention such as rehabilitation and/or surgery. In this chapter space does not permit a wide-ranging presentation of biomechanical analyses of a great number of sporting events. The purpose of the chapter is therefore to present the most commonly used methods of biomechanics to readers, who are assumed to be only remotely familiar with biomechanics. After the methodological part a few examples of biomechanical movement analysis are presented. It is hoped that by the end of the chapter the reader will appreciate the possibilities of biomechanics in relation to sports medicine.
Biomechanical equipment
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Fig. .. Kinetic analysis of a continuous flexion/extension of the elbow joint. The top panel shows the net joint moment calculated by inverse dynamics. Extensor dominance is here defined as positive values. The middle panel shows the angular velocity; extension is positive. The lower panel shows the muscle power obtained by multiplication of joint moment and angular velocity; positive power indicates concentric contraction and negative power eccentric contraction of the dominating muscle group at a given point during the movement. Adapted from Winter [].
A major part of all biomechanical research is concerned with movement analysis, which requires some sort of recording of the actual movements. In the early days of biomechanics and up until recently, -mm cine-film was widely used for this purpose. One advantage of film was that it could easily be recorded at various frequencies, up to several thousands of frames per second if necessary during very fast movements. The major disadvantages were that the media were expensive and the development process often took days. The use of video cameras provides instant recordings but normally at slow sampling frequencies like or Hz, which is sufficient for walking but not for faster move-
Chapter . ments. Also, the resolution of video recordings is much poorer than that of film and with high-speed video cameras poorer still. However, the technology is constantly improving and high-speed video has started to appear in less expensive versions with increasingly high resolution. A high-speed shutter is a common facility, which should not be confused with high-speed video recordings. Shutter refers to the duration of the exposure of each frame. During recordings of fast movements it is normally necessary to use a shuttertime of / or / of a second to ‘freeze’ the movement, otherwise fast-moving markers will appear blurred on the video recordings. When using several video cameras it is often convenient to ensure that they operate synchronously. This can easily be accomplished through a standard genlock facility, which allows one camera (master) to control exposure of the other cameras (slaves). Cameras with a built-in video recorder (camcorders) cannot be genlocked. Using several cameras will normally also require some sort of event synchronization, which means that one frame corresponding to a certain time position of a recording can be identified on all cameras. A simple way to perform event synchronization is to flash a light in the field of view from a position visible to all cameras.
Force platforms A force platform is a device designed to measure external reaction forces, which are often termed ground reaction forces. A force platform can normally measure forces in three orthogonal directions together with torsional moments about three orthogonal axes. The latter are used for calculations of center of pressure, which is the location on the force platform where the resultant force is applied. During dynamic movement the center of pressure changes location continuously (Fig. ..) and it may be used to find the point of application of force on the foot during e.g. running, which is required to calculate joint moments by inverse dynamics (see later). The center of pressure on a force platform may also be used as a biomechanical parameter itself representing projections of the whole-body center of mass (postural sway) during standing. A force platform needs to be of a particular size if it is to record reliable forces during human movement.
Fig. .. Top: the resulting vector of the ground reaction forces must be aligned to the foot to calculate joint moments by inverse dynamics. The point of force application called the center of pressure changes continuously during e.g. the stance phase of walking, as demonstrated in the lower panel.
Most platforms are about ¥ ¥ cm, which gives the construction a resonance frequency of about Hz. This is sufficient to ensure that vibrations are not created by forces originating from human movements. Hitting the platform with a hammer will start a vibration of the natural frequency. Biomechanical laboratories for the investigation of, for example, gait have been designed in various ways.
Biomechanics of Locomotion
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Fig. .. Schematic drawing of a gait lab with five cameras (C–), two force platforms (P and P) and photocells to record the gait velocity during experiments.
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One approach is to use a motor-driven treadmill with a number of cameras placed around it. The use of a treadmill has both advantages and disadvantages. The advantages are that it may reduce the space requirements considerably and that the gait velocity can be strictly controlled. The major disadvantage is that investigation of kinematics is limited. To calculate net joint moments by inverse dynamics in two dimensions both the vertical and the horizontal ground reaction force need to be measured and the center of pressure aligned to the spatial positions of the foot. Therefore, the majority of gaitlabs consist of some sort of walkway containing one or two force platforms (Fig. ..).
In vivo tendon and ligament force measurements in humans Information on the forces produced by individual skeletal muscles, tendons and ligaments is important to the understanding of muscle mechanics, muscle physiology, musculoskeletal mechanics, neurophysiology and motor control. The methods applied to produce these forces have been both direct and indirect. Indirect estimation can refer to such methods as the mathematical solution of the actual muscle force in the indeterminate musculoskeletal system. Electromyography (EMG) has been used as an
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indirect predictive measure of individual muscle torques. Both of these estimates are subject to error, the magnitude of which may vary considerably. For example, the main problem in the use of EMG is its sensitivity to varying conditions of muscle action types, velocity of shortening or lengthening, fatigue, training and detraining. Recent developments in technology and surgical implantation procedures have made it possible to measure forces of the muscle–tendon unit (and ligaments) quite successfully. Since Salmons [] introduced a version of the buckle transducer for recording tendon forces in animals, a number of experiments have been performed, especially investigating cat locomotion. These important developments then led to application of this direct in vivo technique in human locomotion [], primarily for studying the loading of the Achilles tendon (AT) during normal activities such as walking, running, hopping and jumping [–]. The buckle transducer in human experiments is shown schematically in Fig. ... The transducer consists of a main frame, two strain gauges, and a center bar placed across the frame. The size of the frame and bending of the cross-bar varies depending on the size of the AT in question. Final selection of the frame and cross-bar is done during surgical operation, which is performed under local anesthesia. To provide normal propriocep-
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Fig. .. (a) Schematic presentation of the ‘buckle’-type transducer designed for experiments in which human subjects can perform even maximal activities, e.g. in running and jumping. A, Main buckle frame; B, cross-bar. R1 and R2 are resistors of the 1/2 Wheatstone bridge configuration. The lower part demonstrates schematically (and with slight exaggeration) the bending of the Achilles tendon when the transducer is in situ. (b) Schematic presentation of the buckle transducer implanted around the Achilles tendon [].
tion, lidocaine is not injected into the tendon or muscle tissues. The operation usually lasts – min while the subject is in a prone position on the operating table. The cable containing the wires from the strain gauges is threaded under the skin and brought to the exterior approximately cm above the transducer. After the cut has been sutured and carefully covered with sterile tapes, the cable of the transducer is connected to an amplifying unit for immediate check-up. Calibration of the transducer is usually performed immediately before the experiments. In contrast to the animal experiments, a slightly more indirect approach must be used to calibrate the AT transducer in human subjects. Experiments can then be performed for approximately – h, depending on the quantity of local anesthesia applied, and measurements can vary from slow walking to maximal jumping. Use of the buckle transducer in the study of AT force measurements produces important parameters such as peak-to-peak force and rate of force development which can then be used to describe the loading characteristics of the tendon under normal locomotion. When these parameters are combined with other external measurements, such as cinematography for calculation of muscle–tendon complex length
changes, the important concepts of muscle mechanics, such as instantaneous length–tension and force– velocity relationships can be examined in natural situations such as stretch–shortening cycle (SSC) activities [,]. Simultaneous recording of EMG activity can add to the understanding of the force potentiation mechanism during SSC-type movement. The major advantage of direct in vivo measurement is that continuous recording of AT force is possible, which is immediately available for inspection. The second important feature of this measurement approach is the fact that several experiments can be performed in one session and the movements are truly natural. The section on p. gives examples of the AT force recordings during different locomotion tasks performed with the buckle transducer. The buckle transducer method is naturally quite invasive, and may raise objections from the ethical committee in question. Due to the relatively large size of the buckle there are not many tendons which can be selected for measurements. The AT is, however, an ideal one due to large space between the tendon and bony structures within the Karger triangle. Other restrictions in the use of this method are difficulties in the calibration procedure, and problems in the applica-
Biomechanics of Locomotion
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Fig. .. Basic demonstration of how compression on the optic fiber (left) causes microbending (right) and less light through the core–cladding interface. (From Alt et al. [].)
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tion of the technique when long-term and repeated implantation may be of interest. As is the case in animal experiments the buckle transducer method cannot isolate the forces of the contractile tissue from the tendon tissues. The method can therefore only be used to demonstrate the loading characteristics of the entire muscle–tendon complex.
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In order to overcome some of the disadvantages of the buckle transducer technique, an alternative method has recently been developed. As was the case for the buckle method this new optic fiber technique was first applied to animal tendons []. However, it had already been successfully used as a pressure transducer in sensitive skin application [] and for measurement of foot pressure in different phases of cross-country skiing []. The measurement is based on light intensity modulation by mechanical modification of the geometric properties of the plastic fiber. The structure of optical fibers used in animal and human experiments [,–] consists of two-layered cylinders of polymers with small diameters. When the fiber is bent or compressed the light can be reduced linearly with pressure, and the sensitivity depends on fiber index, fiber stiffness and/or bending radius characteristics. Figure .. demonstrates the principle of the light modulation in the two-layer (cladding and core) fiber when the fiber diameter is compressed by external force. The core and cladding will be deformed and a certain amount of light is transferred through the core–cladding interface. In order to avoid the pure effect of bending of the fiber, when the fiber is inserted through the tendon (Fig. ..) it must have a loop large enough to exceed the so-called critical bending radius.
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Optic fibre signal (V) Fig. .. Measured forces and moment arms for the calibration of patellar tendon force (PTF). The optic fiber output was related to the muscle force (F) that had been converted from the external force output (F¢) using equation Fd = Fd¢, where d is moment arm of tendon force and d¢ is moment arm of the foot or leg [].
Figure .. demonstrates how the optic fiber is inserted through the tendon. A hollow -gauge needle is first passed through the tendon (a). The sterile optic fiber is then passed through the needle; the needle is removed and the fiber remains in situ (b). Both ends of the fiber are then attached to the transmitter–receiver unit and the system is ready for measurement (c). The
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Optic fiber compression (c) Fig. .. Demonstration of the insertion of the optic fiber into the tendon. (a) After the -gauge needle has been inserted through the tendon, the . mm thick optic fiber is threaded through the needle. The needle is then removed and the optic fiber remains in situ inside the tendon (b), and both ends of the fiber are connected to the transmitter–receiver unit (c). In real measurement situations this unit is much smaller and can be fastened onto the skin of the calf muscles.
calibration procedure usually provides a good linear relationship between external force and optic fiber signal. Figure .. gives a representative example of such a relationship for the patella tendon measurements. Although the optic fiber method may not be more
accurate than the buckle transducer method, it has several unique advantages. First of all it is much less invasive and can be reapplied to the same tendon after a few days of rest. In addition, almost any tendon can be studied provided that the critical bending radius is not exceeded. The optic fiber technique can also be used to
Biomechanics of Locomotion measure the loading of the various ligaments. In the hands of an experienced surgeon the optic fiber can be inserted through even deeper ligaments such as the anterior talofibular ligament []. In such a case, however, special care must be taken to ensure that the optic fiber is in contact with the ligament only and that contact with other soft tissue structures is prevented by catheters.
Foot pressure transducers Force platforms as described above can be used to measure both static and dynamic plantar forces provided that the platform is capable of producing independent measures of both vertical and shear forces. In many applications, both clinical and athletic, it is desirable to have a continuous recording of the pressure distribution under the foot. Forces acting under the foot in various foot pathologies such as diabetic neuropathy, leprosies, injury and deformation are naturally different from these measured in healthy athletes. Post-operative follow-up of corrective surgery such as free flap reconstruction of severe tibial factures can be performed by measuring plantar pressures under the foot []. The behavior of the foot–shoe interface cannot usually be detected with force plates or even with pedopadographs. For this reason discrete in-shoe transducers have been developed. In the basic design a number of pressure-sensitive transducers are implanted in the shoe insole. The sensors can be of different types, such as capacitive, conductive polymer, sensitive ink or various forms of piezoelectric resistors. For technical details the reader is referred to the thorough review article of Cabb and Claremont []. The number of sensors per insole varies depending on the manufacturer. In some cases there can be close to discrete sensors or as few as in one insole. The common rule is that the smaller the number of sensors, the more carefully the sensor locations must be planned in order to match the important anatomic loading sites of the foot. In athletic activities it is desirable to use devices which allow continuous recording for several minutes. In the author’s (Komi) laboratory considerable experience has been gained from the use of a portable, in-shoe pressure data acquisition system (Paromedsystem®, GmBH, Germany) (Fig. ..), which
Fig. .. In-shoe data acquisition system (Paromed-system“, GmBH, Germany) widely used in measurements of plantar pressures during different activities. Both insoles have piezoelectric microsensors embedded into water-filled hydrocells.
measures simultaneously plantar pressure distribution and EMG activities. The system has in each insole piezoelectric microsensors embedded into water-filled hydrocells. The insoles ( in total) and EMG cables (from muscles) are connected to the ‘Data Logger’ which is fixed by a belt to the subject’s back. The sampling frequency for the plantar pressures is Hz. The analysis produces continuous records from each channel and the computer software produces (also continuous) contour curves during the entire contact phase on the ground. Figure .. gives an example of the pressure contours from a patient who had clear asymmetry due to femur length discrepancy. As with any biomechanical method, plantar pressures provide only partial information on locomotion and loading characteristics. For this reason it is very desirable to combine plantar pressure recordings with other parameters obtained from e.g. video cameras and EMG amplifiers. Figure .. is an example of such an arrangement, where ski-jumping take-off is studied using a variety of different measuring techniques []. In addition to plantar pressure measurements, the forces can also be recorded from a -m force plate placed under the take-off table [] or from the smaller force plates implanted into the ski bindings (Pelkonen et al. in progress).
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Fig. .. Example of the plantar pressure contour curves during the contact phase of walking in a patient with considerable leg length discrepancy [].
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Goniometers and accelerometers An electrogoniometer is an analog device used to record joint angles. A simple type of goniometer consists of a potentiometer with two rods, which can be aligned and attached to, for example, the thigh and the shank to measure the knee-joint angle. The potentiometer type of goniometer has to be aligned so that the axis of rotation of the potentiometer is more or less identical to the joint’s axis of rotation. Another type of goniometer is based on strain gauge technology as it measures the bending of a spring. This type has the advantage that it does not need to be aligned to the
Fig. .. Schematic presentation of how plantar pressure measurements can be combined with other biomechanical parameters in the study of ski-jumping [].
joint’s axis of rotation and it is available for measurements in two perpendicular planes, e.g. for flexion/extension and abduction/adduction at the shoulder joint. Three-dimensional goniometers, which also include inward/outward rotation, exist but they are rare. A typical example of the use of goniometers is in the measurement of muscle strength parameters in isokinetic devices. Compression of soft tissues usually dislocates the joint’s axis of rotation with respect to the axis of rotation of the lever arm, resulting in inaccurate data on joint position (Fig. ..) []. Accelerometers are small lightweight transducers
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Fig. .. Knee joint angle and force vs. time measured during a concentric contraction at °/s. The curves labeled ‘KinCom’ and ‘Goniometer’ are angle measurements from the KinCom machine and the knee-mounted goniometer, respectively (‘ deg.’ denotes full extension). The goniometer signal shows the correct knee joint angle because the center of the knee joint becomes misaligned with the machine’s axis of rotation during the maximal contraction [].
capable of measuring acceleration. Like force transducers they can be based on strain gauge or piezoelectric technology. The latter transducers can only measure dynamic events, while an accelerometer based on strain gauges is capable of measuring the gravitational acceleration, when for example lying on a table. Major problems with the use of accelerometers are that they are difficult to ‘mount’ on a human being and that they measure the acceleration in only one direction. One solution is to use three accelerometers mounted perpendicular to each other and then compute the ‘resulting’ acceleration. This gives an accurate value but the direction of the acceleration is largely unknown. The reader is referred to Winter et al. [] and Dyhre-Poulsen et al. [] for examples of the use of accelerometers.
Electromyography Electrical potentials from active muscle fibers may be recorded by intramuscular needle or wire electrodes or on the skin by surface electrodes. During dynamic movement needle electrodes are considered too inconvenient. Wire electrodes are useful for recording from
‘deep’ muscles as surface electrodes have a pick-up depth of only a few mm. Very thin wires (ª mm) are used to record from single motor units but wires of about mm in diameter inserted a few cm apart largely resemble the EMG from surface electrodes. Wire electrodes are difficult to work with, but in some cases there are no alternatives as, for example, with the iliopsoas muscle [,]. To obtain high-quality EMG signals from the skin it is necessary to remove hair and dead cells to reduce skin resistance. Ag/AgCl adhesive electrodes with a lead-off area of ª mm2 with some sort of electrolytic gel are normally placed about cm apart along the estimated muscle fiber direction. A bipolar set-up means that the two electrodes will measure the potentials relative to a reference electrode, preferably placed over bony tissue. The surface EMG is an AC signal, which oscillates between negative and positive values some – times per second. It is, however, a compound signal made of many interfering action potentials from single motor units. Therefore, the surface EMG contains frequency components from about to Hz. Normally, a sampling frequency of Hz is sufficient to obtain an acceptable digital representation of a raw surface EMG. When used for biomechanical movement analysis EMG signals are often full wave rectified and lowpass filtered with a cut-off frequency of about – Hz (Fig. ..). This representation is called a ‘linear envelope’ and it is convenient for quantification in terms of amplitude, integrated EMG and duration. The integrated EMG is the area under the linear envelope. Recordings of EMG during dynamic movement are often contaminated by so-called movement artefacts, which are low-frequency components of the recordings originating from movements of the electrodes rather than being a part of the EMG. In the recording phase such artefacts can be more or less abolished by the use of preamplifiers positioned close to the recording electrodes, because these preamplifiers not only amplify the signal but also lower the impedance before ‘transportation’ through wires to the main amplifier. It is possible to remove movement artefacts further subsequently by application of a highpass filter with a cut-off frequency of – Hz. Electromyography is very useful when combined
Chapter . Biomechanical analysis Offline/online digitization
Fig. .. (a) A so-called ‘raw’ EMG recording of the soleus muscle during walking. In (b) the signal is rectified and all negative values are made positive and in (c) the rectified signal has been lowpass filtered with a cut-off frequency of Hz to form a linear envelope.
with biomechanical movement analysis. Calculation of net joint moments by inverse dynamics gives only the net result of the muscle contractions about the joint. Information about cocontraction cannot be provided without simultaneous EMG recordings.
Computer systems for biomechanical movement analysis can be divided into offline and online systems. The latter may use active or passive markers. Active markers emit light or sound or other signals which are registered by a receiver unit several times per second. Passive markers most often reflect infrared light, which is flashed by special video cameras. The video signal is looped through a special electronic device, which will extract only the light of infrared intensity. The center of each marker is then calculated and x,y-coordinates are transferred to a computer. This whole process runs on line, i.e. – times per second for up to six cameras. As a consequence the visible video pictures are lost and only the coordinates of the small markers placed at anatomic landmarks on the subject are left in a computer. If anything goes wrong, for example if markers passing close by each other get mixed or if a marker cannot be ‘seen’ by at least two cameras at any time, it is often difficult to correct the errors. However, when such systems work perfectly, they can provide almost instant results. Online systems are typically limited to permanent laboratories. Offline systems are based on video recordings. Normally, analog video signals are stored on tape and later sampled by a computer with a so-called frame-grabber. Video recordings from digital cameras can also be input to a computer by commercial interface devices. Once the video sequences exist in digital form in a computer, they can be processed frame by frame by specially dedicated software. Usually contrasting markers are placed at anatomic landmarks on the subject and these can then be digitized manually or semiautomatically to obtain x,y-coordinates from each frame. If the software can identify a large number of markers on most of the frames the process of offline digitization may be fairly fast, meaning for example – min for frames corresponding to a gait cycle of frames per camera and five cameras. A major advantage of offline video analysis is that field events can easily be recorded and analysed even from sports competitions without markers on the subjects.
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Biomechanics of Locomotion R. asis 7
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Fig. .. Vertical displacement of an ankle joint marker during a normal walking cycle. The noisy curve is raw data from digitization while the smooth curve represents the same signal lowpass filtered with a cut-off frequency of Hz (the film was recorded at frames/s).
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Fig. .. Marker placement on a three-dimensional link segment model [].
Noise reduction/filtering In every process of digitization of markers placed on a subject small errors will be present. A marker placed on the skin will move with the skin, but most importantly it is impossible for either a computer or a human being to digitize exactly the center of a marker. These errors represent a kind of noise component superimposed on the pure movement signal (Fig. ..). It can be shown that the noise is of a random character but of an absolute amplitude []. This amplitude may be – mm on a scale of m. The result of a digitization is so-called time–position data and the noisy component seems to affect the time–position data only to a certain degree. However, when the first derivative is taken (differentiation) to obtain velocity data, the noise becomes more evident, and with the second derivative it becomes clear that something has to be done to reduce the errors from digitization. Various types of digital smoothing or filtering can be applied to time–position data to reduce the noise, but most often a so-called th order lowpass Butterworth filter is used to remove frequency components above e.g. Hz. However, this implies that both the noise and some fraction of the real movement signal are attenuated and it follows that movement data will never be accurate when originally obtained as time–position data. After filtering, velocity and acceleration can be calculated so that clear signals are obtained, and provided the same
cut-off frequency is used throughout an experiment the error component can be assumed to be of a constant and systematic nature (Fig. ..).
Link-segment models In a biomechanical analysis of movement the human body is normally converted into a model consisting of rigid body segments connected by hinge joints (two dimensional) or spherical joints (three dimensional) (Fig. ..). The segments are most often assumed to be rigid, each segment mass is set to a certain fraction of the whole body and the segment center of mass is assumed to be located at a certain proportional distance along. The anthropometric data used to establish a link-segment model are normally based on Dempster [] and the model is therefore confined to data from a limited number of Caucasian cadavers. Biomechanics worldwide is in great need of additional anthropometric data relating to ethnic differences. It is obvious that a link-segment model is basically inaccurate in many aspects. However, it is reasonable to assume that the inaccuracies of a model represent a systematic error, which allows the investigator to compare results on the same subject in various situations. Several mechanisms may be studied with link-segment models, while absolute values can never be accurate.
Chapter . Kinematics A kinematic analysis of a movement usually includes calculation of joint angles. An anatomic joint angle is an angle between two segments while a so-called segment angle is between a segment and the vertical or the horizontal plane. Joint angular velocity obtained by time differentiation of angle data is also often considered part of a kinematic analysis, because this parameter can be expressed as, for example, flexion and extension indicated by positive and negative angular velocity, respectively (see Fig. .. above). All positions and velocities are in principle kinematic parameters. Segmental mechanical energy in terms of potential, kinetic and rotational energy also belongs to kinematics, because accelerations are not needed for these calculations.
Kinetics Kinetic parameters are acceleration, force and moment (torque). The most common kinetic parameter is so-called net joint moments calculated by inverse dynamics. These moments provide information as to which muscle group is exerting the strongest force on a joint and how strongly these muscles are pulling on the bones. When no external forces are acting on the body segments of interest, as occurs e.g. during kicking or throwing, the calculation of inverse dynamics is fairly simple. Continuous extension and flexion of the elbow joint represents a situation with no external forces. A calculation of joint moments by inverse dynamics shows that this movement is fairly complicated with regard to muscle action and contraction mode (see Fig. ..). It can be seen that a positive moment in this case indicates extensor muscle dominance while a negative moment indicates flexor dominance. A counterclockwise pulling direction is normally defined as positive. The term dominance refers to the fact that both flexors and extensors may be active simultaneously (cocontraction) and as a consequence a zero moment could theoretically be the result of intensive cocontraction. It is further seen from Fig. .. that flexion and extension are ‘out of phase’ with the joint moment in certain time periods. However, this could merely mean that, for example, the flexor muscles decelerate the last part of the extension and then turn the movement directly into flexion. Multiplication of angular
velocity and joint moment yields power and it is seen that negative power means eccentric muscle work and positive power concentric work (Fig. ..). It is considered an important feature of inverse dynamics that the method can provide information about the contraction mode of the muscles. During jumping, walking and running external reaction forces are applied to the most distal segment, the foot. These forces have to be measured by a force platform together with the center of pressure on the platform, so that the point of force application on the foot can be found on every frame. This method of inverse dynamics is also called the free body segment method, because the calculations are performed on one segment at a time. The calculation includes joint reaction forces acting on both ends of the segment, inertial properties and the influence of the moment from the previous segment (Fig. ..). The joints of the lower extremities are positioned so that a positive moment about the ankle joint is a dorsiflexor moment, a positive moment about the knee joint is an extensor moment and a positive moment about the hip joint a flexor moment. The example of walking shows that the ankle joint is plantar–flexor dominated during the stance phase, the knee joint shows short flexor, extensor, flexor and extensor dominance while the hip joint is extensor dominated in the first half of the stance phase and flexor dominated in the last part of the stance phase (Fig. ..). The reason why walking with flexor dominance about the knee joint is possible without collapsing is that the movement is dynamic and that the three joints of the leg operate together. The moments of the ankle, knee and hip joint are often added to form a so-called support moment representing the action of the whole leg. Doing so requires extensor moments to be considered as positive during the calculation (Fig. ..). If the support moment is positive, the leg will not collapse. Bone-on-bone forces can be calculated as the sum of all forces acting about a joint. After calculation of the net joint moment it is necessary to compute an estimated internal moment arm for the dominating muscle group to obtain the muscle force. Bone-on-bone forces are often confused with joint reaction forces, which are a part of the inverse dynamics calculation (see Fig. ..). Cocontraction about the actual joint will cause the bone-on-bone forces to be underesti-
Biomechanics of Locomotion Fyj θj
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Mp Fig. .. Free body diagram showing the calculation of inverse dynamics in two dimensions. M denotes a moment; F, joint reaction force; EF, external reaction force; I, moment of inertia; a, angular acceleration; m, segment mass; W, m ¥ g of a segment; R a, distance to segment mass center; a, linear acceleration of segment mass center; q, segment angle with respect to the horizontal plane. Suffix j denotes the joint of interest and the proximal end of the segment; p refers to parameters transferred from the previous segment and acting on the distal end of the segment; x, horizontal direction; y, vertical direction.
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mated; it is therefore considered ideal to record an EMG simultaneously. The reader is referred to Scott and Winter [] and Simonsen et al. [] for examples of bone-on-bone forces during locomotion.
Muscle–tendon unit models As mentioned above it is possible to deduce from inverse dynamics whether the muscles contract eccentrically or concentrically. However, this applies to muscles spanning only one joint. Several muscles are bi-articular and their length changes depend on the motion of the two joints they cross. On the basis of cadaver studies [,] it is possible to model a number of muscles in the lower extremities all working in the sagittal plane with flexion or extension. Models of the soleus and the gastrocnemius muscles are seen in Fig. ... The length of a muscle–tendon unit is in this case calculated from origin to insertion. Since the muscle fibers are normally only a few cm long and connected in series with the aponeurosis and tendons it is not possible to separate the length changes of the muscle fibers and the tendinous structures, respectively.
Three-dimensional analysis Using only one camera for a movement analysis limits the calculations to two dimensions (D). This is not necessarily considered a disadvantage since many movements take place primarily in the sagittal plane and a D analysis is much easier to perform than a three-dimensional (D) one []. A D set-up requires that each marker of interest is visible to at least two cameras at any point during the movement. Most systems require some sort of calibration cube to be filmed by all cameras. Digitizing markers on the cube with known coordinates in D makes it possible to calculate the exact position of the cameras and to calculate further the third dimension of each marker by so-called direct linear transformation [].
Three-dimensional kinetics The complexity of calculating joint moments by inverse dynamics increases almost exponentially when advancing from D to D. In D it is necessary to compute joint centers, but the biomechanical commu-
Chapter . MV
Fy
1000
Ground reaction
N Fx 0 60
Support Hip Knee Ankle
Hip flex. Knee ext.
Nm
Joint moments Plantar flex.
m
–130 300
0.524 RF
0 500
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0 400
0.409 0.320
0 1000
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µV
VL
SO 0 1000
0.319 0.348
0.332 1300
TA 100
300
500
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nity suffers from the lack of anthropometric data for this purpose. The formulas published by Vaughan et al. [] are often used, but these formulas are only based on X-ray data from one subject and alternative formulas are mostly substantiated. Another complication with D is that calculation of joint centers is closely related to specific marker set-ups. It is necessary to place three markers on each segment in order to calculate the segment’s attitude, which again allows for calculation of joint moments about anatomic axes. This means that, for example, a hip flexor moment can
Fig. .. A complete twodimensional analysis of one walking cycle consisting of recordings from film, force platform and EMG. From top to bottom: stick-diagram of the movement, ground reaction forces (the horizontal line represents body mass), net joint moments of ankle, knee and hip joint and the total support moment of the leg, rectified EMGs from the rectus femoris, semitendinosus, vastus lateralis, soleus and tibialis anterior muscles with changes in muscle–tendon lengths superimposed on the EMGs (inflection denotes lengthening of the muscle–tendon unit).
be recognized irrespective of how the subject turns in space during the recorded movement. A major drawback of the D approach is that only few joints are spherical joints. For example, it seems nonsensical to calculate abduction/adduction moments about the knee joint. Nevertheless relatively large moments of abduction/adduction about this joint appear from a D kinetic analysis of walking or running []. Moments of internal/external rotation must also be considered very uncertain due to small movements of segment rotation about a longitudinal axis.
Biomechanics of Locomotion (a)
(b) K
o
l1
K
η2
o l2
A
l2
η3
n
i ζ F
A
η3
n
i ζ F
Fig. .. Trigonometric models of (a) the soleus and (b) gastrocnemius muscles (the two heads are lumped). K, knee joint; A, ankle joint; i, insertion; o, origin; h2, knee joint angle; h3, ankle joint angle; l2, length of the soleus muscle–tendon unit; l1 + l2, length of the gastrocnemius muscle–tendon unit; zF is an angle taken from Frigo and Pedotti [].
Fig. .. Illustration of a three-dimensional link-segment model consisting of pelvis, thigh, shank and foot segments connected by spherical joints. The markers used for digitization are shown; in this case the Helen Hays marker set-up was used, which includes some of the markers on wands sticking out from the segments. To calculate joint moments representing anatomic flexion/extension, abduction/adduction and inward/outward rotation no matter how the subject is oriented in space, it is necessary to define local segment coordinate systems, which are related to the global reference coordinate system of the laboratory. (Adopted from Arial Dynamics Inc.)
Inverse dynamics
Fig. .. The top flow diagram illustrates the process of inverse dynamics. However, the position data are not coordinates of markers but a joint angle calculated using marker coordinates. The lower panel shows the process of forward dynamics (simulation), where you start with muscle force and end with movement. q is a joint angle, w angular velocity, a angular acceleration, I moment of inertia, t muscle moment, l internal moment arm, F muscle force and Dt a time constant.
∆θ =ω ∆t
ω
∆ω =α ∆t
α
τ = ⋅α
τ
F=
τ l
θ
∆t
Simulation Calculation of net joint moments by inverse dynamics is called inverse because one actually works in the opposite direction to nature when measuring the movements and the external forces used to calculate the muscle forces that generated the movement. Using forward dynamics represents a method which simulates biology in the sense that you build a link-segment
F
θ =ω⋅∆t
ω
ω =α⋅∆t
α
α=
τ
τ
τ = F⋅l
Forward dynamics (simulation)
model in a computer with muscles attached to the segments (Figs ..–..). The muscles possess anatomic and physiologic properties like fiber length, tendon length, tendon compliance, internal moment arms of the muscles, force–velocity relationship and length–tension relationship. The computer is then programmed to activate the muscles in random order until the desired movement is accomplished, which
Chapter . Gerritsen et al. [] found that a simulation model of human walking driven by simulated muscles could recover from a sudden perturbation while a model driven by ‘mechanical’ joint moments lost balance and fell to the floor.
Examples of biomechanical investigations Different movement strategies in vertical jumping Vertical jumping is often used as a standard test for dynamic strength in the lower extremities. Three types of vertical jumps prevail in the literature: (i) drop jump, in which the subject starts by jumping downward from a box onto the floor and performs a vertical jump immediately after the landing: this is a typical SSC (stretch–shortening cycle) type of exercise; (ii) countermovement jump, which is also an SSC exercise but with less eccentric loading; and (iii) squat jump (Figs .. and ..), where the subject starts from a static squatting position, i.e. a movement ideally consisting of pure concentric contractions. Fig. .. Illustration of a computer model for simulation of walking. (Adopted from Musculographics Inc.)
may take weeks or months. Optimization of a simulation model is accomplished with a so-called cost function, which signifies the target of the simulation or rather the criteria of success. Performance optimization is, for example, the length of a long jump calculated theoretically from the vertical and horizontal velocities of a long jump model at take-off, but the same movement may be optimized by tracking the joint displacements or the ground reaction forces produced by a real long-jumper. For a review see van den Bogert []. It is often necessary to perform experiments with inverse dynamics to verify the behavior of a model. However, once a simulation model moves realistically it is possible to ‘ask’ the model questions, which cannot easily be investigated experimentally with real subjects. Examples of such questions or rather manipulations are to make certain muscles stronger or weaker or to move the insertion point of a muscle. It is also possible to apply perturbations to a moving model.
Direct in vivo tendon forces during normal locomotion Normal locomotion and/or muscle function usually refers to stretch–shortening cycles [], where the active muscle is first stretched (eccentric action) prior to shortening (concentric action). The purpose of SSC is to make the performance more efficient as compared to isolated forms of either isometric or concentric actions. Figure .. is a typical example of how the buckle transducer technique, which can be used to characterize the loading of the triceps surae muscle– tendon complex, is combined with simultaneous EMG recordings. The figure shows several important features of the loading characteristics in this example of moderate-speed running. First, the changes in the muscle–tendon length (segment length) are very small (–%) during the stretching phase. This suggests that the conditions favor the potential utilization of short-range elastic stiffness (SRES) [] in the muscle. Various length changes are reported in the literature demonstrating that the effective range of SRES in in vitro preparations is –% [,]. In the intact muscle tendon, in vivo, this value is increased because series
Biomechanics of Locomotion
Nm
TO
SJ
700 500 o/s 300 100 –100 500
Hip joint Knee joint Ankle joint Angular vel.
300 100
–100 3000 2000 w 1000 0 –1000 800
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Power m. glut. max.
0 500
m. add. magn.
0 2500
Fig. .. A squat jump performed with a simultaneous strategy. From top to bottom: stick diagram showing a subset of the frames, which were recorded at Hz; angular velocity of extension; net joint moments; net joint power; and rectified EMG from seven muscles. Extensor-dominated moments are all positive and positive power indicates concentric contractions. SJ is start of the jump and TO is toe-off.
µV
m. rect. fem.
0 1500
m. vast. lat.
0 800
m. semit.
0 2000
m. gastroc.
0 1500 m. soleus 0 –300
elasticity and fiber geometry must be taken into account. This could then increase the muscle–tendon lengthening to –%. When measurements are made at the muscle fiber level the values could be naturally smaller, as shown by Roberts et al. [] in turkeys running on level ground. Achilles tendon force (ATF) curves similar to the one shown in Fig. .. can then be used to plot both the peak-to-peak ATF and the rate of ATF development during ground contact against the running velocity. This presentation is from a subject who was
–200
–100 Time (ms)
100
able to run at different velocities (ranging from to m/s) with the buckle transducer around his AT. The figure shows that the maximum ATF seems to have reached its highest value by a speed of m/s, in which case the value was kN corresponding to . body weight (BW). As the cross-sectional area of the tendon was . cm2, the peak force for this subject was . kN/cm2, a value which is well above the range of the single load ultimate tensile strength []. The qualitative presentation shows that the maximum rates of ATF development, measured during the sharp
Chapter .
SJ
700 500 o/s 300 100 –100 500 Nm
TO Hip joint Knee joint Ankle joint
300
Angular vel.
100 –100 3000 2000 w 1000 0 –1000 1500
Net. moment
Power m. glut. max.
0 800
m. add. magn.
0 2500
µV
m. rect. fem.
0 1500
m. vast. lat.
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m. semit.
0 2000 m. gastroc.
0 1500
m. soleus
0 –300
–200
–100 Time (ms)
rising phase after the contact, increased linearly with the increase in running velocity during contact. This information is important, because it suggests that the rate of force development rather than the peak-to-peak force may be more relevant for characterizing biological tissue loading during locomotion. It is well known from basic muscle physiology that the force–velocity (F–V) relationship [] describes the fundamental mechanical properties of human muscle. This Hill curve differs, however, in one fundamental respect from the natural situation: the forces
100
Fig. .. A squat jump performed with a sequential strategy. From top to bottom: stick diagram showing a subset of the frames, which were recorded at Hz; angular velocity of extension; net joint moments; net joint power; and rectified EMG from seven muscles. Extensor-dominated moments are all positive and positive power indicates concentric contractions. SJ is start of the jump and TO is toe-off.
are measured during constant (maximal) activities. In natural and normal locomotion, such as SSC of Fig. .., the EMG activity is variable and not constant in any parts of the cycle. Thus the instantaneous force– velocity curves measured for the functional contact phase are consequently very different from the classical curve obtained for pure concentric actions with isolated preparations [] or with human forearm flexors [,]. Figure .. gives examples of the instantaneous F–V curves for running (a) and hopping (b). The
Biomechanics of Locomotion B
C
10
1 mV
M. tibialis anterior
Tendon force (kN)
A
1 mV M. gastrocnemius
(a)
8 6 4
Heel running Ball running
2 0 3
4
5
6
7
8
9
8
9
M. soleus 0 %
Segment length (∆%)
10 500 N
Vertical force
Achilles tendon force
500 N
Horizontal force
100 N 100 ms
Fig. .. Demonstration of stretch–shortening cycle (SSC) for the triceps surae muscle during the (functional) ground contact phase of human running. Top: Schematic position representing the three phases of SSC (preactivation (A), eccentric (B) and concentric (C)). The rest of the curves represent parameters in the following order (from top to bottom): rectified surface EMG records of the tibialis anterior, gastrocnemius and soleus muscles; segmental length changes of the two plantar flexor muscles; vertical ground reaction force; directly recorded Achilles tendon force; and the horizontal ground reaction force. The vertical lines signify, respectively, the beginning of the foot (ball) contact on the force plate and the end of the eccentric phase. The subject was running at moderate speed [].
buckle experiments (left) did not include comparative records obtained in a classical way, but the form of the FV curves suggests considerable force potentiation in the concentric phase. Our recent experiments with the optic fiber technique, although not yet performed at high running speeds, suggest similar potentiation. The right side of Fig. .. shows simultaneous plots for both patella and AT forces during hopping. The
Tendon force development (kN/s)
1 mV 200 (b) Ball running
150 100
Heel running
50 0
3
4
5
6
7
Running velocity (m/s) Fig. .. Peak Achilles tendon forces (a) and peak rates of tendon force development (b) for one subject running at different velocities. The buckle transducer was implanted around the subject’s Achilles tendon [].
data signify that in short contact hopping the triceps surae muscle behaves in a bouncing ball-type fashion (see also [,]). When the hopping intensity is increased or changed to countermovement-type jumps, the patella tendon force increases and the AT force may decrease []. The classical type of curve obtained with constant maximal activation for an isolated concentric action is also superimposed with the AT force in the same graph (Fig. .., right). The shaded area between the two AT curves suggests a remarkable force potentiation for this submaximal effort. The direct in vivo technique reliably measures the forces in the tendon (and ligament), but the results and relationships obtained cannot, however, be used to generate simultaneous information about: (i) the change in length of the muscle fibers; (ii) the change in the fiber orientation with the line of force application; or (iii) the change in length of the tendinous compartment. Thus the force–velocity curves presented in Fig. .. must be interpreted more correctly as referring
Chapter . (a)
F 10
4
(b) 5.78 m / s
3
8 6
F AT
2
9.02 m / s
4 1 2 –1.5
–1
–0.5
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1
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2
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–0.4
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0.2
0.4
0.6
Velocity (m / s)
Fig. .. Examples of instantaneous force–velocity curves measured in (a) human running and (b) hopping. The records on the left were obtained with the buckle transducer [] and those on the right with the optic fiber []. Each record is for a functional (contact) phase on the ground. In each curve the upward deflection signifies stretching (eccentric actions) and the downward deflection shortening (concentric action) of the muscle tendon complex during ground contact. The velocity axis has been derived from segmental length changes according to Grieve et al. [].
to the function of the muscle–tendon as one entity. However, experiments are currently in progress to utilize a relatively high resolution and frame rate (> Hz) ultrasound technique to capture the movements in the fascicle compartment during SSC actions in combination with the optic fiber and EMG recordings for both triceps surae and quadriceps femoris muscles.
Plantar pressures during sporting activities The basic methodology of plantar pressure recording was introduced above on p. . The experimental setup shown schematically in Fig. .. was successfully used in actual ski-jumping. Figure .. gives examples of how this methodology produced results from the various plantar pressure sensors and from the EMG activities recorded from selected muscles. It is clear from simple observation of Fig. .. that the jumper ML had a clearly unbalanced take-off as shown by dramatic bilateral differences in the pressure contours at the moment of take-off. These results also demonstrate that during the run-in and take-off, the locations which detect the pressures are primarily points and (heel area) and and (toe area). Figure .., on the other hand, gives a unique demonstration of the plantar pressures of selected insole points and EMG activities throughout the entire ski-jumping performance, including not only the takeoff but also the entire run-in, flight and landing. While ski-jumping take-off represents an explosive
type muscle action with relatively small impact loading, the triple jump is an activity where the impact loads on muscle, joint and bones are probably the highest of all sporting activities (Figs ..–..). Figure .. gives an example of the ground reaction forces and plantar pressures (one sensor only) during the contact phases of the hop, step and jump. In these situations the maximal vertical force (Fz) can exceed kN in the braking phase, being slightly higher on the ‘step’ contact as compared to ‘hop’ or ‘jump’ of the triple jump. In relative units these values represent – times the body weight. When compared with normal walking, for example, the triple jump loading, as measured with Fz ground reaction forces, is almost times greater.
Modeling anterior cruciate ligament loadings at the knee joint A side-cutting maneuver is an important and common movement in many sports events, especially ballgames. The purpose of the maneuver is to pass a defending player by faking the direction opposite to the intended movement. Normally, the player will approach the defending player head on, touch down on the left foot, brake the forward velocity and step to the right side. During the braking action, the quadriceps femoris muscle contracts eccentrically causing an anterior shear force on the tibia that stresses the anterior cruciate ligament (ACL) of the knee joint (Fig. ..). The peak knee joint moment ( Nm) calcu-
Biomechanics of Locomotion
Take-off
Run-in
Jumper ML 82 m,22.4 m/s
Jumper APN 93 m,23.2 m/s
Fig. .. An example of the selected pressure, EMG (GL, gluteus; VL, vastus lateralis; GA, gastrocnemius) and sync pulse curves from one ski-jump with run-in speed of . m/s and length of jump m [].
EMG (mV)
Plantar pressure (N/cm2)
Fig. .. Examples of the pressure contours from two different ski jumpers (ML and APN) during the run-in and take-off phases. Sensor locations of the pressure insoles are shown as well [].
Landing
Take-off 20
Run-in
Curve
Flight L #2
20 20 20 20
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1 GL 1
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Chapter . lated by inverse dynamics was found to occur during the braking action at a knee joint angle of ° (average of six subjects). The model then showed an average shear force on the ACL of N (range – N) (Fig. ..). The ACL has been shown to have a maximum strength of N in young people []. Therefore, the side-cutting maneuver cannot directly cause a rupture of a normal ACL []. The hamstring muscles have frequently been sugHop
Step
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Fz Fy
5000 N
P14
50 N cm2
GM
0.5 mV
2500 N
gested to be able to lower the loadings on the ACL. However, an EMG analysis showed that these muscles were only moderately activated during the braking action of the side-cutting maneuver. The peak amplitudes of the medial and lateral hamstrings were and % of maximum EMG, respectively (Figs .. & ..). In comparison the vasti were activated close to %. Estimates of shortening and/or lengthening velocities were calculated by muscle models based on cadaver data from Frigo and Pedotti [] and expressed as percentage muscle fiber length per second using cadaver data from Wickiewicz et al. []. These calculations showed that the hamstring muscles shortened during the braking action and that the shortening velocity was up to about % fiber length per second, which strongly indicates that the muscles cannot produce force of any significance in this situation. Thus the hamstring muscles cannot reduce ACL loadings during a side-cutting maneuver [].
Summary 100 ms Fig. .. Example of the two-dimensional ground reaction forces, plantar pressure distribution of the forefoot sensor (P), and raw EMG signal of the gluteus maximus (GM) in the triple jump. The length of jump was . m [].
1000
15 16 14 11 10
13 12
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Pressure (kPa)
Walking Hop of the triple jump Step of the triple jump Jump of the triple jump
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8
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7
Biomechanics is an interdiscipline mostly concerned with movement analysis. The laws of physics are used to calculate strain applied to anatomic structures during movement. Movements are recorded by video cameras, and small markers or sensors are placed on the subject at anatomic landmarks. The video signals
6 4 1
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3
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Fig. .. Example of the peak pressures of the various sensors for one male jumper measured during the hop, step and jump phases of the triple jump and during walking. The missing standard deviation bars indicate that the signals exceeded the range of sensors [].
Biomechanics of Locomotion Hop
Step
Jump
Touchdown
Midstance
Fig. .. The contour curves of the plantar pressures measured ms after touchdown, in the middle of the stance phase and the toe-off. The arrows indicate jumping direction [].
Toe-off
700
Pressure (kPa)
P6
600
r = 0.96 P < 0.01 n = 10
P9 r = 0.92 P < 0.01 n = 10
P12 r = 0.88 P < 0.01 n = 10
Q
500
b H
400
β F 10
11
12 13 Length (m)
14
15
a
C
P
Hs Fig... Relationship between the length of the triple jump and the peak plantar pressures of the lateral forefoot (sensors , and ) of one experienced male jumper measured during the hop, step and jump.
are analysed by computer in real time or off line depending on the specific equipment. The coordinates of the markers are used to calculate velocities and accelerations and joint angles, and when combined with measurements of external forces acting on the body, net joint moments or muscle forces can be calculated by a method called inverse dynamics. Movement analysis in three dimensions requires the use of several video cameras recording from different views. The third dimension is then calculated by direct linear transfor-
T
Qs Fig. .. A biomechanical model of the knee joint intended to evaluate stress applied to the anterior cruciate ligament during movement. Abbreviations: F, femur; T, tibia; P, patella; C, force acting on the anterior cruciate ligament; Q , quadriceps femoris muscle; H, hamstring muscles; Qs, quadriceps shear force; Hs, hamstring shear force; and b, the angle between a and b signifying the angle of the patellar ligament relative to tibia, which changes with the position of the knee joint.
Chapter .
2000 Fy
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mation. External reaction forces are most often measured by force platforms, but a detailed pressure distribution of the plantar surface of the foot can also be measured using special devices mounted inside a shoe. Power generated by the muscles during movement
550
Fig. .. One subject performing a side-cutting maneuver. From top: stick diagram of the left leg during a sidecutting maneuver; the vertical (Fy) and the horizontal (Fx) ground reaction force; the net knee joint moment; EMG from five leg muscles. The EMGs are linear envelopes and expressed relative to a maximum EMG measured during isometric conditions. The curves superimposed on the EMGs are estimates of muscle–tendon unit length changes. Inflection indicates lengthening. Abbreviations: VM, vastus medialis; VL, vastus lateralis; Gmax, gluteus maximus; SMT, semitendinosus and semimembranosus muscles, BFcl, biceps femoris caput longum muscle.
may be calculated using net joint moments and angular velocity. Muscle power then provides detailed information about the muscle activity with regard to eccentric and concentric contractions.
Biomechanics of Locomotion
100 m. tlb. ant. 0 100 m. soleus 0 100 m. gas. lat. 0 100 m. gas. med. 0 100
% maximal EMG
m. biceps fem. 0 100 m. semitend. 0 100
m. glut. max.
0 100
m. vastus lat. 0 100 m. vastus med. Fig. .. Linear envelope EMGs from seven leg muscles recorded during a side-cutting maneuver. The bottom panel is the vertical ground reaction force. The data represent an average of trials across six subjects and are expressed relative to maximum EMG. Error bars are standard error of the mean.
0 1800
N Ground reaction
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Chapter . Multiple choice questions a b c a b c a b c a b c a b c
Noisy movement data are filtered with a: highpass filter bandpass filter lowpass filter. Inverse dynamics is a method used to calculate: joint moments joint angles angular acceleration. A goniometer measures: acceleration velocity angles. Center of pressure is measured on: a force platform the floor the foot. Tendon forces may be measured using: a force platform optic fibers EMG.
References Salmons S. The th International Conference on Medical and Biomechanical Engineering — meeting report. Bio Med Eng ; : –. Komi PV. Physiological and biomechanical correlates of muscle function: Effects of muscle structure and stretchshortening cycle on force and speed. Exerc Sport Sci Rev/ACSM ; : –. Komi PV, Salonen M, Järvinen M, Kokko O. In vivo registration of Achilles tendon forces in man. I. Methodological development. Int J Sports Med ; : –. Komi PV. Relevance of in vivo force measurements to human biomechanics. J Biomech ; (Suppl. ): –. Gregor RJ, Komi PV, Browing RC, Järvinen M. A comparison of the triceps surae and residual muscle moments at the ankle during cycling. J Biomech ; : –. f*ckashiro S, Komi PV, Järvinen M, Miyash*ta M. Comparison between the directly measured Achilles tendon force and the tendon force calculated from the ankle joint moment during vertical jumps. Clin Biomech ; : –. Voigt M, Dyhre-Poulsen P, Simonsen EB. Stretch-reflex control during human hopping. Acta Physiol Scand ; (): –. Komi PV. Stretch-shortening cycle: a powerful model to study normal and fatigued muscle. J Biomech ; : –. Komi PV, Belli A, Huttunen V, Bonnefoy R, Geyssant A, Lacour JR. Optic fiber as a transducer of tendomuscular forces. Eur J Appl Physiol ; : –.
Bocquet J-C, Noel J. Sensitive skin-pressure and strain sensor with optical fibres. In: Proceedings of nd Congress on Structural Mechanics of Optical Systems, – January , Los Angeles, California, USA. Candau R, Belli A, Chatard JC, Carrez J-P, Lacour J-R. Stretch shortening cycle in the skating technique of cross country skiing. Sci Motricité ; : –. Arndt AN, Komi PV, Brüggemann G-P, Lukkariniemi J. Individual muscle contributions to the in vivo Achilles tendon force. Clin Biomech ; : –. Finni T, Komi PV, Lepola V. In vivo muscle dynamics during jumping. In: Third Annual Congress of the European College of Sport Science, – July , Manchester, UK. Finni T, Komi PV, Lepola V. In vivo human triceps surae and quadriceps femoris muscle function in a squat jump and counter movement jump. Eur J Appl Physiol ; : –. Alt W, Lohrer H, Gollhofer A, Komi P. Estimation of ankle ligament load using a fiber optic transducer in vivo. ; in press. Perttunen JR, Nieminen H, Tukiainen E, Kuokkanen H, Asko-Seljavaara S, Komi PV. Asymmetry of gait after free flap reconstruction of severe tibial fractures with extensive soft-tissue damage. Scand J Plastic Reconst Surg Hand Surg ; (): –. Cabb J, Claremont DJ. Transducers for foot pressure measurement: survey of recent developments. Med Biol Eng Computing ; : –. Komi PV, Virmavirta M. Ski jumping take-off performance: determining factors and methodological advances. In: Müller E, ed. Science and Skiing. Cambridge: Chapman & Hall, Cambridge University Press, : –. Virmavirta M, Avela J, Komi PV. A comparison of different methods to determine the take-off velocity in vertical jumps. In: Häkkinen K, Keskinen KL, Komi PV, Mero A, eds. Book of Abstracts. XVth International Congress of Biomechanics, : –. Sørensen H, Zacho M, Simonsen EB, Dyhre-Poulsen P, Klausen K. Joint angle errors in the use of isokinetic dynamometers. Isokinetics Exerc Sci ; : –. Winter DA, Wells RP, Orr GW. Errors in the use of isokinetic dynamometer. Eur J Appl Physiol Occup Physiol ; : –. Dyhre-Poulsen P, Laursen AM. Programmed electromyographic activity and negative incremental muscle stiffness in monkeys jumping down. J Physiol ; : –. Dorge HC, Andersen TB, Sørensen H, Simonsen EB, Aagaard H, Dyhre-Poulsen P, Klausen K. EMG activity of the iliopsoas muscle and leg kinetics during the soccer place kick. Scand J Med Sci Sports ; (): –. Andersson EA, Nilsson J, Thorstensson A. Intramuscular EMG from the hip flexor muscles during human locomotion. Acta Physiol Scand ; (): –. Winter DA. Biomechanics and Motor Control of Human Movement. New York: John Wiley & Sons, Inc., . Dempster WT. Space Requirements of the Seated Operator.
Biomechanics of Locomotion
WADC Technical Report. Ohio: Wright Patterson Airforce Base, : –. Scott SH, Winter DA. Internal forces at chronic running injury sites. Med Sci Sports Exerc ; (): –. Simonsen EB, Dyhre-Poulsen P, Voigt M, Aagaard P, Sjøgaard G, Bojsen-Møller F. Bone-on-bone forces during loaded and unloaded walking. Acta Anat ; : –. Frigo C, Pedotti A. Determination of muscle length during locomotion. In: Asmussen E, Jørgensen K, eds. International Series of Biomechanics VI-A : –. University Park Press, Baltimore. Grieve DW, Pheasant S, Cavanagh PR. Predictions of gastrocnemius length from knee and ankle joint posture. In: Asmussen E, Jorgensen K, eds. Biomechanics VI-A. Baltimore: University Park Press, : –. Alkjær T, Simonsen EB, Dyhre-Poulsen P. Comparison of inverse dynamics calculated by two- and three-dimensional models during walking. Gait Posture ; in press. Miller NR, Shapiro R, McLaughlin TM. A technique for obtaining spatial kinematic parameters of segments of biomechanical systems from cinematographical data. J Biomech ; : –. Vaughan CL, Davis BL, O’Connor JC. Dynamics of Human Gait. Leeds, UK: Human Kinetic Publishers, : –. van den Bogert AJ. Analysis and simulation of mechanical loads on the human musculoskeletal system: a methodological overview. Exerc Sports Sci Rev ; : –. Gerritsen KG, van den Bogert AJ, Hulliger M, Zernicke RF. Intrinsic muscle properties facilitate locomotor control — a computer simulation study. Motor Control ; : –. Rack PMH, Westbury DR. The short range stiffness of active mammalian muscle and its effect on mechanical properties. J Physiol ; : –. Ford LE, Huxley AF, Simmons RM. Tension responses to sudden length change in stimulated frog muscle fibres near slack length. J Physiol ; : –. Huxley AF, Simmons RM. Proposed mechanism of force generation in striated muscle. Nature ; : –.
Roberts TJ, Marsch RL, Weyand PG, Taylor CR. Muscular force in running turkeys. the economy of minimizing work. Science ; : –. Butler DL, Grood ES, Noyes FR. et al. Effects of structure and strain measurement technique on the material properties of young human tendons and fascia. J Biomech ; : –. Hill AV. The heat and shortening of the dynamic constant of muscle. Proc Royal Soc London, B ; : –. Wilkie DR. The relation between force and velocity in human muscle. J Physiol ; : . Komi PV. Measurement of the force–velocity relationship in human muscle under concentric and eccentric contraction. In: Jokl E, ed. Medicine and Sport, Biomechanics III, Vol. . Basel: Karger, : –. f*ckashiro S, Komi PV. Joint moment and mechanical power flow of the lower limb during vertical jump. Int J Sports Med ; : –. Woo SL, Hollis JM, Adams DJ, Lyon RM, Takai S. Tensile properties of the human femur–anterior cruciate ligament–tibia complex. The effects of specimen age and orientation. Am J Sports Med ; : –. Simonsen EB, Magnusson SP, Bencke J, Næsborg H, Havkrog M, Ebstrup JF, Sørensen H. Can the hamstring muscles protect the anterior cruciate ligament during a side-cutting maneuver. Scand J Med Sci Sports ; : –. Wickiewicz TL, Roy RR, Powell PL, Edgerton VR. Muscle architecture of the human lower limb. Clin Orth Rel Res ; : –. Perttunen JR, Kyröläinen H, Komi PV, Heinonen A. Biomechanical loading in the triple jump. J Sports Sci ; : –. Komi PV. Stretch–shortening cycle. In: Komi PV, ed. Strength and Power in Sport. The IOC Encyclopaedia of Sports Medicine, Vol. III. Oxford: Blackwell Scientific Publications : –. Virmavirta M, Komi PV. Plantar pressures during ski jumping take-off. J Appl Biomechan ; (): –.
Chapter 1.6 Connective Tissue in Ligaments, Tendon and Muscle: Physiology and Repair, and Musculoskeletal Flexibility PETER MAGNUS S ON, TI MO TA KA LA , STEVEN D. AB RA MOWI TCH, JOHN C. LOH & SAVI O L - Y. WOO
Classical reference Woo S.L-Y. et al. Mechanical properties of tendons and ligaments II. The relationships of immobilization and exercise on tissue remodeling. Biorheology ; : –. Considering the enormity of problems related to injuries to tendons and ligaments, relatively little used to be known about the stress-related remodeling of these soft tissues. Tipton, Akeson, Noyes and Woo are credited with demonstrating the deleterious effects of immobilization on tendons and ligaments around the knee, including joint stiffness and significant weakening of the biomechanical properties of ligaments. On the other hand, studies were also performed to reveal the positive, but limited, effects of exercise on the properties of tendons and ligaments. It was then possible to establish a non-linear relationship between increased or decreased stress and motion, and the homeostasis of soft tissues. Whether these processes cause changes in the mechanical properties or changes in the mass of these tissues, or both, was the subject addressed in the paper by Woo and coworkers. Using a rabbit model, femur–medial collateral ligament–tibia complexes (FMTC) were tensile tested after and weeks of immobilization, and after weeks of immobilization followed by weeks of
remobilization. It was found that the - and -week immobilized groups had failure loads of only % and %, respectively, of the contralateral controls (P < .) with all specimens failing by tibial avulsion. In the remobilized groups, the mechanical properties of the FMTC remained inferior to the controls and the mode of failure was still tibial avulsion. The effects of short-term ( months) and long-term ( months) exercise in the swine digital extensor and flexor tendons were also compared. Animals were exercised by running at a speed of – km/h for a total of km/week. In the extensor tendon of the forepaw, exercise had no significant effects on mechanical properties in the short term, but long-term increases in cross-sectional area and tensile strength over those of age-matched, non-exercised controls were observed. On the other hand, in the flexor tendon, there were no significant effects on mechanical properties nor cross-sectional area of the tissue substance, but there was a % increase in ultimate load which could be attributed to an increase in strength of the tendon–bone junction. As a result of the data obtained in this study, together with those published by Noyes, Tipton and Laros, a hypothetical curve was drawn to represent the homeostatic response of soft tissues in response to stresses and motion, depicting a highly non-linear relationship (Fig. ..). Immobilization can significantly compro-
Connective Tissue in Ligaments, Tendon and Muscle Decrease stress
Tissue mass, tissue stiffness, and strength
Immobilization
Increase stress Normal activity
Exercise
In-vivo loads and activity levels Fig. .. Hypothetical response of ligaments to levels of stress.
mise both the structural properties of the bone– ligament–bone complex and the mechanical properties of the ligament, with weakening more pronounced at the insertion sites. The effects of exercise or increased tension are much less pronounced, as the gains are minimal even with a substantial duration of exercise.
Biochemical composition of muscle extracellular matrix: the effect of loading Extracellular matrix Multicellular organisms are formed of specialized cells that are assembled in tissues. The extracellular matrix (ECM) outside the cells is a complex and dynamic meshwork that contains collagens, noncollagenous glycoproteins, proteoglycans and elastin. The extracellular matrix supports the cellular elements and maintains the structural integrity of multicellular organisms. Further, it helps cells to bind together and regulates various cellular processes, such as cell growth, proliferation, differentiation, migration and adhesion.
Skeletal muscle collagen Collagen is the most abundant protein of the ECM and constitutes about –% of all protein in the body []. To date distinct collagen types have
been identified in vertebrates []. They are usually divided into two subgroups on the basis of their supramolecular structures: fibrillar-forming and nonfibrillar-forming collagens. In skeletal muscle, collagen is mainly present in three fibrillar-forming forms, collagen types I, III and V, and one non-fibrillarforming collagen, type IV of basem*nt membranes [,]. Of these, types I and III are the most abundant. In addition, collagen types II, XI, XIII, XIV, XV and XVIII have been found in skeletal muscle and type VI in cardiac muscle [–]. In epimysium and perimysium collagen type I and III are present, with the former dominating, while all major collagen types have been observed in the endomysium [,]. It has been shown that slow-twitch muscles contain more collagen than fast-twitch muscles [–], and that the concentration of endomysial collagen is higher around slow than fast skeletal muscle fibers in rats [].
Post-translational processing of collagen In skeletal muscle collagen is produced principally by fibroblasts on the membrane-bound ribosomes of the rough endoplasmic reticulum. Collagen biosynthesis is characterized by the presence of an extensive number of co- and post-translational modifications of the polypeptide chains, which contribute to the quality and stability of the collagen molecule [] (Fig. ..a). The polypeptide chains form triple-helical procollagen molecules that are secreted into the extracellular space by exocytosis. Procollagens contain aminoterminal and carboxy-terminal extension peptides at the respective ends of the collagen molecule, and after secretion, the amino-propeptides are cleaved by specific proteinases and the collagens self-assemble into fibrils or other supramolecular structures. The three polypeptide chains, which form the triple-helical structure, are called a-chains. The molecular organization of the different collagen types differs so that type I collagen is a heterotrimer of two identical a(I) chains and one a(I) chain, type III collagen is a hom*otrimer with a(III) chains. The most common form of type IV collagen consists of two a(IV) chains and one a(IV) chain, although other forms also exist. The a-chains are composed of repeating amino acid sequences Gly-X-Y, where the glycine residue in every third position enables the three a-chains to coil around one another. Proline and
Chapter . (a)
DNA
DNA
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Fig. .. (a) Collagen expression. Scheme of pre- and post-translational events in collagen expression (PH, prolyly -hydroxylase; LO, lysyl oxidase). PH activity correlates with collagen synthesis. LO activity is required for formation of pyridinoline cross-linked stable collagen. (b) Collagen degradation. Matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) regulate the degradation of collagen.
-hydroxyproline residues appear frequently at the Xand Y-positions, respectively, and promote the formation of intermolecular cross-links []. The stability and quality of the collagen molecule are largely based on the intra- and intermolecular cross-links. The hydroxyproline as a part of the polypeptide chain is an almost unique feature of collagen, and its assay is therefore suitable for evaluating collagen content []. The formation of -hydroxyproline is catalyzed by
prolyl -hydroxylase (PH). The levels of PH activity generally increase and decrease with the rates of collagen biosynthesis, and assays of the enzyme activity have been used for estimating changes in the rate of collagen biosynthesis in many experimental and physiologic conditions [,–]. The activity of galactosylhydroxylysyl glucosyltransferase (GGT), another post-translational enzyme of collagen synthesis, also reflects the rate of collagen biosynthesis, although the changes in GGT activity are usually less pronounced and occur more slowly than in the case of PH [,,,–].Total collagen concentration is –% higher in slow-twitch than in fast-twitch muscle []. The concentration is higher both around individual type I fibers than type II fibers, and in the endomysium and perimysium of slow-twitch muscle than fast-twitch muscle []. Muscle is attached to its tendon at the end of the fibers, where the collagen fibrils of muscle fuse or interdigitate with the collagen fibrils of the tendon []. Collagen degradation is initiated by matrix metalloproteinases (MMPs), which are present in tissues mostly as latent proMMPs. Tissue inhibitors of MMPs (TIMPs) inhibit their activation. The scheme of collagen degradation is presented in Fig. ..(b).
Functions of collagen in skeletal muscle The connective tissue network of skeletal muscle has a dynamic role during muscle differentiation and normal muscle growth and it serves as a supportive structure in skeletal muscle and tendon [,,,]. Collagen forms the linkages between the muscle and its associated collagenous tissues such as tendon or fascia, and is also the fibrillar component of the cell-tocell connections both between individual muscle cells and between the muscle cells and neighboring small blood vessels and nerves. It gives coherence and mechanical strength and also functions as an elastic, stress-tolerant system as well as distributing the forces of muscular contractions in both muscle and tendon. The tensile strength is based on intra- and intermolecular cross-links, and the orientation and density of the fibrils and fibers. In addition, collagen like the other ECM compounds conforms to the microenvironment around single muscle fibers and participates in the growth of cells and tissue regeneration after damage [].
Connective Tissue in Ligaments, Tendon and Muscle (a) Relative to the control
Effects of immobilization on collagen in skeletal muscle synthesis and degradation
Control Immobilized
The metabolism of muscular and tendinous collagen and the connective tissue network is known to respond to altered levels of physical activity. Cast immobilization of rat hind limb leads to a decrease in the enzyme activities of collagen biosynthesis in both skeletal muscle and tendon [,], which suggests that the biosynthesis of the collagen network decreases as a result of reduced muscular and tendinous activity. The rate of total collagen synthesis depends mostly on the overall protein balance of the tissue [], but it seems to be positively affected by stretch in both muscle and tendon [,]. Changes in the total collagen content of muscle, measured as hydroxyproline content, are usually small or absent during immobilization lasting for a few weeks, which probably reflects the slow turnover of collagen [], but increased collagen contents have also been observed []. Collagen expression during immobilization has been shown to be at least partially down-regulated at the pretranslational level []. The mRNA for the a-subunit of PH had already decreased after day of immobilization. The mRNAs for type I (Fig. ..a) and III collagens were also decreased after days of immobilization. Stretch seems to counteract this decrease []. Breakdown of ECM compounds like collagens is initiated by MMPs. Immobilization leads to an increase in proMMP- expression at both pre- and post-translational levels suggesting accelerated collagen breakdown. It is of interest that stretch partially prevents this phenomenon also [].
GGT enzyme activities and the hydroxyproline (Hyp) concentration decreased to the control level in spite of accelerated muscular growth [].
Effects of denervation and reinnervation on collagen in skeletal muscle
Effects of increased physical activity on collagen in skeletal muscle
The responses in muscular collagen biosynthesis differ between denervation and disuse atrophies []. Denervation atrophy is associated with an increase in the activities of PH and GGT and muscular collagen concentration suggesting development of fibrosis of the muscle tissue. Thus denervation seems to ‘uncouple’ the regulation of the adaptive responses of muscular collagen biosynthesis from the atrophy process of the whole muscle []. Perimysial collagen accumulation occurs also in muscle of spinal cord-injured individuals []. During reinnervation both the PH and
The specific activities of PH and GGT, as well as Hyp concentration, are known to be greater in the antigravity soleus muscle than in the dorsiflexor tibialis anterior which is not tonically active [,]. Skeletal muscle is known to respond to increased loading caused by endurance training [,,], acute exercise [] (Fig. ..b) or experimental compensatory hypertrophy [,] by increased collagen synthesis and/or accumulation in the muscle. Strenuous exercise, especially acute weight-bearing exercise that contains eccentric components, is known to cause muscle dam-
1 ***
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Time after running (days) Fig. .. (a) Type I collagen mRNA level in cast-immobilized soleus muscle. The results indicate a rapid pretranslational down-regulation of type I collagen expression during immobilization. (b) Prolyl -hydroxylase (PH) after a single bout of prolonged exercise in rat quadriceps femoris muscle (MQF). The results suggest accelerated collagen synthesis.
Chapter . age []. Up-regulation of collagen synthesis may be a part of the repair process but may also occur without any evidence of muscle damage []. Acceleration of collagen biosynthesis after exercise may thus reflect both physiologic adaptation and repair of the damage. Exercise training before exhaustive running has been shown to partially prevent the increase in collagensynthesizing enzymes []. (Pro)MMP- is upregulated at both pre- and post-translational levels after a single bout of exercise, suggesting an increase in the capacity of collagen degradation.
Tendon injury Tendons serve to transmit force from the contractile unit to the bone in order to produce movement. In contrast to the muscle, the cross-sectional area of the tendon is relatively small, and thus, the stress (force/area) imposed on the tendon is substantial during physical activities. However, tendons are remarkably strong and can withstand stresses that far exceed those transmitted during daily activities, including sports. Nevertheless, tendon injuries as a result of physical activity remain a substantial clinical problem, and the reasons for these injuries remain an enigma. Moreover, it is particularly puzzling that these patients are often relatively well-trained individuals. Consequently, appropriate and effective treatments, and possible preventive efforts, based on scientific evidence are currently lacking. Many tendon injuries are thought to be caused by ‘overloading’ of the tendon with a gradual onset of symptoms and a presumed associated inflammatory response and structural changes. However, a large portion of the existing knowledge on connective tissue properties and metabolism has been limited to animal models and some cadaver studies with respect to tendon mechanical properties. While such studies have contributed important information to our understanding of connective tissue they also draw attention to the limited conclusive evidence available on in vivo changes in the physically active human body. One problem with animal studies has been the difficulty in establishing a model that could reproducibly mimic an ‘overload’ time course of events. Moreover, there has been a lack of techniques that allow for the continuous sampling of tissue variables during exercise, which may prove useful in studying potential contributory factors for ‘overload’ reactions. However, some recent
in vivo human models have been developed that can monitor metabolism, blood flow and inflammatory activity and collagen turnover during exercise. These methods, together with the recently developed method of ultrasound determination of the mechanical properties of human tendon during muscular contraction, may prove valuable in future research efforts to understand tendon adaptation to physical activity.
Collagen metabolism and tendon loading It is commonly believed that, if not inert, tendon is metabolically relatively inactive. However, animal studies suggest that tensile strength, stiffness, crosssectional area and collagen content are augmented with increases in physical activity, which suggests that the tendon is metabolically active. In contrast, decreased physical activity and immobilization down-regulate collagen biosynthesis [,]. Collagen synthesis depends on overall protein synthesis, but appears to also be affected by tensile loading [,]. Interestingly, in an animal model it has been demonstrated that cell metabolism and matrix turnover is not necessarily uniform throughout the whole tendon tissue (deep vs. superficial) []. Therefore, the possibility cannot be excluded that intratendinous connective tissue turnover is multicompartmental, with ‘rapid’ and slow turnover compartments, rather than involving just a single compartment. Ultimately, such intratendinous differences may have a profound effect on the corresponding mechanical properties. Recently the microdialysis technique was used for in vivo determination of indirect markers of collagen turnover in the peritendinous tissue about the Achilles tendon [,]. It was shown that both a single bout of exercise and chronic ( weeks’) exercise appear to stimulate human type I collagen synthesis [,] (Fig. ..). Furthermore, collagen degradation seems to be transiently elevated initially, but with time a net synthesis takes place []. Whether the synthesis results in macroscopically increased tendon mass, and thereby increased strength and stiffness, remains unknown. However, it was recently shown that well-trained runners had a markedly greater Achilles tendon cross-sectional area than age-matched sedentary controls (Magnusson et al., unpublished) (Fig. ..). These data suggest that the human tendon is metabolically active and that it is affected by physical activity. How-
Connective Tissue in Ligaments, Tendon and Muscle
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Fig. .. Carboxy-terminal propeptides of type I collagen (PICP) measured as a marker for collagen synthesis during rest, immediately after (recovery) and h after a -km run.
Blood flow (mL/100g tissue/min)
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Fig. .. Mean blood flow values as determined with the Xe washout technique in the peritendinous space cm proximal to the insertion of the human Achilles tendon, in vivo. Note that blood flow increases –-fold with intermittent static exercise.
70 60 50 0
Fig. .. The cross-sectional area of the Achilles tendon in well-trained runners (> km/week) and controls (Magnusson et al., unpublished).
ever, it remains unknown exactly how degradation and synthesis are affected by the time course of events (loading/restitution) and to what extent various forms of loading affect their interrelationship.
Blood supply and inflammatory reaction It is widely believed that the Achilles tendon is injury prone secondary to a compromised blood supply – cm proximal to the insertion onto the calcaneus. Using a xenon washout technique it was recently shown that blood flow in the peritendinous region of the human Achilles tendon rose up to – times during resisted plantar flexion, which parallels the augmented flow to the muscle [,] (Fig. ..). Further, the
simultaneous use of near-infrared spectroscopy indicates that vasodilatation and tissue oxygenation are coupled during exercise []. These data suggest that blood flow is not necessarily compromised in the region of the Achilles tendon, although its role in tendon pathology remains unknown. Moreover, exactly how and what factors contribute to the regulation of blood flow in the tendon region remains to be addressed. Bradykinin plays a role in both vasodilatation and nociception, and is therefore particularly interesting as a potentially important regulator in tendon tissue. For human mesenchymal tendon cells in cultures, it has been demonstrated that repeated stretches lead to an increase in prostaglandin production that can be blocked by endomethacin []. A system has recently been developed that allows cells to be grown in microgrooves instead of substrates with smooth culture surfaces []. In this new culture system, tendon fibroblasts were found to become elongated in shape and aligned in the direction of microgrooves with and without stretching, and therefore the shape and alignment of the tendon fibroblasts and their loading conditions are similar to those in vivo (Fig. ..). Furthermore, preliminary data revealed
Chapter .
Fig. .. Fibroblasts grown in silicon microgrooves and aligned along the direction of stretch.
that cyclic stretching of the tendon fibroblasts induced the production of PGE in a stretchingmagnitude-dependent manner. Specifically, at % stretching the PGE production was not increased; however, at % and % the PGE levels were increased about .- and .-fold, respectively, compared with the unstretched cells. Since PGE is a known inflammatory mediator, the results of this study suggest that tendon overuse injury may involve the release of PGE from overstretching of tendon fibroblasts in vivo, and this may subsequently result in the tendon inflammation and pain often seen in the clinical setting. Moreover, in a human model it has also been shown that exercise is associated with peritendinous release of prostaglandin [,]. That is, inflammatory mediators are released in response to tensile loading of the human tendon, but to what extent this response is related to collagen synthesis/degradation and hence tissue strength and quality, and thus ability to withstand repetitive tensile loading remains unknown. While it is generally believed that repetitive loading leads to microscopic failure of collagen structures and an inflammatory process followed by symptomatic pain, the exact etiology remains to be established. Animal models have been developed in an effort to examine the initiating factors of tendon overuse injuries. One such representative model of tendon injury was created by injection of bacterial collagenase into Achilles tendons of horses and rabbits [,]. Microscopic examination revealed degenerative
changes in the tendons and increased numbers of capillaries. However, according to current standards for evaluating tendon disorders, these models appear to represent tendinosis rather than tendon overuse injury, which is associated with tendon inflammation. Recently, our research center developed an animal model of tendon overuse injury [] by means of the use of cell activating factors (a combination of various cytokines). When injected into rabbit patellar tendons, the cytokines produced biologic and biomechanical changes in the tendons. These include increased cellularity at and around the injection site (Fig. ..), and decreased failure load of the tendon (Fig. ..). Thus, this model offers an opportunity to study tendinitis, but whether this model represents tendon overuse injury induced by repetitive loading remains to be verified.
Tendon strain and regional differences The tendon stress during muscular contraction is associated with a given tendon strain (% elongation). Although unsubstantiated, it is commonly believed that the magnitude of tendon strain may be associated with microtears of the tendon and subsequent clinical symptoms. Investigations of human tendon behavior have largely been limited to biomechanical testing of isolated cadaver tissue specimens. However, the recent advance of using real-time ultrasonography has provided a useful method for studying human aponeurosis and tendon tissue behavior during contraction, in vivo. Using such a method it was recently shown that the mechanical properties of the human Achilles tendon and aponeurosis, in vivo, exceeded those mechanical properties previously reported for the human tibialis anterior tendon, in vivo, but were similar to those obtained for various human and mammalian tendons during isolated biomechanical testing procedures [] (Fig. ..). It remains unexplored whether the mechanical properties of the tendon are altered in response to various types of exercise. The tendon has a complex anatomic hierarchy and whether there are regional differences in the stress– strain distribution throughout the tendon is also unknown at present. It has been shown that strain of the collagen fibril is less than that of the whole tendon []. Such a discrepancy in fibril and tendon strain suggests that some structural gliding may develop
Connective Tissue in Ligaments, Tendon and Muscle
Fig. .. Saline solution injection causes minimal cellularity at the injection site (a). In contrast, cytokine injection increases cellularity at weeks (b). The matrix appears unchanged.
(a)
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Fig. .. Cytokine-injected tendons in rabbits had significantly lower ultimate load (*P < .) at weeks after injection compared with the control group injected with saline. Data are adapted from Stone et al. [].
Tendon load (N)
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within the tendon. Whether such an intratendon differential strain (shear) plays a role in mechanical signaling for tendon metabolism, or if it is a potential mechanism for ‘microtear’ and subsequent inflammatory reactions and clinical symptoms is unresearched. Further, intra- and intermolecular cross-links are formed that promote stability of the collagen molecule and collagen fibril, respectively. Pyridinoline is an important component of cross-links of the mature collagen fiber, and it has been shown that the ratio of pyridinoline to collagen is particularly high in tendon and ligament compared to bone []. Therefore, crosslink formation probably plays an integral role in tissues that are subjected to tensile stress. Nevertheless, it re-
2
4 6 8 Deformation (D mm)
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Fig. .. The estimated stress–strain for the proximal and distal human Achilles tendon and aponeurosis after correction for small amounts of ankle joint rotation and antagonist coactivation.
mains unknown whether various aspects of physical activity (contraction mode, intensity, duration and restitution time) have any effect on these cross-link formations and subsequent tendon properties. Animal models have shown that there is an inverse relationship between type III and type I collagen fibril diameter during development: type III collagen fibril
Chapter . number declines with maturation and larger type I fibrils increase [], which may reflect a change to a larger and more stress-resistant fibril. However, regionspecific observations of fibril morphology have not been made in a human tendon model, nor has it been investigated whether the different regions within a tendon vary in their mechanical properties.
Biomechanics of human skeletal muscle–tendon flexibility Physical activity is important to maintain good health, and human movement is not possible without some degree of the fitness component commonly called musculoskeletal flexibility. Flexibility training is thought to be an important and effective training stimulus for maintenance and augmentation of flexibility. Clearly the demands of participation in sports require a certain sport-specific musculoskeletal flexibility. In sports such as gymnastics the necessity for immense flexibility is obvious; however, reaching for a ball in soccer, clearing a hurdle or performing a tennis serve may also require a certain sport-specific flexibility, which may be achieved by specifically designed flexibility training programs. However, it should also be kept in mind that an individual’s existing flexibility may be an inherent characteristic or a sport-specific adaptation, and not just the result of flexibility training []. Although there is presently no universally accepted definition of flexibility it is most commonly defined as maximal joint range of motion across a joint or series of joints. Flexibility has also been defined as the length–tension relationship of the muscle–tendon unit. However, the former appears to be a more clinically useful definition since it can easily be measured with a goniometer. It should be noted that a goniometer endpoint measurement is subjective in nature and therefore provides no information about the resistance the muscle provides throughout the range of motion; thus the ‘stiffness’ or ‘compliance’ of the muscle cannot be evaluated. The following section will consider the biomechanics of stretching of the muscle–tendon unit, and it should be kept in mind that it does not cover stretching of the injured or immobilized muscle–tendon unit, complex issues like flexibility and injury risk.
Mechanisms for flexibility improvement It is indisputable that increases in musculoskeletal
flexibility can be achieved by flexibility training. However, the mechanisms for both the short- and longterm changes in flexibility as a result of flexibility training have until recently been largely unclear. The immediate or short-term response to stretching has previously been attributed to either neurophysiologic [] or mechanical factors []. The neurophysiologic explanation suggests that the limiting factor during stretching is muscular resistance attributed to reflex activity, as measured by electromyography (EMG). Thus, the aim of stretching would be to inhibit the reflex activity, which in turn would reduce resistance and thereby allow for further increases in joint range of motion []. Paradoxically, the particular stretching techniques most effective in increasing joint range of motion have been associated with an elevated EMG response []. At the same time, it has been shown that during a -s static stretch resistance declines by ~ % in the absence of any measurable EMG response []. Therefore, contractile reflex activity does not appear to significantly contribute to resistance to stretch. The other common explanation for the effects of stretching includes an altered mechanical property of the muscle []. Yet a third mechanism was recently suggested, where improvement in joint range of motion was attributed to an amplified stretch tolerance, rather than a change in EMG activity or mechanical properties [,].
Biomechanical response to stretch The relationship between the force and the deformation (expressed as the slope of the line, DF/DL) is the stiffness of the structure []. That is, the increase in deformation is proportional to the applied force (Hooke’s law), such that a stiffer structure will deform less for a given applied external load. The reciprocal of stiffness (DL/DF) is termed compliance. The area under the curve is the energy absorbed by the structure that can potentially be returned when the load is removed. The application of an external applied tensile force will be opposed by the internal bonds of the structure. This tensile stress can be defined as the internal force divided by the cross-sectional area of the material (F/area). The stress will cause the structure to change in shape, or deform, which is called tensile strain. Tensile strain can be defined as the change in length divided by the original length ((DL/Lo), which
Connective Tissue in Ligaments, Tendon and Muscle
A single static stretch In the animal models it is known that materials respond in a non-linear fashion during the dynamic and static loading phase of a stretch, indicating viscoelastic behavior [,,]. Recently it was also shown in a human model that the muscle–tendon unit behaves in a similar fashion during stretching [–,–]. That is, the muscle displays viscoelastic properties in the absence of any measurable EMG response from the target muscle being stretched (Fig. ..). During the dynamic loading phase there is a non-linear increase in resistance to stretch, and during the static loading phase there is a non-linear decline in resistance to stretch, a viscoelastic stress relaxation response. The viscoelastic stress relaxation response is most pronounced in the initial – s, but continues to significantly abate for approximately s. During a -s static stretch resistance declines by about % altogether. Although there is significant viscoelastic stress relaxation during a -s static stretch there is no measurable effect on the subsequent immediate stretch []. This means that resistance to stretch diminishes during the static phase of a stretch, but has no lasting effect on the viscoelastic properties.
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is a dimensionless unit, but often expressed as a percentage of the original length. The relationship between stress and strain (Dstress/Dstrain) is the elastic modulus of the material, sometimes referred to as Young’s modulus. Biological materials are viscoelastic and do not respond to external loading in a way that can be described in simple linear mechanical terms. Viscoelastic behavior has been described in rheological models where the relationship between force and deformation is dependent on time. Linear elasticity is a load-dependent response and linear viscosity is a rate-dependent response []. Typically tissues will respond in a non-linear fashion with an initial ‘toe-region’ followed by an approximately linear region during dynamic loading on account of its viscoelastic properties. If the tissue is held fixed at some new length, static loading, the tension will decline in a non-linear fashion with time, which is termed viscoelastic stress relaxation (Fig. ..). These are the two phases that a muscle–tendon undergoes during a static stretch.
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Fig. .. A static stretch of the hamstring muscle group for one individual. (a) The passive torque about the knee joint that corresponds to the tension in the hamstring muscles during the passive static stretch procedure is shown. A maximal voluntary contraction (MVC) is performed at the end of the stretch. (b) The corresponding EMG amplitudes. Note the absence of EMG activity in the hamstring muscles despite the increase in torque in the dynamic loading phase, and the decline in torque in the static loading phase (viscoelastic stress relaxation). (c) The angle (negative value indicates greater angle of stretch) of the mechanical lever arm that passively stretches the hamstring muscles at . rad/s (∞/s) during the dynamic loading phase. During the static loading phase the lever arm remains stationary.
Repeated stretches — short-term effect Animal data demonstrate that if the target tissue is stretched repeatedly, resistance to stretch, in both the dynamic and the static portion, will decline with each subsequent stretch []. Therefore, stretching of a muscle group in the sports arena or rehabilitation setting is typically not performed once as described above, but is repeated several times. In the human muscle–tendon complex the effect of five consecutive
Chapter .
Repeated stretches — long-term effect While earlier literature attributed short-term changes in flexibility to neurophysiologic events, it commonly ascribed long-term improvements in flexibility to changes in the passive properties []. In a recent study static stretching exercises for the human hamstring muscle group were performed in the morning ( ¥ s) and in the afternoon ( ¥ s) on one leg while the opposite side served as control []. After weeks the resistance to stretch for a given angle was unchanged on both sides (Fig. ..). However, when stretched to a maximal tolerated joint angle the stretch side could be extended further after training, i.e. the subjects became more flexible. This increase in angle was accompanied by a comparable increase in peak torque and energy (without any change in EMG activity). Therefore, increases in flexibility, i.e. maximal range of motion, can be achieved from stretch training as a consequence of increased tolerance to tensile load, rather than through a change in the viscoelastic properties of the muscle. On the basis of these results, and since the change in the viscoelastic behav-
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-s static stretches has been examined []. To see if any effect was lasting in nature the resistance to stretch was re-examined h later. In the last of the five stretches both passive energy (the area under the curve of the dynamic loading phase) (%) and stiffness (%) declined. However, surprisingly, the observed decline in the viscoelastic properties was transient since they had returned to baseline values when measured h later. In contrast to a single -s stretch, the -s stretch had an effect on the subsequent stretch; however, again the effect on the viscoelastic properties was transient (> h). Although stretching procedures places tensile load on several structures it remains unknown what their relative contributions are to the stress relaxation response. The transmission of tension in passively stretched muscle is complex and may engage several structures, including titin, intramuscular connective tissue and tendon. Passive stretch in a physiologic range results in % strain of tendon, but % strain of the muscle–tendon junction [], demonstrating differential viscoelastic properties in various regions of the muscle–tendon unit, and that tendon is less likely to deform during loading.
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Angle (rad) Fig. .. Maximal torque-angle data for one subject in the dynamic loading phase of a static stretch before and after weeks of flexibility training twice a day. (a) The training side. Note that after training the subject reached a greater knee joint angle prior to the onset of discomfort with an accompanying increase in torque. It should also be noted that the pre- and posttraining slope is similar. That is, the muscle–tendon unit did not change its passive properties (slope), but the subject’s tolerance to stretch was enhanced after training. (b) The control side: The slope and the endpoint do not differ over the training period.
ior is transient in nature and reverses within h (see above), it is questionable if stretching, as it is commonly performed by athletes, can permanently change the passive properties of a muscle. The mechanism for an altered stretch tolerance is presently unknown. However, the increased tolerance on the training side and lack thereof on the control side suggests that peripheral mechanisms, such as afferent information from muscle, tendon and joint receptors,
Connective Tissue in Ligaments, Tendon and Muscle 40
Stiffness (D Nm / D rad)
may play a role. However, the possibility cannot be excluded that central factors may be involved as well. Finally, from a clinical standpoint it is important to point out that although the passive properties do not appear to be altered as a result of flexibility training it does lead to improvements in joint range of motion. Therefore, to meet sport-specific flexibility demands it may be desirable to perform flexibility training. Finally, the possibility cannot at present be ruled out that stretching in a skeletally immature person may have a long-lasting effect on the viscoelastic properties of the muscle–tendon unit, nor is it known whether such changes are advantageous or not.
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Unquestionably people exhibit differences in musculoskeletal flexibility. A component of a person’s existing flexibility may be inherited, a sport-specific adaptation (loading history) or achieved by flexibility training. Previous investigations on human flexibility have measured maximal joint range of motion, but not the passive properties of the muscle–tendon unit. At the same time, it has been shown that tolerance to tensile load plays an important role in short-term and long-term gains in flexibility (see above) rather than the passive properties of the muscle. To address whether tolerance also contributed to differences in flexibility endurance athletes were classified as tight (inflexible) and normal based on a simple toe-touch test. It was observed that both passive properties (stiffness) of the hamstring muscle group and stretch tolerance explained the difference in flexibility []. That is, ‘tight’ athletes had a muscle–tendon unit with greater stiffness than athletes with normal flexibility for a given common angle (Fig. ..a). However, the athletes with normal flexibility achieved a greater maximal joint angle (muscle length) and accompanying maximal tensile stress, and thus had a greater tolerance to tensile loading. When the tensions in the individual muscles were analysed it was observed that a combination of a more extended knee joint angle, i.e. a reduced moment arm, and a greater external moment explained the substantial differences in stress between the tight and flexible subjects at a maximal joint angle (Fig. ..b). Towards the extremes of motion, as in hurdling, considerable passive tension is probably generated and may therefore play a role in the deceleration
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Fig. .. (a) Absolute biceps femoris moment stiffness data (mean ± s.e.m.) for angles common to all subjects in the flexible and tight groups (*P < .). The moment stiffness followed an exponential curve and elevated earlier during knee extension in the tight than in the flexible subjects. Thus, after . rad the stiffness reached and DNm/Drad for the respective groups. However, the flexible subjects reached a greater maximal angle of stretch, and had at that angle a greater stiffness than the flexible subjects (tolerance). (b) Muscle stiffness (Dstress/Dlength) for the biceps femoris muscle as a function of normalized length change. Significantly different from inflexible, *P < ., **P < ..
of the leg in the terminal swing phase. The material properties of skeletal muscle are thought to be related to the amount of collagen [], and perhaps collagen content or the number of cross-links contributed to the observed difference in stiffness. It is well known that stiffness of connective tissue increases with aging, in part due to an increase in cross-
Chapter . links. Interestingly, when we examined the musculoskeletal passive properties on a cross-sectional basis in a very narrow age range, younger athletes (– years) had a muscle–tendon unit with greater stiffness than slightly ‘older’ athletes (– years) for a given common angle. Such differences may be related to agerelated changes in connective tissue []. However, the younger athletes also achieved a greater maximal joint angle (muscle length) and accompanying maximal tensile stress, and thus had a greater tolerance. Therefore, it appears that material properties and tolerance to tensile load play a role both in determining differences in flexibility and in age-related changes in flexibility.
Warm-up and stretching Warming up prior to participation in sport is commonly believed to aid performance and reduce injury risk, and because the muscle–tendon unit is thought to exhibit temperature-dependent viscoelastic behavior, it is recommended that warm-up precedes stretching exercises []. Although there is limited scientific evidence in a human model for such a tenet it was recently investigated whether the passive energy absorption of the human muscle–tendon unit would decrease after a brief (-min) warm-up exercise bout, and sustained (-min) exercise []. It was clearly demonstrated that a -min warm-up procedure and min of continuous running elevated intramuscular temperature significantly (from . °C to . °C), but did not affect the passive energy absorption of the hamstring muscle–tendon unit. When static stretching exercises were added to the regimen after the min warm-up period the passive energy absorption declined immediately; however, this reduction in passive energy absorption was not sustained after an additional min of continuous running. It is well known that continuous exercise rapidly results in an equilibrium between heat production and heat dissipation. In the above experiment about % of the temperature increase occurred in the initial min of work, which confirms that increased tissue temperature can be achieved relatively soon after initiation of exercise, and that min of warm-up exercise may be sufficient preparation for muscle performance []. Temperature-dependent viscoelastic behavior of biological tissue has previously been shown in temperature ranges
that far exceed those achieved during a warm-up procedure in human skeletal muscle []. However, it appears that despite the repeated mechanical loading during min of running, and its associated increase in intramuscular temperature, the passive energy absorption of the muscle–tendon unit remains unchanged. It has been suggested that elastic recoil may play a role in energy expenditure during locomotion [,], and although this is speculative, the temperature and repetitive load insensitive passive energy behavior may serve to maintain passive elastic energy return during locomotion.
Ligaments: physiology and repair Athletic activities can result in a wide variety of joint injuries through either direct trauma or repetitive stress []. Although the predilection for specific injuries varies with the sport (e.g. elbow instability in baseball players, shoulder dislocations in football players and wrestlers, knee injuries in basketball players), all injuries can be debilitating and often involve ligamentous structures. Ligaments are structures that are known to play an important role in mediating normal joint mechanics. These parallelfibered, dense connective tissues share the transmission of forces with other periarticular tissues to provide joint stability []. In the knee, a common injury site is the medial collateral ligament (MCL). Injuries to this structure may be isolated to the superficial MCL or extend to include the deep capsular and posterior oblique ligaments [–]. Laboratory studies using animal models have shown that a ruptured MCL can heal spontaneously without surgical intervention. However, the healed tissue remains mechanically, structurally and materially inferior to normal ligaments [–]. Nevertheless, the ability of the MCL to heal offers an opportunity for the examination of the mechanism of ligament healing. In addition, anatomically, the MCL is a broad, flat ligament with a good aspect ratio (length to width) and relatively uniform cross-sectional area making it well suited for biomechanical studies. Understanding healing in the MCL provides a good foundation for understanding the healing processes of other ligaments. In this section ligament healing and repair using the MCL as a model will be presented. Also, current and future approaches towards enhanc-
Connective Tissue in Ligaments, Tendon and Muscle ing the quality of the healed ligament, namely functional tissue engineering that includes the use of growth factors, gene transfer technology, cell therapy, tissue scaffolding and other mechanical factors, will be examined.
Natural history of MCL injury Healing of the MCL has been found to be a long and complex process that is subject to local and external influences. Generally, the process involves several discrete but overlapping phases: the acute inflammatory or reactive response phase, the repair phase, and finally the tissue remodeling phase. In the acute inflammatory phase, the cellular and tissue responses to injury occur within approximately the first h following a given insult. Capillary damage results in enhanced permeability of local blood vessels, allowing inflammatory cells to migrate into the tissue defect. Fibroblastic proliferation and the formation of scar matrix consisting of randomly aligned collagen and amorphous ground substance occurs simultaneously []. The repair phase encompasses those cellular and tissue processes occurring from – h until roughly weeks post injury. This time period marks the gradual subsiding of inflammation together with the active commencement of the healing process. Grossly, highly vascular granulation tissue fills the tissue defect, covering the free ends of torn or ruptured tissue [,]. Fibroblasts become the predominant cell type and continue to actively synthesize extracellular matrix. This matrix becomes progressively more organized with time, yet collagen fibrils remain relatively disorganized. The remodeling phase is also marked by tissue remodeling, lasting months and years after the initial injury. It should be noted that an injured MCL never regains the properties of the normal MCL [–]. The healed ligaments have elevated numbers of vessels, fat cells and voids and increased water content. The diameter of collagen fibers is smaller with fewer numbers of stable collagen cross-links. The healing MCL also contains elevated type III and V collagens, along with an elevated number of proteoglycans (PG).
Biomechanical properties Biomechanical characterization of the MCL can be done via (i) functional testing, which involves deter-
mining its contribution to knee kinematics as well as the in situ forces in the MCL in response to an external load, and (ii) uniaxial tensile testing, which provides an assessment of the structural properties of the femur–MCL–tibia complex (FMTC) and mechanical properties of the ligament substance. Readers are encouraged to study Chapter of The Orthopedic Basic Science Book (published by the American Academy of Orthopedic Surgery) for details []. Functional testing provides insight into the kinematics or motion of the knee joint which is governed by a combination of joint geometry and tensile properties of ligaments. Each joint has six degrees of freedom (DOF): three translations and three rotations. For the knee joint, there are three axes that can be defined: the femoral shaft axis, the epicondylar axis, and a floating anterior–posterior axis perpendicular to these two axes. Translation along these three axes will lead to distraction/compression, medial–lateral translation, and anterior–posterior translation, respectively. Rotations about these three axes will lead to internal–external rotation, flexion–extension, and varus–valgus rotation, respectively. Structural properties of the FMTC are extrinsic measures of performance of the overall structure in response to a uniaxial tensile test. These properties are obtained from the resulting load–elongation curve (Fig. ..a). The stiffness, in N/mm, is the slope of the curve between two defined limits of elongation. The ultimate load, in N, is the highest load placed on the complex before failure and the ultimate elongation, in mm, is the maximum elongation of the complex. Finally, the energy absorbed at failure, in N-mm, is the area under the entire load–elongation curve. These data are a reflection of the overall properties of the complex spanning from insertion to insertion. Mechanical properties of the ligament’s midsubstance are intrinsic measures of the local tensile properties as represented by a stress–strain curve (Fig. ..b). Stress is defined as force per unit crosssectional area, while strain in the MCL is typically defined as the ratio of the difference between the initial length and current length to the initial length. The modulus, in MPa, is obtained from the linear slope of the stress–strain curve between two limits of strain. The tensile strength, in MPa, is the maximum stress achieved; while the ultimate strain (percentage) is the
Chapter . the modulus and tensile strength of the healing MCLs at all time periods, remained significantly inferior, in spite of increased cross-sectional area. Thus, the healing process involves a larger quantity of poorer quality ligamentous tissue.
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There are numerous factors that contribute to the healing response of an injured ligament. Known factors include the site and severity of the injury. In addition to intrinsic factors such as circulation and infection, studies have also shown that treatments such as repair vs. non-repair, rehabilitation and exercise can have significant impact on the process of ligament healing.
Intrinsic factors Ultimate strain
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Fig. .. (a) Typical load–elongation curve of a bone–ligament–bone complex. (b) Typical stress–strain curve describing the mechanical properties of the ligament substance.
strain at failure. Finally, the strain energy density, in MPa, is the area under the stress–strain curve. A system for tracking markers that strategically delineates the midsubstance is necessary to measure local strain. Video analysis techniques have assisted the tracking of stain markers deployed in one- or two-dimensional patterns on the ligament’s surface. In addition, stress is determined from the gross load-cell readings normalized by the specimen’s cross-sectional area. Using the skeletally mature New Zealand white rabbit as a model, the structural properties of the healing FMTC and the mechanical properties of the healing MCL have been demonstrated to remain inferior to those of the intact ligament up to year after injury []. Structural properties of the FMTC, including stiffness and ultimate load to failure improved during the early stages of healing (i.e. from to weeks), but remained inferior to controls. After weeks of healing, only the stiffness of the FMTC returned to near normal levels, while the ultimate load was still significantly lower than the controls. Further,
There exist a number of intrinsic factors that may contribute to the healing response of the injured ligament. In a study on the healing MCL of hypophysectomized rats, interstitial cell-stimulating hormone (ICSH) and testosterone replacement significantly affected the ultimate load of the repaired ligament, as well as the collagen and glycosaminoglycan synthesis or degradation rates []. Any disease that affects endocrine or metabolic homeostasis may also affect ligament healing. For example, diabetes mellitus can result in circulatory abnormalities that may negatively affect ligament healing as insulin deficiency has been shown to alter collagen synthesis and cross-linking [,]. Ligament healing can also be affected by local conditions such as poor circulation or infection which hinders the proliferation of cells, thereby prolonging the inflammatory phase of healing.
Surgical repair vs. non-repair For an isolated MCL injury, animal studies have shown better results with non-operative treatment than surgical repair followed by immobilization []. Earlier studies in the canine model and more recent studies using a rabbit model examined the effects of suture repair of the injured MCL [,,]. At weeks, no statistically significant differences could be demonstrated between surgically repaired and non-repaired groups for any biomechanical property, including varus–valgus knee rotation, and structural properties
Connective Tissue in Ligaments, Tendon and Muscle of the FMTC. However, the mechanical properties of the MCL midsubstance, i.e. the quality of the healed tissue, were significantly different from intact MCLs. These findings are in agreement with clinical reports which have reported positive outcomes with nonoperative treatment followed by early motion and functional rehabilitation []. As a result of scientific studies and clinical experience, it is now generally agreed that the preferred method of treatment for isolated grade III injuries of the MCL [] is nonoperative (conservative).
Immobilization vs. controlled motion and exercise In the past, immobilization following ligament injury was believed to protect the healing ligament from stress []. However, it has been shown in the laboratory that immobilization can result in disorganization of collagen fibrils, decreases in the structural properties of the FMTC, resorption of bone at the ligament insertion sites, and many detrimental effects on the knee joint []. Conversely, controlled motion has been shown to be beneficial to the healing ligament []. Intermittent passive motion has been reported to improve the longitudinal alignment of cells and collagen at weeks. Improved matrix organization and collagen concentration, together with an increase of up to four times in the ultimate load of the FMTC were demonstrated []. Some clinical data exist on the advantages of motion following ligament injury showing that clinical results are better with early motion and functional rehabilitation following isolated MCL injuries at -year follow-up []. Current clinical recommendations after MCL injuries include an early controlled range of motion exercises as soon as pain subsides [,]. However, in an unstable joint, i.e. cases involving multiple ligamentous injuries, motion too early or applied too aggressively may be detrimental to the healing process.
Combined MCL and ACL injuries Severe knee injuries can involve multiple ligaments, and the prognosis for these combined ligamentous injuries is generally worse regardless of which treatment is selected. For a combined ACL + MCL injury, multiple treatment modalities have been studied clinically,
including combined MCL repair and ACL reconstruction, ACL reconstruction only, or non-operative treatment of both ligaments []. No differences in valgus instability or knee function during activities were observed between the three groups studied. The effects of ACL deficiency on the healing of the injured MCL have been studied in our research center using rabbit and canine models []. Biomechanical evaluation indicated that following an untreated ACL + MCL injury, there was a significant increase in varus–valgus laxity, a reduction in tissue quality of the healed MCL, and considerable degeneration of the joint. Other animal studies suggest that MCL repair with ACL reconstruction reduces varus–valgus laxity and improves structural properties of the FMTC in the short term (i.e. weeks). After weeks, however, no differences in biomechanical or biochemical properties were observed. Further studies in our research center revealed that non-operative treatment with full weight bearing and mobilization of the MCL injury with reconstruction of the ACL can result in successful MCL healing []. This approach also appears to be the preferred method of treatment for many clinicians [].
Future directions Functional tissue engineering is a multidisciplinary field that has gained major interest in the scientific community. The ability to produce tissue that replicates or enhances normal functioning tissue is of obvious practical benefit. There are several methods of approach to tissue engineering for ligament healing on the horizon. The use of growth factors, gene transfer technology, cell therapy tissue scaffolding and mechanical factors are all being studied. These new approaches are promising and a brief discussion of each will be presented.
Growth factors Growth factors are small polypeptides synthesized by a variety of cells that function by binding to specific cell surface receptors which activate complex intracellular signal transduction pathways. Growth factors regulate cell migration, proliferation, differentiation and matrix synthesis and aid in repairing a damaged ligament by regulating cellular behavior and modulating the wound environment [–]. At our research center, platelet-derived growth factor-BB (PDGF-
Chapter . BB), basic fibroblast growth factor (bFGF) and epidermal growth factor (EGF) have been found to have a stimulatory effect on cell proliferation, while transforming growth factor-b (TGF-b) promoted matrix synthesis of MCL fibroblasts in a rabbit model suggesting that ligament healing may be promoted with a combination of these factors []. A follow-up in vivo study demonstrated that high-dose PDGF-BB in vivo resulted in an FMTC with higher ultimate load, energy absorbed to failure and ultimate elongation than controls []. Additionally, an ongoing in vitro study (unpublished) in our laboratory suggests a timespecific response to the addition of TGF-b. Preliminary data suggest collagen synthesis to injured rabbit MCL fibroblasts increases with the addition of TGFb at day , but not at days or . To date, only a few growth factors have been studied (TGF-b, PDGF, EGF, etc.); however, much research is required to identify and delineate the effects of yet undiscovered and unstudied growth factors.
Gene transfer technology The application of gene transfer technology to ligament healing was examined recently []. Both retroviral in vitro transfection of the desired genes into the cells followed by the transplantation of genetically modified cells into the host tissue and adenoviral direct delivery of genes into host cells were used in the MCL of rabbit knees [,]. Both techniques resulted in expression of the lacZ marker gene by fibroblasts. Gene expression lasted for up to days in the retroviral technique and up to weeks in the adenoviral technique []. Therapeutic methods for ligament repair using non-viral gene transfer have also been investigated []. In one experiment, the HVJ–liposome complex containing an antisense nucleotide for decorin (a proteoglycan) was injected into the healing sites of injured MCLs. Mechanical properties, including ultimate stress, were shown to be significantly improved. Despite these promising results, major obstacles impede practical implementation of gene transfer as a biological intervention in ligament healing []. These obstacles include immune response of the viral proteins and transgene-encoded proteins [], viability of transfected cells in vivo after retransplantation, and loss of gene expression of the retrovirus by promoter methylation []. Fortunately, it is believed
that ligament healing requires gene expression of the order of weeks, so this strategy is considered very promising.
Stem cell therapy The principle of stem cell therapy is to provide a source of cells for ligaments or a mechanism to introduce genes for gene transfer []. The success of cell therapy for ligament repair relies on the viability of the transplanted cells and the affinity of the cells for the host tissue. Mesenchymal stem cells (MSCs) are considered a candidate for cell therapy. MSCs have been demonstrated to differentiate into various cells that form mesenchymal tissues under different culture conditions in vitro [–]. Multipotent differentiation of these cells into mesenchymal tissues has also been demonstrated in vivo [,]. In our research center, nucleated cells obtained from centrifuged bone marrow were used as transplantation donor cells [–]. Female transgenic rats were used as donors and recipients, with transgenes introduced into chromosome . The nucleated cells were injected into a pocket made around the transected MCL of recipient rats. Preliminary results revealed the survival of donor cells at the healing site of the MCL and days postoperatively. Transplanted donor cells could also be identified in the midsubstance of ligaments at days. This is significant in that the migratory potential of transplanted cells may have been demonstrated. Migration of transplanted cells is an attractive attribute for ligament healing. These early results are encouraging [].
Tissue scaffolds Tissue scaffolds are extracellular matrix materials that serve as the structural framework upon which tissue regeneration can occur. A variety of biological and non-biological scaffolding materials have been used [,]. The application of small intestinal submucosa (SIS) scaffolding techniques to ligament healing has been investigated in our research center. When a mop-end tear of a rabbit MCL was approximated and covered with SIS, the healed ligament was found to have a larger cross-sectional area with increased stiffness. A number of issues including possible host immunological response, ascertaining the strength properties of scaffold-derived grafts, the degree of in-
Connective Tissue in Ligaments, Tendon and Muscle corporation into host tissue, and the long-term viability of tissue remain to be addressed.
Mechanical factors The effects of mechanical factors on ligament fibroblasts have been studied with a new apparatus developed in our research center. Previous studies have shown that cells grown and stretched on culture dishes with smooth surfaces realign nearly perpendicular to the direction of stretch. This orientation is in contrast with the in vivo model where cells align along the collagen fiber direction []. Using a cell stretching apparatus whereby cells are grown in an oriented fashion on silicon dishes that contain parallel microgrooves, we are able to align fibroblasts to grow along the direction of stretch (see Fig. ..). As this model better mimics the in vivo environment, future experiments exploring the effects of ligament fibroblasts will be closer to those in the in vivo situation.
Discussion Ligamentous healing is a complicated process that involves multiple factors including extent of injury, vascular supply, time of medical intervention, and the effects of biomechanical and biochemical environments. New technologies like the Robotic/UFS testing system have opened the door to a better understanding of the effects on joint motion on ligament healing []. Animal and clinical research at different levels of the healing cascade from growth factors to tissue scaffolds has increased understanding of the healing process. Clearly, advances in the ability to heal ligaments will require future investigators that come from multiple fields including biology, biochemistry, bioengineering, medicine, surgery, and others. It is only with this collaborative approach that valuable information may be derived, such that the successful management of the debilitating effects of ligamentous injuries can become more achievable.
Summary The extracellular matrix outside the cells is a complex and dynamic meshwork of collagens, non-collagenous glycoproteins, proteoglycans and elastin. The matrix supports the cellular elements and maintains the structural integrity of multicellular organisms. It also binds cells together and regulates various cellular processes,
including cell growth, proliferation, differentiation, migration and adhesion. The tensile strength of the matrix is based on intra- and intermolecular crosslinks, and the orientation and the density of the fibrils and fibers. The metabolism of collagen and the connective tissue network is known to respond to altered levels of physical activity. Biosynthesis decreases with reduced activity, and changes associated with immobilization can in part be counteracted by stretch. Exercise accelerates biosynthesis, and may reflect both physiologic adaptation and repair of the damage. Tendon injuries as a result of altered and/or increased physical activity are a considerable clinical problem. What constitutes the most effective treatment and possible preventive efforts is currently unknown. Many tendon injuries are thought to be due to ‘overloading’ of the tendon with a gradual onset of symptoms and a presumed associated inflammatory response and structural changes. However, a large proportion of the existing knowledge on connective tissue properties and metabolism has been limited to animal models. Nevertheless, some recent in vivo human models have been developed that can monitor metabolism, blood flow and inflammatory activity and collagen turnover during exercise. These methods, together with the recently developed method of ultrasound determination of the mechanical properties of human tendon during muscular contraction, may prove valuable in the future research efforts to understand tendon adaptation to physical activity. Physical activity can result in a wide variety of joint injuries, and often includes the MCL. Although the MCL can heal spontaneously without surgical intervention it remains mechanically, structurally and materially inferior to normal ligaments. Ligamentous healing is a process that involves multiple factors including extent of injury, vascular supply, time of medical intervention, and the effects of biomechanical and biochemical environments. The healing response may be influenced by intrinsic factors, including endocrine and metabolic homeostasis. The current recommended method of treatment for isolated grade III injuries of the MCL is non-operative, including early controlled range of motion exercises. However, functional tissue engineering, including growth factors, gene transfer technology, cell therapy and tissue scaffolding are being studied with respect to ligament heal-
Chapter . ing. Early data show that some growth factors have stimulatory effects on cell proliferation and the mechanical properties of ligaments. Gene transfer as a biological intervention in ligament healing is also a potentially promising treatment strategy. Stretching is often performed to improve musculoskeletal flexibility, and muscle displays viscoelastic properties in the absence of muscle activity. Resistance to stretch diminishes during a stretch, but has no lasting effect on the viscoelastic properties. Flexibility improvements can be achieved with stretch training due to altered tolerance to tensile load, rather than a change in the viscoelastic properties of the muscle. Physical activity elevates intramuscular temperature, but does not affect the passive properties of the hamstring muscle–tendon unit.
Multiple choice questions Which of the following is a unit of stiffness: a N-mm b N/mm c MPa d mm. Which phase of ligament healing is marked by inflammation, blood vessel permeability, and early fibroblast proliferation: a reactive phase b repair phase c remodeling phase d none of the above. Which of the following influences a person’s musculoskeletal flexibility: a tolerance to tensile load b age c stiffness d all of the above e a and c. Which of the following statements are true? a All major collagen types have been observed in the endomysium. b The concentration of endomysial collagen is higher around slow than fast skeletal muscle fibers. c Proline and -hydroxyproline promote the formation of intermolecular cross-links. d All of the above. The human Achilles tendon responds to acute tensile loading by:
a b c d
an increased blood flow an increased collagen metabolism a but not b a and b.
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Chapter 1.7 Cartilage Tissue — Loading and Overloading KAROLA ME SSNE R, JACK LEWIS, TE D OE GE MA & HEIKKI J. HE L MI NE N
Classical reference Swanepoel MW, Adams LM. The stiffness of human apophyseal articular cartilage as an indicator of joint loading. Proc Inst Mech Eng ; : –. Despite the fact that osteoarthrosis is a considerable problem, relatively little is known about the mechanical properties of joints under mechanical loads.The apophyseal joints are of interest because their primary function is to restrict motion and they are subjected to prolonged loading. It has been hypothesized that articular cartilage is mechanically conditioned by the daily amount of stress imposed on it, such that ‘soft’ cartilage conditioned by low magnitudes of stress is more susceptible to injury by infrequent high magnitudes of stress. Swanepoel and Adams measured the mean thickness and stiffness of the human lumbar apophyseal cartilage in the upper lumbar segments (see Tables .. and ..). The data indicated that there were region-specific differences within the joint. Moreover, compared to previous data in the literature, the data of Swanepoel and Adams suggest that the articular cartilage of human apophyseal joints is softer than the articular cartilage of the ankle, knee and hip joint. Together the results suggest that low daily load conditioning has influenced the mechanical properties of the joint.
ical integrity and biological stability for a lifetime. However, loads that are outside of this range and are too high or too low can stimulate cartilage to remodel, compromising its functional capacity. Also, loads occurring during trauma can lead to cartilage damage and subsequent degeneration. Understanding the response of cartilage to underloading, overloading, impact loading and altered loading is essential in guiding injury prevention and treatment. The mechanical properties of adult articular cartilage depend on the content of the different extracellular matrix proteins (proteoglycans, collagens, etc.), and their three-dimensional structure and interactions. Table .. Thickness distribution of the cartilage of the superior concave apophyseal surface (mm ± % CI). From Table in Swanepoel & Adams. Area
Anterior
Center
Posterior
Superior Center Inferior
1.20 ± 0.23 1.13 ± 0.10 0.91 ± 0.12
1.07 ± 0.18 1.21 ± 0.10 1.14 ± 0.12
0.79 ± 0.17 1.03 ± 0.13 1.09 ± 0.12
Table .. Stiffness distribution of the cartilage of the superior concave apophyseal surface (MPa ± % CI). From Table in Swanepoel & Adams. Area
Anterior
Center
Posterior
Superior Center Inferior
2.84 ± 0.64 2.79 ± 0.30 2.77 ± 0.39
2.23 ± 0.46 3.01 ± 0.35 2.92 ± 0.42
2.21 ± 0.45 2.51 ± 0.48 2.57 ± 0.63
Background Loading is essential for cartilage health and function. Cartilage can sustain loads over a large range of load magnitudes and frequencies and maintain its mechan-
Chapter . Cartilage with a high content of glycosaminoglycans (GAGs), attached to the core protein of aggrecan, the main cartilage proteoglycan (PG), is stiffer during compressive tests than cartilage with a lower GAG content []. Thus, physiologically high-loaded cartilage regions appear to be stiffer than low-loaded areas within the same joint []. Chondrocytes harvested from various regions of adult sheep knees maintain in culture their location-specific production of PGs []. Since chondrocytes from newborn lambs do not show similar location-specific variations in matrix production, it is reasonable to suggest that the loading conditions during postnatal development determine this change in chondrocyte phenotype. Thus, each part of a particular joint is optimally adapted to the physiologic loading conditions in adulthood by the characteristics of its cells and the construction of the extracellular matrix. Since cartilage is a tissue with low turnover, it should be noted that this adaptation takes approximately years in humans.
Responses of articular cartilage to cyclic, static and impact loading Loading models Two tools that have been used to study cartilage response to load are in vitro models of cartilage explant loading and in vivo models of cartilage impact loading. In this section, work in these two areas will be reviewed. These two tools address several issues related to cartilage function. First is the question of what loads are required for healthy cartilage. Too small a load can lead to atrophy, an excessive load can lead to cartilage damage and future degeneration. Second is the question of cartilage response to excessive functional loading, such as might occur during aggressive activity with repetitive loading. Under what loads and conditions might cartilage be damaged, what actually occurs in the cartilage during this injurious loading, how might this be prevented, and how might it be treated if damage does occur? Finally, there is the question of the response of cartilage to traumatic impact loading. Under what conditions is cartilage and the cartilage/bone interface damaged, what is the nature of this damage, and how might it be treated? Before examining these questions, it is useful to de-
scribe what is known of the load environment of articular cartilage. In moderate activities, such as walking, maximum surface pressures in the hip joint have been measured to be of the order of – MPa []. During lifting, pressures rose to nearly MPa []. The time history of this loading would be of the order of /s for walking, with load rise times of the order of ms []. This rise time reduces to approximately ms in jogging []. Surface pressures in trauma can rise to and above the failure level of cartilage. These values for joints are not well known, but from in vitro tests are estimated to be in the range of MPa [,] to MPa, with rise time of a few ms. The in vivo environment of cartilage is thus quite dynamic.
Loading of cartilage explants In vitro models of cartilage response to moderate load have consisted of cartilage explants, subjected to a variety of controlled load environments []. These models usually consist of cartilage removed from an animal at slaughter, maintaining the cells in the living state. Cartilage pieces, with or without the bone, are prepared and loaded in a culture environment. The time history of loading is varied, with load frequency, duration and magnitude as variables. Outcome variables have included synthesis rates of PGs and matrix proteins, gene regulation, tissue swelling as a measure of matrix damage, cell viability and mechanical properties of the explant. The numerous studies all differ in test conditions and outcome variables, making precise comparison difficult. However, several general conclusions have emerged from this work. Static compression of unconfined cartilage explants causes a dose-dependent inhibition of PG synthesis []. Compressive stress of MPa for h in cow cartilage reduced PG synthesis rates by % []. Increased stress or duration further depresses synthesis. Ragan et al. [] further found that h of static compression depressed mRNA levels for both aggrecan and the normal type IIa collagen.
Cyclic and static loading Cyclic or intermittent compression has various effects on cartilage explants, depending on the loading conditions, such as frequency, time between loads and test duration. Cyclic compression generally increases PG synthesis in the short term [] and alters expression of
Cartilage Tissue other matrix proteins []. Unconfined compression of cartilage disks at Hz produced an increase of % in PG synthesis rate []. However increasing both the load magnitude and the duration of loading can reduce PG synthesis [], and increase release from the matrix and cell death []. Cyclic loading also alters the synthesis and retention of fibronectin, with either increases [] or decreases [], depending on the loading conditions. Fibronectin is an important molecule in matrix assembly, which increases during remodeling, but is also rapidly up-regulated in response to matrix damage. The studies discussed so far have focused on cartilage function as influenced by loads within a relatively normal range. Other investigators have specifically explored the upper limits of normal loading and how cartilage explants respond to loads above this limit. Quinn et al. [,] studied the effect of injurious static compression on cartilage explants. They imposed strains over % on bovine cartilage discs mm in diameter by mm thick, leading to grossly visible cracks. They found decrease in tensile strength, increased cell apoptosis and elevated PG turnover, including increased synthesis and loss of the small PGs. Cells also appeared to be slower in response to cell stimulatory factors, such as interleukin (IL-). How much of this change is due to loss of cells and alteration of remaining viable cells is unknown. Chen et al. [] applied cyclic loads of increasing magnitude and loading rate to cartilage explants. They found that damage to the cartilage required repeated impacts with a peak stress of at least . MPa and a stress rate of at least MPa/s for min or longer, suggesting that impact damage is cumulative and stress-rate dependent. Explants loaded repetitively at MPa at . Hz for , and min showed increased water content, increased fibronectin synthesis and increased collagen breakdown. The latter observation supported the assumption that increased water content was due to collagen damage in the matrix. Tests of static and cyclic compression on cartilage explants have shown that load affects chondrocyte metabolism, but it is difficult to understand the relevance of specific values to in vivo conditions. At what point will change in chondrocyte biology lead to cartilage damage in vivo and how is this damage defined? How are the explant loading and stress conditions related to
in vivo conditions? While it is clear that increasingly severe loading leads to a progressive process of matrix damage, reduced synthesis of matrix structural molecules, increased lytic enzymes and cell death, the load conditions in vivo for this process are still poorly defined. These experimental models can be considered useful in the study of cartilage response to loading and damage, but not for simulations of in vivo function. This is still an area of active research that must progress further before clinical relevance can be defined.
Impact loading Impact loading of cartilage explants provides a closer simulation of in vivo injurious load conditions than static and cyclic loading conditions. Joint trauma, and cartilage load during that trauma, are due to a single high-magnitude load, that occurs in the order of milliseconds. Although the specific time/load history will not be known, the approximate histories can be reasonably estimated. The outcome variables are also better defined. Immediate and future cell and matrix damage are the main concerns. Several investigators have studied cartilage explants under impact loading. The classic study was performed by Repo and Finlay [], who loaded cartilage explants with a thin subchondral bone plate with a falling plate, with a displacement stop. They measured cell viability by autoradiography of incorporated radioactive proline, and found that cell death began at about MPa, with fracturing and fissuring occurring simultaneously with cell death. Jeffrey et al. [,] used a different drop weight system to load cartilage explants with no bone with up to MPa surface stress. They found increased mass due to swelling and decreased cell viability with severity of impact. They also found increased loss of newly synthesized protein and GAG when impacted explants were cultured up to days after impact. Torzilli et al. [] and Borelli et al. [] used a similar impact system to impact -mm thick strips of cartilage with stresses ranging from . MPa to MPa. These authors used a conventional materials test machine to load the tissue at a constant stress rate of MPa/s. They measured PG synthesis by sulfate incorporation, cell viability and death with the fluorescing dyes fluoresceine diacetate and ethidium bromide, and water content. They found stimulated PG synthesis at the
Chapter . lower stress levels ( ° following ACL reconstruction is thought to be associated with patellofemoral pain []. It is desirable to have a detection threshold that is less than the clinically relevant measure. This approach to measurement error is much more useful than citing a unitless measurement of reliability such as a test–retest correlation or even a specific error in degrees as described by other researchers for a given test. For many motions, error in goniometric assessment of ROM is primarily due to the subjective nature of assessing the limits of motion. For example, maximum straight leg raise ROM is a standard assessment of hamstring flexibility. Determination of maximum passive ROM is a function of the force applied by the tester and the subject’s perception of the discomfort of the stretch. An increase in ROM may be attributed to a change in muscle tension due to a stretching intervention. However, the increased ROM may simply be due to increased force applied by the tester and increased tolerance of the stretch by the subject []. However, this issue may be less important in the rehabilitation setting where ROM is often limited by pain and the intervention is geared towards limiting the pain restriction rather than altering the mechanical properties of the tissues surrounding the joint. For example, shoulder flexion ROM may be limited by pain in patients with subacromial impingement. Rehabilitation is aimed at reducing the inflammation causing this pain thereby allowing a greater ROM. In this situation an alteration in tolerance of the stretch is the goal, not a source of measurement error.
Chapter . Goniometric and alternative measurement techniques Physical therapists routinely differentiate between passive and active ROM measurements. There are no specific criteria for when to perform one vs. the other, or which is more clinically important. For some motions active ROM may be more accurate because the tester can use both hands to orient the goniometer. For some passive measurements the tester must hold the limb in position while trying to orient the goniometer and this can lead to error. However, active ROM may sometimes be limited by agonist muscle weakness rather than by a restriction of joint motion. Active ROM can also be documented using electrogoniometers. However, these have not gained wide clinical use possibly due to issues of cost. They are most applicable to evaluating functional ROM with specific tasks but measurement error issues remain unresolved []. Fluid-based goniometers, working on the principle of a carpenter’s level, have also been used to measure joint ROM []. While these have not gained popular use, the advent of digital levels in carpentry may provide a new perspective on their use in assessing joint angles. Some alternative techniques negate the use of a goniometer. For example, internal rotation of the shoulder is frequently measured by noting the maximal vertebral level reached by the patient’s thumb []. This may be an easier test for the orthopedist to perform than a goniometric measurement. The question of which is more clinically useful remains open to debate and may depend on the specific pathology. Subacromial impingement is associated with a loss of internal rotation and part of the rehabilitation process involves restoring this motion. The loss of internal rotation ROM is thought to be due to tightness in the posterior capsule. In accordance with this assumption, Tyler et al. [] developed a specific measurement of posterior capsule tightness. This measurement involves measuring the height at which the elbow hangs when the arm is held in an abducted position in sidelying. Intratester reliability was good (intraclass correlation coefficient (ICC) = .–.). Patients with impingement had posterior capsule tightness that was related to the loss of internal rotation ROM []. It has yet to be determined if the posterior capsule measurement is more clinically relevant than internal rotation ROM.
Summary For most orthopedic conditions accurate measurement of joint ROM during rehabilitation is essential for evaluating progress. Standard goniometry is the most accepted and practiced clinical method of assessing ROM. It is important to understand what represents a clinically relevant loss or change in ROM for a given motion and whether the measurement technique can actually detect such a change. To this end the clinician should determine their own threshold of detection for common goniometric assessments.
Evaluation of joint stability Static joint stability Most clinical assessments of joint stability involve manual tests that, for the most part, require a high degree of expertise. Furthermore these manual tests are graded according to a subjective assessment of joint motion. The Lachman test for anterior knee instability and the anterior drawer tests for ankle and anterior shoulder instability are common clinical tests. In general the clinician attempts to assess the magnitude of translation and the quality of the ultimate restraint to translation, i.e. ‘end feel’ or ‘endpoint’. These tests are used initially to diagnose injuries and subsequently to assess the quality of repair. The improvement in joint stability with surgical repairs and reconstructions is usually so dramatic that clinical tests are often adequate for demonstrating improvements despite their subjective nature. However, clinicians often have difficulty in discriminating subtle but clinically important changes in joint stability that may occur during rehabilitation in non-surgical or postsurgical patients. One of the largest postoperative patient populations in sports medicine is the ACL reconstruction patient. The Lachman and pivot shift tests are performed routinely following surgery but it is unclear if these tests are sensitive to changes in graft integrity. For example, a change in Lachman grade from grade (– mm) to grade (– mm) may be difficult to detect in a large number of patients. Various techniques have been developed to increase the sensitivity of clinical tests of joint stability. For example, stress radiography has been used to compare different ankle ligamentous reconstruction procedures []. More applicable to the rehabilitation set-
Principles of Rehabilitation and Sport-Specific Training ting is the use of knee arthrometers to assess graft integrity following ACL reconstruction. The KT is the most widely used arthrometer. It was initially developed to aid in the diagnosis of ACL injuries [] and was also used to document improvements with surgery []. Serial KT- testing is now practiced to assess changes in graft integrity during rehabilitation [,]. While this is definitely a useful adjunct to evaluation in rehabilitation there are several issues that must be taken into account when interpreting the results. As with any test it is necessary to establish the measurement error. Robnett et al. [] estimated that the KT- may only be able to detect a -mm change from a previous measurement in anterior tibial displacement. While this is probably more sensitive than a manual Lachman test a more sensitive measure is probably needed to detect changes in graft integrity on a case-by-case basis. As previously mentioned with respect to goniometric measurements, it is beneficial for the clinician to get an estimate of their own detection threshold, which is about a -mm error for most experienced testers. This detection threshold will allow for detection of clinically relevant changes in graft integrity. The original criteria for interpreting KT- results were based on the ability to detect ACL disruption. A -mm or more side-to-side difference in anterior tibial displacement was established as a valid criterion for identifying ACL disruption []. However, this criterion clearly does not apply to patients who have had ACL reconstructions. As many as onethird of patients can be expected to have a difference of mm or more following ACL reconstruction with a positive endpoint on Lachman tests and no associated symptoms [,]. Postoperatively a difference of less than mm has been categorized as normal, – mm as loose, and greater than mm as a failure []. However, this grading system has not been validated, since the clinical significance of a – mm difference or greater than mm difference postoperatively has yet to be established. The value of postoperative KT- measures has been questioned []. Little is known about what factors affect postoperative KT- results. The tension at which the graft is set intraoperatively will impact on arthrometric stability measurements [,]. If the graft is set at a tension
of N or less patients will have greater postoperative laxity. A tension of – N results in greater stability. It is of note that preoperative KT- measurements are related to postoperative KT- results (r = ., P < .) []. Patients with greater preoperative side-to-side difference in anterior tibial displacement had greater postoperative laxity. About % of our patients have greater than mm side-to-side difference following ACL reconstruction and three-quarters of these patients had greater than mm difference preoperatively. It may not be possible to assess KT- results following surgery without knowing a patient’s preoperative scores. Evaluation criteria for following ACL reconstruction should include the side-to-side difference and the improvement from the preoperative measure. A side-to-side difference of greater than mm with an improvement in anterior displacement of mm or more should be regarded as a good surgical result. The use of arthrometers to evaluate joint stability has been primarily limited to the knee joint. However, some attempts have been made to use a similar approach in documenting anterior shoulder instability [,]. The KT- arthrometer has actually been used for this purpose with promising preliminary results []. However, the development of a jointspecific arthrometer is required. An ankle arthrometer has been developed for measuring anterior–posterior and inversion–eversion laxity []. Preliminary results in subjects without pathology showed good reliability but validity in a patient population has yet to be tested.
Dynamic joint stability Although many surgical and non-surgical treatments are aimed at improving dynamic joint stability true objective tests of dynamic stability are lacking. Eastlack et al. [] have developed a battery of dynamic hopping tests for ACL-deficient patients in an attempt to identify individuals who will not develop functional instability. These tests are an important adjunct to rehabilitation for the ACL-deficient patient. While the long-term prognosis for the patients identified as ‘copers’ remains unknown these tests may be useful in identifying patients for whom surgery can be delayed until the end of a season. This provides an opportunity to rehabilitate the patient to return to play within the
Chapter . season of injury, perform postseason surgery and return to play the following season again. Balance training is an integral part of rehabilitation for ankle instability [,]. Surprisingly, a standardized clinical test has not been developed to assess balance in the athletic ankle instability population. Indices of postural sway based on center of pressure distribution on a force plate have been used to assess balance in patients with a history of ankle sprains, but these tests do not lend themselves to wide clinical use [,,]. Proprioception training (often including balance exercises) is also an integral part of most upper and lower extremity rehabilitation programs. Proprioception refers to the combination of sensation of joint movement and sensation of joint position []. Ligamentous injuries are thought to result in a loss of proprioception while certain rehabilitation techniques are aimed at restoring proprioception (see [] for review). The actual measurement of proprioceptive deficits usually involves testing the ability to detect the initiation of passive joint motion (kinesthesia) or the ability to detect when the joint has returned to a previous position (joint position sense). One of the advantages of these tests is that the movement velocities are extremely slow, thereby reducing measurement error. Information with respect to clinical significance of these proprioception deficits and functional carryover of training effects is lacking. A disadvantage of the measurement technique is that neuromuscular proprioceptive feedback is removed by the passive nature of the test movement. Given the potential for neuromuscular input and adaptation during dynamic motions [] a more integrated approach to the measurement of proprioception may be needed.
Evaluation of muscle function In sports medicine the restoration of muscle function is by far the largest component of most rehabilitation protocols. It follows that most standard evaluations of progress in rehabilitation primarily involve an assessment of muscle function. This assessment is usually based on some measurement of force-generating capacity. A multitude of factors must be considered when choosing a particular test of muscle function. Typical considerations include: What are the specific muscle groups of interest?
Will voluntary or artificially stimulated contractions be evaluated? Is the goal to assess strength, endurance or power? Should the assessment involve concentric, eccentric or isometric contractions? Will the test instrument be an isokinetic dynamometer, a free weight isotonic system, a hand-held dynamometer or some other device? Will measurements be made throughout the range of motion? The answer to each of these questions will vary depending on such factors as the specific injury, the patient’s symptoms, the time post injury or surgery, the functional demands of the particular muscle group to be tested and accessibility of the instrumentation.
Affected muscle groups — linkage It is often a mistake in rehabilitation to concentrate on the muscle groups surrounding the injured joints and ignore potential deficits in muscle groups along the kinetic chain. The concept of linkage describes how impairments in one area can impact other areas in the musculoskeletal system. This has been best illustrated in ankle pathology where proximal muscle groups may be more affected than the muscles surrounding the injured joint []. There is an association between ankle sprains and hip abduction weakness but it is unclear if it is a cause or effect. Furthermore, following ankle injury there is increased reliance on the hip musculature in response to ankle perturbations [].
The role of neuromuscular stimulation techniques For the most part muscle function testing will involve voluntary contractions. However, it is often difficult for clinicians to determine the extent to which muscle weakness is due to incomplete activation as opposed to atrophy. This is an important issue since the optimal treatment for reversing atrophy usually involves resistance exercises aimed at overloading the muscle. By contrast, the optimal treatment for improving muscle activation often involves modalities that reduce pain and/or joint effusion or stimulation protocols aimed at ‘muscle re-education’. Specific stimulation protocols have been developed to identify the contribution of inhibition to muscle weakness []. Stimulation training protocols may be beneficial in conditions where inhibi-
Principles of Rehabilitation and Sport-Specific Training tion limits training effects with voluntary contractions. For example, Snyder-Mackler et al. [] demonstrated that electrical stimulation enhanced recovery of quadriceps strength following ACL reconstruction. However, strength recovery was highly dependent on the training contraction intensity which was limited by the patient tolerance of the associated discomfort. The electrically stimulated training intensity ranged from < % of the contralateral maximal voluntary contraction (MVC) to % of the contralateral MVC. The training dosage involved stimulated contractions three times per week, from the second to the sixth postoperative week. Quadriceps strength was approximately % of the uninvolved side following weeks of stimulation compared with approximately % in the comparison group. While these results are very encouraging, the question of patient comfort remains a confounding factor. In a similar study Lieber et al. [] found that patients could only tolerate electrical stimulation intensities sufficient to elicit contractions from % to % of MVC from to weeks following ACL reconstruction. Not surprisingly, electrical stimulation did not prove better than voluntary contractions. In contrast to electrical stimulation, magnetic stimulation of peripheral nerves represents a relatively painless alternative to electrical stimulation which has a wide application in musculoskeletal rehabilitation. Polkey et al. [] demonstrated that single magnetic pulses to the femoral nerve could be used to objectively assess muscle strength and fatigue in both normal subjects and patients with known muscle weakness. However, they did not quantify contraction intensities elicited from stimulation trains resulting in tetanic contractions. The technology is now available to deliver trains of pulses to peripheral nerves to elicit tetanic contractions for as long as s. This offers the potential to deliver supramaximal contractions to assess strength independently of neural inhibition and to train muscles which cannot be fully activated voluntarily. This technology was recently applied in a group of subjects without pathology []. Magnetic stimulation of the femoral nerve elicited torques of % MVC with minimal discomfort. The magnitude of torque response was inversely related to the subject’s percentage body fat. The primary limitation to eliciting greater torques was related to specifications of the unit
rather than to subject tolerance. With the addition of more booster units, higher frequencies and intensities could be used and should produce even higher torque levels. However, at present this technology is too expensive for wide clinical use and the software applications are not conducive for training protocols.
Strength, endurance and power A common misconception is that decreased muscle strength (weakness) and decreased muscle endurance (increased fatigability) occur concomitantly following injury and associated disuse. However, muscle strength and endurance are at best unrelated and may in fact be inversely related. Snyder-Mackler et al. [] found that quadriceps weakness following ACL reconstruction was inversely related to reduced fatigue. The rate of torque decline (fatigue) during sustained electrically stimulated submaximal knee extension contractions was markedly less on the involved side compared to the non-involved side weeks following surgery. The results were recently confirmed in the same patient population using voluntary contraction and electromyographic indices of fatigue []. Both studies point to the possibility of selective fast-twitch fiber atrophy as a mechanism for the observed effects. The clinical relevance of these findings is that quadriceps endurance exercises are not indicated following ACL reconstruction. The fact that a weak muscle may be less fatigable can be seen as a functional adaptation to counteract the increased demands placed on it. During repetitive activity a weak muscle will be working at a higher relative intensity than a contralateral normal muscle for a given absolute load. Thus the weak muscle can be expected to fatigue more rapidly because it is working at a higher relative intensity. The fatigue resistance (apparent in the weak muscle when tested at similar relative loads) may help to offset the fatigue induced by working at a higher relative intensity. Muscle endurance exercise are often used in rehabilitation to prepare patients for the specific demands of their sports. These exercises are an important part of the sport-specific phase of rehabilitation. It is important that the chosen exercises are as sport specific as possible since endurance exercises have been shown to be very task specific with minimal carryover to related tasks []. Task specificity [] and poor measurement
Chapter . reliability (compared with strength tests) [] may limit the efficacy of standardized endurance tests in rehabilitation. The disassociation between strength and endurance, apparent in patients following ACL reconstruction, is also apparent in patients with low back pain. In this condition patients present with normal strength but decreased endurance []. Thus endurance-type training is indicated for this patient population. Muscle power is frequently overlooked in rehabilitation. Many dynamic sports require the ability to produce high muscle forces in a minimal amount of time. For these activities performance is dependent on muscle power rather than muscle strength. While high load is optimal for strength training the optimal load for power training is dependent on the force–velocity relationship of the muscles involved. For isolated muscles the relationship of muscle force to the velocity of contractile shortening is an inverse hyperbolic curve. Muscle force is highest during low-velocity movements and lowest during high-velocity movements. In contrast the relationship of muscle force to muscle power is parabolic. Maximum muscle power occurs in the midportion of the force–velocity curve at muscle forces of –% of maximum. Training studies have demonstrated that high-velocity training with loads equal to –% MVC result in the greatest gains in power. Clinically, the force–velocity relationships for single joint movements can be estimated according to the relationship of torque to angular velocity. Based on this relationship a power curve can be calculated from which an optimal training intensity can be set for power training.
Contraction type The contraction type to be tested is to some extent dependent on the test instrument used. For the most part clinicians can decide between purely concentric, eccentric or isometric tests or reciprocal concentric/ eccentric tests. Isokinetic dynamometers provide the greatest freedom of choice in this regard. Measurement error is an important consideration in choosing the appropriate contraction type. However, a definitive statement cannot be made regarding differences in measurement error between each of the three contraction types. Error will be affected by the joint being
tested, the muscle group and the chosen contraction velocity. Generally slow-speed concentric and isometric contractions are thought to be the most reproducible []. Clinical factors may dictate the choice of contraction type. For example, isometric strength at ° was used to quantify quadriceps weakness in the early postoperative phase following ACL reconstruction []. The potential for pain during testing was reduced by testing in a position of minimal patellofemoral compression. This could have also been achieved by testing concentrically at high speed, but this may be a less reproducible test. High-speed eccentric testing may be more informative in assessing recovery from a muscle strain [] but may also have increased risk of re-injury. Often concentric testing is preferred because of the low muscle forces relative to eccentric and isometric contractions. There is also less post-test muscle damage with concentric testing. If the goal of a test is to assess fatigability eccentric contractions are not appropriate since eccentric contractions are much more fatigue resistant than concentric and isometric contractions [,].
Test instrument Typically strength can be measured on an isokinetic dynamometer, a free weight isotonic system or a handheld dynamometer or manually using a clinical grading system. While the latter method is common in physicians’ offices or on the sidelines of sports events the other more objective measures are usually available in the rehabilitation setting. The primary disadvantage of isotonic testing using a free weight apparatus is that repeated trials are required to establish a onerepetition maximum. However, this type of testing replicates the training situation for many patients. Although isokinetic dynamometry is regarded as the gold standard for strength assessment, hand-held dynamometers offer a much less expensive, portable alternative. The reliance on tester strength limits the number of motions that can be tested, but hand-held dynamometry has been used effectively to test shoulder abduction [], shoulder internal–external rotation and scapular-plane elevation [,], and hip flexion, abduction and adduction []. In fact measurement error was shown to be better for hand-held dynamometry than for isokinetic testing of shoulder abduction strength [].
Principles of Rehabilitation and Sport-Specific Training Functional range of motion One of the advantages of isokinetic testing is that it allows maximal force to be generated throughout the full range of motion unlike isotonic or single-angle isometric testing. However, only rarely do clinicians take advantage of this and actually examine strength through the functional range. For example strength loss with aging is associated with a loss of functional range of the muscles []. The shape of the length–tension curve (i.e. the ROM–torque curve) may be revealing of functional capacity following injury but has not been studied specifically. A decreased slope on the descending limb of the length–tension curve (i.e. increased force-generating capacity at increased muscle lengths) is thought to protect muscle from exercise-induced damage []. It may be useful to examine the ability to generate muscle force at increased muscle lengths in patients recovering from muscle strains.
Summary Specific tests for assessing joint ROM, joint stability and muscle function encompass most of the types of evaluations performed in rehabilitation. Functional tests, such as the single-limb hop test used in ACL reconstruction rehabilitation, provide an additional picture of general musculoskeletal performance. When such tests are applied they should involve a combination of a sport-specific demand and an injuryspecific demand. Using the same example of the single-limb hop test for the ACL reconstruction patient this involves a sport-specific demand for high friction sports such as basketball and soccer but is an inappropriate test for a low friction sport such as ice hockey []. Certain general principles apply to evaluations regardless of whether they involve testing ROM, stability or muscle function. The measurement error should be sufficiently low to enable the detection of clinically relevant effects. Clinicians should establish their own detection thresholds for commonly used clinical tests. Interpretations of test results must be based on established criteria validated for the specific patient population. As new tests and new testing equipment are developed to provide more accurate or less expensive assessments, these tests should be validated with the appropriate patient populations.
Fitness training and performance testing Introduction In order to understand how to perform fitness training and how to evaluate performance in a sport the physical requirements of the sport have to be understood. Performance in any sport is determined by the athlete’s technical, tactical, physiological and psychosocial characteristics (Fig. ..). These elements are closely linked to each other, e.g. the full technical quality of an athlete may not be exploited if the athlete’s physical capacity is low. The physical demands in a sport are very much related to the activities of the athlete. In some sports continuous exercise is performed with either a very high or moderate intensity during the entire event, such as a -m and a marathon run, respectively (Fig. ..). In other sports like soccer and basketball athletes perform different types of exercise ranging from standing still to maximal running, and the intensity can vary at any time. Under optimal conditions the physical demands of the sport are closely related to the athlete’s physical capacity, which can be divided into the following categories: (i) the ability to perform prolonged exercise (endurance); (ii) the ability to exercise at high intensity; (iii) the ability to sprint; and (iv) the ability to develop a high power output (force) in single actions during competition such as kicking in soccer and jumping in basketball (Fig. ..). The basis for performance within these categories is the characteristics of the cardiovascular system and the muscles, combined with the interplay of the nervous system. These characteristics are to a great extent determined by genetic factors but they can also be developed by training. A number of environmental factors such as temperature and for outdoor sports the weather and the surface of the competition ground also influence the demands on the athletes. In some sports it is important that the athlete has a very high capacity within at least one of the categories of physical capacity to perform at a top level; for example, a marathon runner needs a high endurance capacity, but not a well-developed ability to produce a high power output. In other sports, such as team sports, an athlete may need an all-round fitness level. In such sports an athlete with a moderate en-
Chapter .
Psychological/social Tactical
Performance
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Coordination Flexibility Sensorimotor
External factors temperature attitude field condition nutrition (diet/fluid)
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Aerobic performance aerobic power aerobic capacity
Intrinsic factors age/maturation sex anthropometry
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Anaerobic performance anaerobic power anaerobic capacity
Cardiovascular system
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Muscle strength low-speed force high-speed force
Muscle characteristics
Fig. .. Physiologic factors within a holistic model of performance in a sport. Performance is determined by an athlete’s tactical, psychological/social, technical and physiologic capacity. These areas overlap and influence each other. The physiologic factors can be divided into several performance abilities (upper part). These are dependent on variables, which in part can be evaluated separately (middle part). Cardiovascular capacity, neural factors and muscle characteristics comprise basic components of physiologic performance that are determined by both intrinsic biologic make-up and training status (lower part). Performance in a sport can also be influenced by various external factors, including environment and nutrition.
durance capacity may to some extent compensate for this weakness by having good capabilities in other areas relevant to the sport, e.g. a high technical standard or good sprinting ability. In the remainder of this chapter the general principles of training to improve specific aspects of physical performance will be described and the use of tests to evaluate performance of athletes will be discussed.
Physiology of training Fitness training in any sport has to be focused on the demands of the sport, and in many sports it has to be multifactorial in order to cover the different aspects of
physical performance in the sport. To be able to fulfil these requirements, it is useful to divide fitness training into a number of components related to the purpose of the training (Fig. ..). The terms aerobic and anaerobic training are based on the energy pathway that dominates during the activity periods of the training session (Fig. ..). Aerobic and anaerobic training represent exercise intensities below and above the maximum oxygen uptake, respectively. However, in some sports like ball games, in which the ball is used in the fitness training, the exercise intensity for an athlete varies continuously, and some overlap exists between the two categories of training.
Principles of Rehabilitation and Sport-Specific Training 100
100 m
90 800 m
Intensity (% of maximum)
80 70 60 50 40
. V O2max Marathon
30 20 10
Cycling
Soccer Time
Fig. .. Examples of exercise intensities in various sports. Note that the intensity corresponding to the maximum oxygen · uptake (V 2 max) is around % of maximal intensity, but there are large individual differences.
The separate components within fitness training are briefly described below. They include aerobic, anaerobic and specific muscle training.
Aerobic training Aerobic training causes changes in central factors such as the heart and blood volume, which result in a higher maximum oxygen uptake []. A significant number of peripheral adaptations also occur with this type of training []. The training leads to a proliferation of capillaries and an elevation of the content of mitochondrial enzymes, as well as the activity of lactate dehydrogenase – isozymes (LDH1–2). Furthermore, the mitochondrial volume and the capacity of one of the shuttle systems for NADH are elevated []. These changes cause marked alterations in muscle metabolism. The overall effects are an enhanced oxidation of lipids and sparing of glycogen, as well as a lowered lactate production, both at a given and at the same relative work-rate []. The optimal way to train central and peripheral factors is not the same. Maximum oxygen uptake is most effectively elevated by exercise intensities of –% of V˙2 max (–% of maximal intensity; Fig. ..). For a muscle adaptation to occur, an extended period of training appears to be essential, and therefore, the mean intensity needs occasionally to be below % of V˙2 max. This does not imply that high-intensity train-
ing does not elevate the number of capillaries and mitochondrial volume in the muscles engaged in the training, but that the duration of this type of training is often too short to obtain optimal adaptations at a local level. The dissociation between changes in V˙2 max and muscle adaptation by means of training and detraining is illustrated by results from two studies. In one study long-distance runners were kept inactive for weeks (first week with the leg in a cast) which did not result in a change in V˙2 max []. On the other hand, the detraining period led to a % decrease in performance in an exhaustive run (from about –. min) which was associated with a % lowering of the activity of the oxidative enzyme succinate dehydrogenase (SDH). During the following weeks of retraining V˙2 max did not change, whereas performance and SDH were still lowered by and %, respectively. The level of inactivity does not have to be as extreme as in this study to have a marked effect on performance and muscle respiratory capacity. In another study topclass soccer players abstained from training for weeks []. It was found that V˙2 max was unaltered, whereas performance in a field test was lowered by %, and there was a reduction in oxidative enzymes of –% (Fig. ..). The recovery processes from intense exercise are related both to the oxidative potential and to the number of capillaries in the muscles []. Thus, aerobic training not only improves endurance performance of an athlete, but also appears to influence an athlete’s ability to repeatedly perform maximal efforts. The overall aim of aerobic training is to increase the work-rate during competition, and also in ball games to minimize a decrease in technical performance as well as lapses in concentration induced by fatigue towards the end of a game. The specific aims of aerobic training are as follows. • To improve the capacity of the cardiovascular system to transport oxygen. Thus, a larger percentage of the energy required for intense exercise can be supplied aerobically, allowing an athlete to work at higher exercise intensity for prolonged periods of time. • To improve the capacity of muscles specifically used in the sport to utilize oxygen and to oxidize fat during prolonged periods of exercise. Thereby, the limited store of muscle glycogen is spared and an athlete can
Chapter .
FITNESS TRAINING Low-intensity training AEROBIC TRAINING
Moderate intensity training Highintensity training Production training Speed endurance training
ANAEROBIC TRAINING
Maintenance training Speed training
Muscle strength training SPECIFIC MUSCLE TRAINING
Functional training
Low-speed training Concentric training
Basic training
High-speed training
Isometric training
Muscle speed endurance training Flexibility training
CS
11.5
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HAD mmol/min g d.w.
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min
L/min
Maximum oxygen uptake
Fig. .. Components of fitness training.
50 40 30 20
Fig. .. Maximum oxygen uptake, performance in a field test, activities of oxidative enzymes citrate synthase (CS) and b-hydroxy-CoA-dehydrogenase (HAD; involved in fat oxidation) of Danish top-class soccer players during the season and after weeks of holiday.
Principles of Rehabilitation and Sport-Specific Training exercise at a higher intensity towards the end of a game. • In some sports, like team sports, to improve the ability to recover after a period of high-intensity exercise. As a result, an athlete requires less time to recover before being able to perform in a subsequent period of high-intensity exercise.
Components of aerobic training Aerobic training can be divided into three overlapping components: aerobic low-intensity training (aerobicLI), aerobic moderate-intensity training (aerobicMO) and aerobic high-intensity training (aerobicHI) (Fig. ..). Table .. illustrates the principles behind the various categories of aerobic training, which take into account the fact that in some sports the training may be performed as a game, and thus the heart rate of the athlete may frequently alternate during the training. During aerobicLI athletes perform light physical activities, such as jogging and low-intensity games. This type of training may be carried out the day after a competition or the day after a hard training session to help the athlete to return to a normal physical state. AerobicLI may also be used to avoid athletes getting into a condition known as ‘overtraining’ in periods involving frequent training sessions (maybe even twice a day) and a busy competitive schedule. The purpose of aerobicMO is to elevate the capillarization and the oxidative potential in the muscle (peripheral factors). Thus, the functional significance is an optimization of substrate utilization and thereby an improvement in endurance capacity. One of the aims of aerobicHI is to improve central factors such as the
pumping capacity of the heart which is closely related to V˙2 max. These improvements increase an athlete’s capability to exercise repeatedly at high intensities for prolonged periods of time.
Anaerobic training In a number of sports an athlete performs activities that require rapid development of force, such as sprinting, quickly changing direction or jumping. Also, in many sports the lactate-producing energy system (glycolysis) is highly stimulated during periods of competition. Therefore, the capacity to perform highintensity exercise may specifically have to be trained. This can be achieved through anaerobic training. Anaerobic training results in an increase in the activity of creatine kinase (CK) and glycolytic enzymes; such an increase implies that a certain change in an activator results in a higher rate of energy production of the anaerobic pathways. Intense training does not appear to influence the total creatine phosphate (CP) pool, but it allows the muscle glycogen concentration to be elevated, which is of importance for performance during repeated high-intensity exercise []. The capacity of the muscles to release and neutralize H+ (buffer capacity) is also increased after a period of anaerobic training []. This will lead to a lower reduction in pH for a similar amount of lactate produced during high-intensity exercise. Therefore, the inhibitory effects of H+ within the muscle cell are smaller, which may be one of the reasons for a better performance in high-intensity tests after a period of anaerobic training. Another important effect of the anaerobic training is an increased activity of the muscle
Table .. Principles of aerobic training. Heart rate
Oxygen uptake
% of HRmax
Low-intensity training Moderate-intensity training High-intensity training *If HRmax is 200 beats/min.
% of V·O2 max
Beats/min
Mean
Range
Mean*
Range*
Mean
Range
65 80 90
50–80 65–90 80–100
130 160 180
80–160 130–180 160–200
55 70 85
20–70 55–85 70–100
Chapter . Table .. Principles of anaerobic training. Duration
Speed training
Exercise
Rest
Intensity
Number of repetitions
2–10 s
> 10 times the exercise duration
Maximal
2–10
> 5 times the exercise duration 1–3 times the exercise duration
Almost maximal High
2–10 2–10
Speed endurance training Production 15–40 s Maintenance 20–90 s
Na+/K+ pumps resulting in a reduced net loss of potassium from the contracting muscles during exercise, which may also lead to increased performance []. The overall aim of anaerobic training is to increase an athlete’s potential to perform high-intensity exercise. The specific aims of anaerobic training are summarized below. • To improve the ability to act quickly and to produce power rapidly. Thus, an athlete reduces the time required to react and elevates sprinting performance. • To improve the capacity to produce power and energy continuously via the anaerobic energyproducing pathways. Thereby, an athlete elevates the ability to perform high-intensity exercise for longer periods of time. • To improve the ability to recover after a period of high-intensity exercise, which is particularly important in ball games. As a result, an athlete requires less time before being able to perform maximally in a subsequent period of exercise, and in ball games the athlete will therefore be able to perform high-intensity exercise more frequently during a match.
Components of anaerobic training Anaerobic training can be divided into speed training and speed endurance training (Fig. ..). The aim of speed training is to improve an athlete’s ability to act quickly in situations where speed is essential. Speed endurance training can be further separated into two subcategories: production training and maintenance training. The purpose of production training is to improve the ability to perform maximally for a relatively short period of time, whereas the aim of maintenance training is to increase the ability to sustain exercise at a
high intensity. Table .. illustrates the principles of the various categories of anaerobic training. Anaerobic training must be performed according to an interval principle. During speed training the athletes should perform maximally for a short period of time (< s). The periods between the exercise bouts should be long enough for the muscles to recover to near-resting conditions, so as to enable an athlete to perform maximally in a subsequent exercise bout. In many sports, speed is not merely dependent on physical factors. It also involves rapid decision-making which must then be translated into quick movements. Therefore, in ball games speed training should mainly be performed with a ball. Speed drills can be designed to promote an athlete’s ability to sense and predict situations, and the ability to decide on the opponents’ responses in advance. Through speed endurance training the creatine kinase and glycolytic pathways are highly stimulated. The exercise intensity should be high (> % of maximal intensity; Fig. ..), to elicit major adaptations in the enzymes associated with anaerobic metabolism. In production training the duration of the exercise bouts should be relatively short (– s), and the rest periods in between the exercise bouts should be comparatively long (– min) in order to maintain a very high intensity during the exercise periods throughout an interval training session. In maintenance training the exercise periods should be – s and the duration of the rest periods should be one to three times longer than the exercise periods, to allow athletes to become progressively fatigued. The adaptations caused by speed endurance training are mostly localized to the exercising muscles. Thus, it is important that an athlete performs move-
Principles of Rehabilitation and Sport-Specific Training
is to increase performance of a muscle to a higher level than can be attained just by participating in the sport. Specific muscle training can be divided into muscle strength, muscle speed endurance and flexibility training (Fig. ..). The effect of this form of training is specific to the muscle groups that are engaged, and the adaptation within the muscle is limited to the kind of training performed. A brief description of muscle strength training is given below. Further information about strength training can be obtained in Chapter .. (a)
18
180
16
160
14 12
140
10 120
8
100
6 4
80
2 E 0
(b)
Lactate concentration (mmol/L) ( )
Heart rate (beats/min) ( )
Strength training
E 1
2
E
3 4 5 6 Time (min)
E 7
8
Fig. .. Speed endurance soccer training game. Two against two with man-to-man marking and two goalkeepers. The players play for min followed by min of rest. Below is shown the heart rate and blood lactate response for a player. The high heart rate towards the end of the exercise periods and the high lactate levels show that the anaerobic system is heavily stimulated.
ments in a manner similar to those used during competition, e.g. an oarsman should train in the boat or on a rowing ergometer. In ball games this can be obtained by performing high-intensity games or drills with a ball. Figure .. illustrates a soccer game within the maintenance category of speed endurance training. It also shows heart rate and blood lactate values for a player during the game, illustrating that the game fulfils the criteria for speed endurance training.
Specific muscle training Specific muscle training involved training of muscles in isolated movements. The aim of this type of training
In many sports there are activities which are forceful and explosive, e.g. high jumping, hiding in boxing and turning in ice hockey. The power output during such activities is related to the strength of the muscles involved in the movements. Thus, it is beneficial for an athlete in such sports to have a high level of muscular strength, which can be obtained by strength training. Strength training can result in hypertrophy of the muscle, partly through an enlargement of muscle fibers. In addition, training with high resistance can alter the fiber type distribution in favor of fast-twitch fibers []. There is also a neuromotor effect of strength training and part of the increase in muscle strength can be attributed to changes in the nervous system. Improvements in muscular strength during isolated movements seem closely related to training speeds. However, significant increases in force development at very high speeds (– rad/s) have also been observed with slow-speed high-resistance training []. One essential function of the muscles is to protect and stabilize joints of the skeletal system. Hence, strength training is also of importance in preventing both injuries and reoccurrence of injuries. A prolonged period of inactivity, e.g. during recovery from an injury, will considerably weaken the muscle. Thus, before an athlete returns to training after an injury, a period of strength training is needed. The length of time required to regain strength depends on the duration of the inactivity period but generally several months are needed. In a group of soccer players observed for years after a knee operation, it was found that the average strength of the quadriceps muscle of
Chapter . the injured leg was only % of the strength in the other leg []. The overall aim of muscle strength training is to develop an athlete’s muscular make-up. The specific aims of muscle strength training are: • to increase muscle power output during explosive activities such as jumping and accelerating; • to prevent injuries; and • to regain strength after an injury. Components of strength training Strength training can be divided into functional strength training and basic strength training (Fig. ..). In functional strength training, movements related to the sport are used. The training can consist of activities in which typical movements are performed under conditions that are physically more stressful that normal. During basic strength training muscle groups are trained in isolated movements. For this training different types of conventional strength training machines and free weights can be used, but the body weight may also be used as resistance. Strength training should be carried out in a manner that resembles activities and movements specific to the sport. Based on the separate muscle actions the basic strength training can be divided into isometric, concentric and eccentric muscle strength training (Fig. ..). Several principles can be used in concentric strength training. Table .. illustrates a principle which is based on determinations of five-repetition maximum ( RM) and which allows for muscle groups to be trained at both slow and fast speeds.
Common to the two types of strength training is that the exercise should be performed with a maximum effort. After each repetition an athlete should rest a few seconds to allow for a higher force production in the subsequent muscle contraction. The number of repetitions in a set should not exceed . During each training session two to four sets should be performed with each muscle group, and rest periods between sets should be longer than minutes. During this time the athletes can exercise with other muscle groups.
Training methods A major part of fitness training in any sport should be performed in a manner closely related to the activities specific to that sport, e.g. with a ball in basketball, since this ensures that the specific muscle groups used in the sport are trained. In addition, in some sports the athletes will thus develop technical and tactical skills under conditions similar to those encountered during a match. Thirdly, this form of training usually provides greater motivation for the athletes compared to training not focused on the sport. Individual physical demands must be considered when planning fitness training and a part of the fitness training may, even in team sport, be performed on an individual basis. The training should be focused on improving both the strong and weak abilities of an athlete. It is important to be aware of the fact that, due to hereditary differences, there will always be differences in the physical capacity of athletes, irrespective of training programs.
Table .. Principles of muscle strength training.
Concentric Low-speed High-speed
Workload
Number of repetitions
Rest between repetitions (s)
Number of sets
5RM* 50% of 5RM
5 15
2–5 1–3
2–4 2–4
5–15
2–4
Isometric 85–100% of max maintained for 5–15 s *RM, repetition maximum.
5–10
Principles of Rehabilitation and Sport-Specific Training Evaluation of physical performance
180 170 160 Nm
This section will deal with various aspects of evaluation of physical performance and give a number of examples of tests that are relevant and easy to use.
150
Reasons for testing
140
Competition naturally provides the best test for an athlete but it is difficult to isolate the various components within the sport and get objective measures of performance. Fitness testing can provide relevant information about specific parts of a sport. Before selecting a test, clear objectives should be defined. There may be a number of reasons for testing an athlete: • To study the effect of a training program. • To motivate an athlete to train more. • To give an athlete objective feedback. • To make an athlete aware of the aims of the training. • To evaluate whether an athlete is ready to compete. • To determine the performance level of an athlete during a rehabilitation period. • To plan short- and long-term training programs. • To identify the weaknesses of an athlete.
130
Choosing a test To obtain useful information from a test, it is important that the test to be performed is relevant and resembles the conditions of the sport in question. For example, a cycle test is of minor relevance for a swimmer. There are a number of laboratory tests which evaluate various aspects of performance (Fig. ..) and are commonly used. These include determination of maximum aerobic power (maximum oxygen uptake) to evaluate the athlete’s ability to take up and utilize oxygen as described in Chapter .. A Wingate test consists of s of maximal cycle exercise aiming at determining the maximum anaerobic power and ability to maintain a high power output. Strength measurements in which strength or power of an isolated muscle group is measured during either isometric, concentric or eccentric contractions are other laboratory tests often used. Such tests provide general information about the capacity of an athlete and may separate different performance levels of athletes within a sport. For example, for soccer players the
*
*
120 0 GoalCentral Fullbacks Midfield Forwards keepers defenders players
Fig. .. Maximum knee extensor torque (Nm) under isokinetic loading at a velocity of °/s for Danish top-class soccer players in various positions. Means + SE are given. * Significantly different from goalkeepers, central defenders and forwards.
strength produced by the knee extensors during an isokinetic movement at a velocity of °/s was significantly higher for goalkeepers, defenders and full-backs than for midfield players and forwards (Fig. ..). In some sport such general tests can provide information as to sport-specific requirements; e.g. to be a top-class cross-country skier a maximum oxygen uptake of higher than mL/min/kg is needed. Such classical laboratory tests may also be useful for comparisons of performance between various sports. However, they may only to a limited extent express the performance of the athlete during competition. For example, Fig. .. shows that for top-class soccer players there was no relationship between peak knee extensor power output and kick performance, suggesting that the strength of the knee extensors alone does not determine the final impact on the ball in a kick. Strength of other muscle groups, such as the hip muscles, may be important and technical skill is also a predominant factor in the soccer kick, which incorporates a complex series of synergistic muscle movements, involving the antagonistic muscles as well. Being more specific to the sport will increase the validity of a test, i.e. the test result better reflects the performance of the athlete. Below are provided a number of examples of sport-specific tests that are simple to organize; some require special equipment in order to
Chapter .
Moment, 30°/s (Nm)
450 400 350 300 250 200 150 0
r = 0.28 0
95
100
105
110
115
Peak ball velocity (km/h) Fig. .. Individual relationship between kick performance (peak ball velocity) and maximum knee extensor torque (Nm) under isokinetic loading at a velocity of °/s for Danish top-class soccer players.
simulate the activities in the sport and others require only simple materials.
Rowing performance Rowing is characterized by a certain movement involving muscles of the whole body. A rowing ergometer has been developed in which it is possible to simulate the movement in the boat. Performance can be evaluated by measuring the total work performed within a given time, e.g. min as in some races, or the time to exhaustion at a given external work rate []. To obtain further information about the oarsman a number of physiological measurements can be added to the test such as pulmonary oxygen uptake in which the rate of rise of oxygen uptake in the initial phase of exercise and the peak oxygen uptake during the rowing are determined. It is of no doubt that such a test has a high validity for rowing performance on water.
Running tests One of the most widely used field tests is the Cooper test. In the Cooper test the participants run the furthest possible distance in min. It is simple to perform, but it has the disadvantage that the athletes need to know how to tactically perform the test in order to obtain the best test result. It also requires a course with a distance of at least m. Its popularity probably re-
sults from the fact that it is simple and a correlation between performance and V˙2 max has been observed. However, the type of running in the test may only be relevant for track runners and they have the most simple test in any case, namely the competition. Furthermore, the relationship between the test and V˙2 max may not be very useful, since in many sports, such as ball games, V˙2 max is a poor marker of physical performance during competition. The ‘yo-yo’ tests are a series of tests that evaluate various aspects of performance in an easy way []. The tests contain running activities that are relevant for many sports. With the tests the physical capacity is evaluated in a fast and simple manner. Two markers are positioned m apart. A CD is placed in a CD player and the test can be performed. The participant runs like a yo-yo back and forth between the markers at given speeds that are controlled by the CD. The speed is regularly increased, and when the individual no longer can maintain the speed, the test is ended. The test result is determined as the distance covered during the test. It is also possible to perform the tests without exhausting the participants. In this case the test is stopped after a given time and the heart rate is measured to evaluate the development of the cardiovascular system. The lower the heart rate the higher is the capacity of the individual. This type of test is especially useful for athletes that are in a rehabilitation period. The tests can be used by anyone, irrespective of training status, since each of the three tests has two levels. There is a test for untrained and less trained individuals, and one test for well-trained athletes. There are three yo-yo tests. In one test the participants perform continuous exercise, called the yo-yo endurance test, and in two tests the participants carry out intermittent exercise, namely the yo-yo intermittent endurance test and the yo-yo intermittent recovery test. The principles of the yo-yo intermittent tests are similar to the continuous yo-yo test, except that in the intermittent tests the athletes have a period of active rest between each of the ¥ -m shuttles. The tests are briefly described below and examples given of sports where each of the tests is relevant. Also provided are examples of how the tests have been used to determine the performance of athletes.
Principles of Rehabilitation and Sport-Specific Training PreDuring preparation period
1800 1200
*
1600
*
*
*
1100
1400 1300 1200
Distance (m)
Distance (m)
900
*
1000 900
*
800 700
Guard
Forward
Center
Fig. .. Yo-yo intermittent endurance test performance of male top-class basketball players in different positions. * Significantly different from center players.
Yo-Yo endurance test The yo-yo endurance test lasts for – min and is used for the evaluation of the ability to work continuously for a longer period of time. This test is especially useful for individuals that participate in endurance exercise, such as distance running. Yo-Yo intermittent endurance test The yo-yo intermittent endurance test lasts – min and consists of –-s intervals of running interspersed with regular -s rest periods. The test evaluates an individual’s ability to repeatedly perform intervals over a prolonged period of time. The test is especially useful for the athlete that performs interval sports, such as tennis, team handball, basketball and soccer. Figure .. shows the performance of topclass basketball players in different positions. Yo-Yo intermittent recovery test The yo-yo intermittent recovery test lasts – min and focuses on the ability to recover after intense exercise. Between each exercise period (– s) there is a -s pause. The test is particularly suitable for sports in which the ability to perform intensive exercise after short recovery periods can be decisive for the outcome of a competition, such as badminton, soccer, basketball, ice hockey and football. The test is able to pick up changes in performance illustrated in Fig. .., which shows the performance level of professional
0 Fullbacks Central Midfield Forwards defenders players Fig. .. Yo-yo intermittent recovery test performance of professional male soccer players in different positions of a team at the start (open bars) and at the end (solid bars) of a -week preparation period prior to the season. Means are given. * Significantly different from the start of the preparation period.
soccer players before and after a preparation period before a new season. All player groups had marked improvements, showing that the test is able to detect significant changes in physical capacity in soccer. Repeated sprint test The ability to be able to run fast and to perform repeated sprints can be tested easily by having the athlete sprint a given distance a number of times separated by a period of recovery that allows a decrease in performance. In relation to the latter aspect Balsom et al. [] observed that performance in a -m sprint could be maintained when subjects have a recovery period between each sprint of s, but a marked decrease was found when the recovery time was s. This means that in order to evaluate an athlete’s ability to recover from intense exercise the rest period between -m sprints should be less than s and preferably s. In a test to measure the ability to sprint and at the same time change direction, athletes perform seven sprints each lasting about s, separated by -s rest periods. Figure .. shows how the performance of professional soccer players changed during a preparation period. The significant decrease in the sprint time shows that the test can be used to detect changes in performance.
Chapter . Preparation period Start of season
7
Time (s)
6
*
*
*
*
5
4 0 Fullbacks
Central defenders
Midfield players
Forwards
Fig. .. Mean time of repeated sprints for professional male soccer players in different positions of a team at the start (open bars) and at the end (solid bars) of a -week preparation period prior to the season. Means are given. * Significantly different from the start of the preparation period.
Summary The performance potential of an athlete can be improved by fitness training, which can be divided into aerobic training, anaerobic training, and specific muscle training. Common to all types of fitness training is the fact that the exercise performed during the training should be as similar as possible to the sport. There are a number of reasons to use tests to evaluate performance of an individual. It is, however, important that the test chosen is relevant for the activity of the individual, e.g. a cycling test for a cyclist and an intermittent running test for a basketball player. Laboratory tests can provide general information about the fitness level of an individual, but they rarely give an exact measure of performance in a sport. By using a field test a more precise measure of performance will often be obtained.
Multiple choice questions Standard goniometric measurements: a can detect changes in joint range of motion of ∞ b have associated errors that are objective in nature c have associated errors that are related to the patient’s perception of tension d measure joint range of motion, but not muscle– tendon stiffness e all of the above.
Immobilization: a causes muscle atrophy b results in a disproportionate loss of muscle endurance and strength c in the early phase of rehabilitation should focus on local muscle endurance training d all of the above e a and b, but not c. In speed endurance training: a changes mainly of central factors are induced b performance intensities should be –% of V·2 max c the duration of exercise bouts should be relatively short (– s) d the specific aim is to oxidize fat during prolonged exercise periods e all of the above. Strength training: a Strength training results in hypertrophy of the muscle fibers and changes in the nervous system. b In basic strength training muscle groups are not trained in isolated movements. c High-resistance training can change the fiber type distribution towards fast-twitch fibers. d The number of repetitions in a set should exceed . e a and c. f All of the above. Relevant for a soccer player: a isokinetic strength of the knee extensors b yo-yo intermittent endurance test c yo-yo intermittent recovery test d repeated sprint test e all of the above.
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Principles of Rehabilitation and Sport-Specific Training
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Chapter .
weakness in different pathological states of the lower extremity. Am J Sports Med ; : –. Beckman SM, Buchanan TS. Ankle inversion injury and hypermobility: effect on hip and ankle muscle electromyography onset latency. Arch Phys Med Rehab ; : –. Manal TJ, Snyder-Mackler L. Failure of voluntary activation of the quadriceps femoris muscle after patellar contusion. J Orth Sports Phys Ther ; : – . Snyder-Mackler L, Delitto A, Stralka SW, Bailey SL. Use of electrical stimulation to enhance recovery of quadriceps femoris muscle force production in patients following anterior cruciate ligament reconstruction. Phys Ther ; : –. Lieber RL, Silva PD, Daniel DM. Equal effectiveness of electrical and volitional strength training for quadriceps femoris muscles after ACL surgery. J Orth Res ; : –. Polkey MI, Kyroussis D, Hamnegard CH, Mills GH, Green M, Moxham J. Quadriceps strength and fatigue assessed by magnetic stimulation of the femoral nerve in man. Muscle Nerve ; : –. Kremenic I, McHugh M, Ben-Avi S, Leonhardt D. Quadriceps activation via transcutaneous magnetic stimulation of the femoral nerve. In: Proceedings of the Orthopaedic Research Society th Annual Meeting. San Francisco, CA, – February . Snyder-Mackler L, Binder-Macleod SA, Williams PR. Fatigability of human quadriceps femoris muscle following ACL reconstruction. Med Sci Sports Exerc ; : – . McHugh MP, Tyler TF, Nicholas SJ, Browne MG, Gleim GW. Electromyographic analysis of quadriceps fatigue following anterior cruciate ligament reconstruction. J Sports Phys Ther ; : –. Enoka RM, Stuart DG. Neurobiology of muscle fatigue. J Appl Physiol ; : –. Pincivero DM, Lephart SM, Karunakara RA. Reliability and precision of isokinetic strength and muscular endurance for the quadriceps and hamstrings. Int J Sports Med ; : –. Suzuki N, Endo S. A quantitative study of trunk muscle strength and fatigability in the low back pain syndrome. Spine ; : –. Sapega AA. Muscle performance evaluation in orthopaedic practice. J Bone Joint Surg (Am) ; : –. Jonhagen S, Nemeth G, Eriksson E. Hamstring injuries in sprinters. The role of concentric and eccentric hamstring muscle strength and flexibility. Am J Sports Med ; : –. Hortobágyi T, Tracy J, Hamilton G, Lambert J. Fatigue effects on muscle excitability. Int J Sports Med ; : –. Tesch PA, Dudley DA, Duvoisin MR, Hather BM, Harris RT. Force and EMG signal patterns during repeated bouts
of eccentric muscle actions. Acta Physiol Scand ; : –. Magnusson SP, Gleim GW, Nicholas JA. Subject variability of shoulder abduction strength testing. Am J Sports Med ; : –. Magnusson SP, Constantini NW, McHugh MP, Gleim GW. Strength profiles and performance in Masters’ level swimmers. Am J Sports Med ; : –. Magnusson SP, Gleim GW, Nicholas JA. Shoulder weakness in professional baseball pitchers. Med Sci Sports Exerc ; : –. McHugh MP, Spitz AL, Lorei MP, Nicholas SJ, Hershman EB, Gleim GW. Effect of anterior cruciate ligament deficiency on the economy of walking and jogging. J Orth Res ; : –. Brown M, Fisher JS, Salsich G. Stiffness and muscle function with age and reduced muscle use. J Orth Res ; : –. McHugh MP, Connolly DAJ, Eston RG, Kremenic IJ, Gleim GW. The role of passive muscle stiffness in symptoms of exercise-induced muscle damage. Am J Sports Med ; : –. Tyler TF, McHugh MP. Neuromuscular rehabilitation of a female olympic ice hockey player following ACL reconstruction. J Sport Phys Ther ; : –. Ekblom B. Effect of physical training on oxygen transport system in man. Acta Physiol Scand Suppl ; (): . Henriksson J, Hickner RC. Skeletal muscle adaptation to endurance training. In: Macleod DAD, Maughan RJ, Williams C, Madely CR, Charp JCM, Nutton RW, eds. Intermittent High Intensity Exercise. London: E and FN Spon Publication, : –. Schantz P, Sjøberg B. Malate–aspartate and alphaglycerophosphate shuttle enzyme levels in untrained and endurance trained human skeletal muscle. Acta Physiol Scand ; : A. Houston ME, Bentzen H, Larsen H. Interrelationships between skeletal muscle adaptations and performance as studied by detraining and retraining. Acta Physiol Scand ; : –. Bangsbo J, Mizuno M. Morphological and metabolic alterations in soccer players with detraining and retraining and their relation to performance. In: Reilly T, Lees H, Murphy WJ, eds. Science and Football I. London: E & FN Spon Publication, : –. Tesch PA, Wright JE. Recovery from short-term intense exercise: its relation to capillary supply and blood lactate concentration. Eur J Appl Physiol ; : –. Reilly T, Bangsbo J. Anaerobic and aerobic training. In: Elliott B, ed. Applied Sport Science: Training in Sport. Australia, : –. Pilegaard H, Domino K, Noland T, Juel C, Hellsten Y, Halestrap AP, Bangsbo J. Effect of high intensity exercise training on lactate/H+ transport capacity in human skeletal muscle. Am J Physiol ; : E–E.
Principles of Rehabilitation and Sport-Specific Training Bangsbo J. Physiology of muscle fatigue during intense exercise. Clin Pharm Sport Exerc ; –. Andersen JL, Klitgaard H, Bangsbo J, Saltin B. Myosin heavy chain isoform in single fibres from m. vastus lateralis of soccer players: effects of strength-training. Acta Physiol Scand ; : –. Aagaard P, Trolle M, Simonsen EB, Klausen K, Bangsbo J. Moment and power generation during maximal knee extension performed at low and high speed. Eur J Appl Physiol , ; : –.
Ekstrand J. Soccer injuries and their prevention. Thesis, Linköping University Medical Dissertation , . Bangsbo J, Petersen A, Michalsik L. Accumulated O2 deficit during intense exercise and muscle characteristics of elite athletes. Int J Sports Med ; : –. Bangsbo J. Fitness Training in Football — a Scientific Approach. Bagsvaerd: HO & Storm, . Balsom PD, Seger JY, Sjödin B, Ekblom B. Physiological responses to maximal intensity intermittent exercise. Eur J Appl Physiol ; : –.
Chapter 2.3 Physical Activity and Environment PETER BÄRTSCH, BODIL NI E LSE N J OHA NNS E N & JUHANI L E PPÄLUOTO
Classical reference Nielsen M. Die Regulation der Körpertemperatur bei Muskelarbeit. Skand Arch Physiol ; : –. The thermal environment has profound effects on performance and health. The maintenance of core temperature at optimal level in a range of environmental temperatures is essential for performance. This is accomplished through the action of the autonomic control centers in the hypothalamus. The rise in body core temperature during exercise was considered to be the result of a failure in the ability of the organism to dissipate fully the increased heat produced during exercise. Marius Nielsen demonstrated that the rectal temperature increased and after – min reached a new, higher level, which was maintained until the exercise was stopped. (He had one subject work at constant intensity and rectal temperature for 1/2 h.) From his experiments it seemed that the rise in core temperature was only dependent on the exercise intensity. Thus, at ambient temperatures of between and °C, the core temperature level for a given intensity was the same, despite large variations in the contribution of evaporation, convection and radiation to the total heat loss. He concluded from the experiments that the rise in body temperature during exercise was a regulated rise, probably beneficial for performance. Discussions on the setting of body temperature during exercise have now gone on for more than years. The knowledge of the anatomic organization and function of the temperature centers in the brain
inspired discussions as to the validity of rectal temperature as an index of the regulated temperature. Other candidates such as tympanic temperature, supposed to reflect brain temperature, or esophageal temperature, an index of the temperature of the blood leaving the heart were proposed. The latter is today preferred by exercise physiologists for reflecting fast changes in core temperature and signals to the brain centers. The concept of a setting of the temperature at higher levels during exercise has also changed. Now it seems that a mathematical/technical description of the resetting during exercise is rather a reduction in the set point, rendering the ‘human thermostat’ more sensitive to
Fig. ... Rectal temperature during exercise at different intensities. From [].
Physical Activity and Environment an absolute core temperature during work. How the setting of the core temperature during exercise relative to the V˙2 max is accomplished is still an open question. The beneficial effect of a high core temperature in endurance sport activities is now also questionable, as discussed in the section on exercise and temperature (p. ).
Introduction The first part of this chapter discusses the profound effects thermal environment has on performance and health. The maintenance of core temperature at optimal level for performance is accomplished through the action of the autonomic control centers in the hypothalamus. This is possible within a wide range of environmental temperature conditions, the prescriptive, or thermoneutral zone. The historical figure (Fig. ..) shows data from the work of M. Nielsen. This paper supports the notion of regulation of body core temperature at an optimal level for performance. The individual’s capacity for heat production by shivering and heat loss by sweat evaporation and vasodilatation determines the limits for performance. Proper clothing allows activity in even the coldest climates. However, cold exposure can result in injuries, local tissue damage and hypothermia. The cooling effect of the environmental temperature is strongly influenced by the wind speed. In hot environments the cardiovascular stress is increased, and sweating may result in dehydration. This combination markedly reduces performance, especially in endurance-type events and may lead to heat-related illness. These disorders, heat exhaustion and heat stroke can best be prevented by fluid replacement and by a prior acclimatization to heat. The second part of this chapter discusses the effects of altitude on physical performance. Reduced air pressure (and consequently reduced partial pressure of oxygen), reduced air density, lower temperature and a lower water content of air may all affect physical performance at high altitude in different ways and degrees depending on the type of exercise. Hypoxia is certainly the factor that has the biggest impact on life at high altitude. Immediate adjustments to maintain adequate oxygen supply to the tissue are an increase of ventilation and cardiac output for a given workload. The major long-term adjustments (acclimatization) con-
sist of a further slow increase of ventilation, increased erythropoiesis and adaptations at the tissue level. Athletes try to profit from altitude acclimatization for sealevel performance by training at high altitude. Because the decrease of performance at altitude may offset benefits from acclimatization, many athletes prefer to ‘sleep high and train low’. Most issues regarding different modalities or concepts of high altitude are still rather controversial. Rapid adjustments to hypoxia may not always be very successful. A significant number of individuals develop acute mountain sickness and some even life-threatening illnesses such as high-altitude pulmonary or cerebral edema during the first few days after rapid ascent to altitudes above – m. The prevalence of these acute highaltitude illnesses increases with altitude and rate of ascent. Furthermore, there is a considerable interindividual difference in susceptibility to these illnesses.
Thermal environment Introduction Temperature regulation is a good example of a homeostatic mechanism. It keeps the (deep) body temperature within a very narrow range that allows maintenance of bodily functions in almost every climatic condition. Humans with their naked skin and numerous sweat glands are tropical animals, and the capacity of the thermoregulatory system is directed towards heat dissipation rather than heat conservation. Technical developments in clothing and housing have, however, allowed people to inhabit permanently all places on the earth and even in space at temperatures close to absolute zero.
Heat balance The metabolic processes liberate heat as a waste product. When substrates are metabolized in the human body most of the energy equivalent of the combusted substrate is converted into heat. During exercise some of the energy is transformed to external work, but the efficiency of these processes is usually less than –%. The efficiency, E, is defined as: E % = (external work ¥ 100%) metabolic energy cost
Chapter .
M±W=±C±R±E±S (Heat liberation = heat loss) where M is metabolic energy liberation W is external work (positive when going downhill) C is heat exchange by convection R is heat exchange by radiation E is heat exchange by evaporation and S is heat storage. This last term becomes zero when the heat gains and losses are equal. Physical laws determine the direction and magnitude of the heat exchanges by convection and radiation, i.e. the temperature difference between the body surface and the air temperature, respectively, the mean radiant temperature of the environment. The heat loss by evaporation depends on the water vapor pressure difference between the skin surface and the air[]. However, physiologic mechanisms influence the skin surface temperature and vapor pressure through the control of skin blood flow and sweating. The skin surface temperature varies with the temperature in the environment. In cool conditions the difference to the environment is wide, so heat loss by C and R are the main routes for heat loss. The warmer the environmental conditions become, the more the skin surface temperature approaches the environmental temperature, and therefore, the need for evaporative heat loss increases. At an air temperature of about °C skin temperature equals environmental temperature, and the total heat liberation must be dissipated by evaporation of sweat (Fig. ..). In the diagram the
700 I 500 Watts
Therefore, –% of the liberated energy appears as heat in the active muscle tissue. The amount of heat generated in the body must be dissipated to the environment, or else the heat content and the temperature of the body will increase and endanger the homeostatic milieu of the body. The autonomic temperature centers in the hypothalamus control the body core temperature by appropriate activation of, respectively, heat loss or heat conservation processes. In this way the body core temperature is maintained at a constant, regulated level in the face of varying environmental temperatures. This balance can be described by the heat balance equation:
III II
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Temperature (°C) Fig. .. Heat exchange during exercise at W for min at different room temperatures in a nude subject. I Total heat production, II heat loss, III evaporative heat loss, IV convective and radiative heat loss (after []).
heat lost by convection, radiation and evaporation in an exercising (cycling) person is illustrated for environmental temperatures between °C and °C. During exercise part of the heat production is stored in the body, causing the core temperature to increase.
Core temperature The core temperature of the body is measured in the deep esophagus or in the rectum. For clinical purposes a less reliable measurement can be obtained by measuring oral temperature or tympanic temperature, the latter by infrared radiation receivers. The body temperature during rest is maintained close to °C, varying in a circadian rhythm. During exercise the body temperature increases to higher levels, proportional to the relative workload, i.e. to the percentage of the maximal aerobic capacity of the individual [] (Fig. ..). This higher temperature is maintained as long as the exercise is continued, and within the prescriptive zone, it is independent of the environmental temperature.
The prescriptive zone The body core temperature during exercise is uninfluenced by environmental temperature over a wide range of temperatures [,] due to the thermoregulatory control of the heat production and heat loss mecha-
Physical Activity and Environment C°
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Fig. .. Esophageal temperature (Tes) at -min exercise in seven subjects with different maximal aerobic capacity. (a) Tes plotted against absolute oxygen uptake; (b) Tes plotted against relative oxygen · uptake, %V 2 max (after []).
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Physiologic responses to cold exposure
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Ta (°C) Fig. .. Esophageal temperature in one subject after h at rest and cycling at intensities between and W at environmental temperatures between – and °C. The thermoneutral zone marked with arrows moves to the left with increasing work and heat production (adapted from Kitzing et al. Int Z Angew Physiol ; : –).
nisms, i.e. shivering, skin blood flow and sweating. The range of environmental conditions in which the body temperature is independent of these conditions is called the prescriptive zone []. Above the upper critical temperature, core temperature increases to a higher level than during exercise in thermoneutral conditions, while on the other hand, below the lower critical temperature the core temperature falls. The actual range of the prescriptive zone, also called the thermoneutral zone, depends on the rate of heat production and additionally, for the upper limit, on the physiologic capacity for heat dissipation, whereas for the lower critical temperature, on the maximal rate of heat production and vasoconstriction (Fig. ..).
Technical developments have changed the situations in which humans are exposed to cold. The number of people working outdoors in cold conditions is presently declining, while that of people participating in recreational activities, e.g. winter sports is evidently increasing. Physical fitness is important for the thermoregulatory responses to cold. Fit people have a higher metabolic response and a higher skin temperature at the onset of shivering. On the other hand, body fat provides protection against cooling []. Cold can be defined as conditions which activate heat conservation responses, and may be experienced in air or water, or in contact with solid materials. Unclothed or clothed parts of the body can be locally exposed to cold (hands, face and legs) or the whole body may be cooled. The duration of the cold exposure may last for seconds to several weeks, and can be recurrent. The effects of cold exposure will therefore depend on these factors. Many of the cold-induced physiologic responses attenuate physical performance. Low temperature of muscles causes poor efficiency and coordination, and risk of muscle and tendon tears. Shivering muscles make use of energy stores, and shivering may also cause clumsiness. Physiologic mechanisms activated by cold are presented in the box below. Cold-induced skin vasoconstriction leads to increased blood pressure, plasma extravasation (leakage of fluid from the plasma to the interstitium) and diuresis. Increased sympathetic activation and hemoconcentration reduce maximal physical performance. Finally bronchoconstriction in winter athletes is common and may lead to exercise-induced asthma (see Chapter .). A recent study showed that % of the Olympic winter
Chapter . sport athletes in the US had exercise-induced bronchoconstriction [].
Physiologic mechanisms activated by cold Increased heat production: • cold sensations activate voluntary movements • sympathetic nerves become active • norepinephrine secreted, availability of thyroid hormones increased • all leading to increased expression of mitochondrial uncoupling proteins for heat production in muscle • muscle tension increases and shivering starts • food intake increases. Decreased heat loss: • skin blood flow decreases • horripilation • behavioral activity, curling up.
Heat production in the cold Voluntary activity (behavioral thermoregulation) Unpleasant cold sensations result in behavioral responses (increased motor activity, curling up and searching for warmer places and clothing). Shivering The hypothalamic temperature center receives inputs from skin cold receptors and projects them to the motor cortex and finally to the motor nerves. This leads to increased muscle tone and to oscillating contractions of muscles, shivering, that occurs mostly in trunk muscles. Shivering increases metabolic rates by – times the resting value. Due to the increased metabolic rate shivering should be avoided in winter sports.
Chemical or non-shivering thermogenesis Chemical thermogenesis is well established in rodents and newborn humans and closely related to uncoupling protein (UCP ) in brown fat. Cold exposure elicits the release of norepinephrine and thyroid hormones and activates sympathetic nerves that stimulate the expression of UCP . It uncouples the normal oxidative phosphorylation in the mitochondria and the production of protons is decreased. Less ATP is formed and more heat is generated (Fig. ..). The role of UCP in adults is not well established, but recent studies have shown the presence of hom*ologues of UCP . UCP is widely expressed in fat, muscles and viscera and stimulated by starving and fatty acids. UCP is abundantly expressed in skeletal muscles and is stimulated by cold. UCP and also regulate the production of ATP and their roles in heat production are under research []. Meals increase heat production by a mechanism formerly called specific dynamic action, now dietinduced thermogenesis (DIT). The resting metabolic rate is increased about % for – h after a meal.
Heat loss In cold environments radiation and convection are the main avenues for heat loss. In winter sports convection dominates the heat transfer, since warm layers of air around the body are rapidly conveyed away from the skin by the air movement produced by the ongoing activity. The so-called wind chill index (WCI) has been constructed in which the combined effects of environmental temperature and wind are converted to a hypothetical temperature in still air, which has the same cooling effect as the actual wind speed and temperature [,]. The values calculated are rates of heat loss per m2 (Fig. ..). For instance, – °C at a wind speed of m/s corresponds to the temperature of – °C in still air. Climatic conditions with a WCI of between and W/m2 are very cold, between and W/m2 bitterly cold and between and W/m2 dangerous: exposed flesh will freeze in min. Frostbite begins to occur when WCI is over W/m2. The WCI concept was re-examined [], and the predictions compared with the incidences of finger frostbite. The conclusion was that there is little risk of finger frostbite at temperatures above – °C independent of wind velocity, while below – °C the
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Fig. .. Diagram for estimating the combined cooling effect of temperature and wind speed (wind chill index, WCI). The index estimates the effect on exposed, unprotected skin areas (in W/m2) and the exposure time before freezing. The curves were constructed by using the formula WCI = ( · v2 + . – v) · ( – Ta), where v is wind velocity and Ta ambient temperature.
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competitions, but wind speed has not been taken into account, which it ought to be. Physicians responsible for medical care in skiing competitions or mass events should be encouraged to use a WCI rather than the simple thermometer reading.
Clothing
Fig. .. Mitochondrial activity in basal state, and after cold stimulation. After cold stimulation the uncoupling protein (UCP) in brown fat allows a shortcut for protons through the mitochondrial membrane, releasing the energy bound in the H+ as heat. The stimulation is achieved by norepinephrine (NE) or thyroid hormone (T), which increase the formation of cAMP, lipase and free fatty acids (FFAs). FFA displaces uridine triphosphate (UTP) from the UCP channel (protein allowing protons to enter the mitochondria).
effect of wind speed is underestimated. Thus, in skiing competitions or other outdoor mass events special caution has to be paid to the WCI. If the weather conditions show a WCI of more than W/m2, sports competitions should be cancelled, and expeditions require special clothing. In the Nordic countries the lower limit is set at – °C air temperature for skiing
In cold weather appropriate clothing is necessary to maintain the proper heat balance. In winter sports such as skiing, biathlon and orienteering heat production is high, and the main emphasis should be placed on the protection of fingers, feet, ears and nose against local cooling and frostbite. An additional problem due to the unavoidable sweating is the transport of the moisture away from the skin and through the clothing. New synthetic fibers allow sweat to pass through the textile, but they are not suitable in events in which heat production is smaller, such as mountaineering or trekking. In cross-country skiing competitions the metabolic rate exceeds W; in this situation clothing with an insulation value of –. clo units is sufficient at the temperature of – °C. At the same temperature a resting subject needs an insulation of – clo units. (The clo unit is defined by the insulation value of traditional indoor clothing; clo = . m2 · °C/W. See also [].) This great variation in required insulation between
Chapter . rest and activity is a problem for people who have accidents or get tired during outdoor activities in cold climates. Furthermore, clothing soaked by rain loses its thermal insulation properties and presents a serious thermoregulatory problem in cold and windy conditions []. Enough (and dry) clothing must be brought along! The IREQ index [] makes it possible to calculate the cold protective clothing needed for any combination of activity level and climatic variables.
Acclimatization to cold Practically no studies exist in which the effects of cold acclimatization on physical performance have been studied. We know from some studies that the unpleasantness of cold sensations becomes reduced or habituated after – daily cold exposures, and that increased sympathetic activity and shivering is attenuated within a week [–]. True cold acclimatization is difficult to induce in humans. Three types of adaptation to cold are described: (i) metabolic, where a greater metabolic response to cold stress is developed [,]; (ii) hypothermic, where core temperature falls (e.g []); and (iii) insulative [] with a lowering of the skin to environment gradient and heat loss, and with little change in core temperature and metabolic rate during cold exposure. Immersion in cold water days per week over weeks has been found to induce the type of adaptation described as insulative []: a lowering of resting rectal temperature, a slower rise in metabolic rate (indicating a delay in onset of shivering) and a lower skin temperature. It appears that a repeated fall in core temperature is necessary to induce the sympathetic activation, while a cold skin alone is enough to stimulate the increased vasoconstrictor response obtained after weeks’ daily cold water immersions []. However, when healthy men were exposed to cold air for days, a hypothermic type of acclimatization was observed instead (i.e. reduced cold sensations, decreased core and increased skin temperature in some places, reduced norepinephrine response, and no changes in metabolic rate or heat debt responses) []. It is evident that acclimatization in cold water is different from that in cold air. Moreover, cold water acclimatization increases norepinephrine response and peripheral resistance, and decreases cardiac output [,], all of which are not beneficial for physical performance.
Therefore, cold air and not cold water acclimatization is perhaps the type of acclimatization that should be used if performance in cold air is to be improved. It is evident that unacclimatized subjects perform less well than acclimatized, and therefore some kind of cold acclimatization should be obtained before winter sports competitions. It is in the author’s knowledge that subjects who are about to participate in the demanding polar expeditions acclimatize by sleeping overnight outdoors for several weeks before their expeditions (see Case story ..).
Performance in cold conditions As mentioned in the introduction most of the energy liberated during physical exercise is converted to heat. Depending on the metabolic rate, the prescriptive zone and upper and lower critical temperature shifts (see Fig. ..) and the physiologic mechanisms for heat loss and heat conservation are taxed to varying degrees, depending on how the heat balance is attained. Therefore, some benefits for exercise and performance are obtained in cooler environments. In submaximal cycling at ambient temperatures of , , and °C, the time to exhaustion was longest at °C and shortest at °C, demonstrating that the effect of ambient temperature on exercise capacity follows an inverted U-shaped relationship []. This study demonstrates that exercise capacity is greater in low suprazero ambient temperatures than at higher temperatures, where the physiologic load on the circulatory system is higher. The ambient temperatures in winter sports are usually below the freezing point and evidently the best conditions for prolonged high intensity physical activity prevail close to but above zero. Optimal performance must therefore be obtained by choosing the proper clothing. The deleterious effects of cold on performance are manifested on two levels. The more common is the effect of peripheral vasoconstriction and cooling, which lowers the temperature in the tissues, e.g. in hands and feet. The rate of the physiologic and chemical processes is then slowed down, including the rate of muscle contraction and nerve conductivity. Furthermore, stiffness in tendons and connective tissue is increased. This leads to clumsiness and increases the risk for injury (Fig. ..). Thus, for winter sports competitions warming up is of great importance.
Physical Activity and Environment
Case story 2.3.1 Instructions to participants in mass events in winter sports After mass sport events we often read in newspapers that a participant, usually an older man, has succumbed before the finishing line. Several studies on sport-related sudden deaths have been reported and recently reviewed []. The incidence of sudden deaths increases after – years of age and peaks at – years. Males clearly outnumber females. Deaths are often related to high dynamic loads (tennis, skiing, swimming, cycling). The incidence is higher in cross-country skiing than in jogging/running, indicating that skiing produces a higher cardiovascular load than running. Cold
Stimulation 35.8°C
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General The harmful effects of cold on the human body may be a direct effect of the low temperature, e.g. frostbite, trenchfoot and hypothermia. Indirectly, cold environments may exert a stress on human health. Cold weather in winter is a challenge and a significant risk factor, especially in the elderly, causing an excess mortality from cardiovascular diseases. A short review of cold injuries and their treatment is presented in a recent paper []. Their occurrence in winter sports is fairly uncommon. The physicians of the Finnish elite skiing team and the mass skiing events report that during the last years no cold injuries have been diagnosed (Dr P. Mäkelä, team physician, personal communication). An annual incidence of cold injuries in Finland is presently . cases per inhabitants and they are mostly mild. The annual incidence of mild cold injuries varies from . to .% of the population exposed to winter conditions by their recreational or professional activities []. The inci-
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exposure also contributes an increased risk for cardiac deaths. In younger age groups infections or vaccinations are further risk factors. Based on these findings some suggestions for participants in winter sports can be made. Long-term training and cold acclimatization is necessary before demanding mass events in cold climates. Subjects over years should have a cardiac check-up. Ongoing infections and recent vaccinations are absolute risk factors for participation. Finally, the organizers must arrange appropriate medical aid (resuscitation unit with defibrillator) at larger mass events and competitions.
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Fig. .. The effect of local tissue temperature on muscle action potential. Note the increased latency and the stretched duration of the potential with decreasing temperatures (after Vanggaard Aviat Space Environ Med ; : –).
Chapter . dence of frostbite requiring hospitalization is far lower: .–.% []. On the other hand, fatal casualties have at all times occurred in conjunction with polar and high-altitude expeditions, and also in subjects using alcohol or drugs affecting the central nervous system in winter conditions. Direct cold injuries Frostbite and trenchfoot Skin begins to freeze at temperatures between and – °C. Vascular endothelium is damaged by ice crystals. Edema, inflammation and blisters develop. At lower temperatures larger skin areas freeze and become marble-white and hard. Symptoms are numbness, pain and cold, and pale or bluish skin. In mild cold exposures a small white area on skin (frostnip) develops, which disappears rapidly when warmed. For clinical reasons frostbite is divided into superficial and deep injuries; the former is limited to skin only but the latter extends to subcutis and muscles. Trenchfoot or immersion foot develops usually when the feet are exposed for several hours (> h) to wetness and temperatures between and °C (but not below zero). Trenchfoot is a vascular injury leading to edema. The foot is swollen, numb and often bluish. After some time there is a hyperemic phase with pain and ulcerations. Treatment of frostbite and immersion foot Local pain, frostnip and numbness in cold environment are warning signs of the development of frostbite. When frostbite has occurred, the following measures should be taken: Prevent further heat loss, e.g. with warm clothing, drinks and shelter. Immobilize the frostbite area and transfer the patient to first aid, or deep injuries to hospital. If frostbite is deep, thawing during transport should be avoided if it is not absolutely certain that refreezing can be prevented. The following measures are strictly forbidden: thawing and refreezing, rubbing with snow or hand, ointments, alcohol, local warming by fire. First aid of superficial frostbite consists of thawing in a warm water bath, analgesic drugs, sterile bandages, immobilization and elevation of the frostbitten area.
Table .. Symptoms and signs at different levels of hypothermia (after []). Core temperature (°C) 36 35
34 33–31 30–28 27–25 24–20 17 9
Symptoms Increased metabolic rate Maximal shivering, hyperreflexia, speech disorders, delayed cerebration Responsive and compatible with exercise, blood pressure normal Amnesia, consciousness clouded, pupils dilated, blood pressure low Slow pulse and breathing, cardiac arrhythmia, muscular rigidity Unconscious, reflexes lost,‘cold and dead’, ventricular fibrillation Pulmonary edema, mortality high, cardiac arrest Isoelectric ECG Surgical hypothermia
Blisters should not be punctured. Deep injuries should always be treated in hospital. Recent information on the occurrence and modern treatment of frostbite is described by Paton []. Hypothermia (Table ..) Whole-body cooling may occur during winter sports activities due to fatigue or accidents. In such situations of decreased heat production the clothing is no longer sufficient to maintain heat balance; this may also occur if the insulation effect of the clothing has become reduced due to soaking with sweat. Hypothermia may also occur after accidents in water. In this case the cooling is very rapid, and the victim may lose consciousness within – min. The thermal conductivity and the specific heat capacity of water are, respectively, and times that of air. This means that the heat loss to the environment is much greater in water than in air at the same temperature. Furthermore, the skin temperature becomes almost equal to the water temperature. The heat loss to the water is determined by the heat transport from the core to the skin surface, that is the ‘conductance of the peripheral tissues’, which depends on the skin circulation and also on the amount of the insulating fat tissue
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2.0 35.0
Swim 0.5 m/s TH2O 16°C 38.0
37.0 Fig. .. Core temperature and oxygen uptake during swimming in water at °C followed by cycling in °C. Oxygen uptakes, V2, are shown as bars, the shaded areas being the V2 in thermoneutral condition, the light areas the extra V2 due to shivering. One subject (from B. Nielsen. Acta Physiol Scand ; : –).
10 20
in the skin. The range of the prescriptive zone in water is very narrow compared to air, only – °C. A resting lean subject in water cannot maintain thermal balance at water temperatures below – °C. At water temperatures of – °C the core temperature will fall about – °C in min in a swimmer despite swimming activity and maximal shivering (Fig. ..). The fall in core temperature causes a reduction in muscle force and contraction velocity, a fall in V˙2 max and early fatigue []. Hypothermia is defined as a condition where deep body temperature is below °C and actions have to be taken to restore the normal body temperature. In hostile mountain conditions four states of hypothermia have been recognized: (i) below °C full consciousness but shivering; (ii) impaired consciousness but no shivering; (iii) below °C unconsciousness; and (iv) below °C cardiac and respiratory arrest. Treatment of hypothermia When respiratory movements and heart function stop death will occur within minutes to half an hour, depending on the cooling rate. Even in this state patients can be revived. The proper procedure is under discussion, and depends on whether it takes place under field conditions, or in a hospital ward. If the deep temperature is below °C, the physician/hospital should always be consulted. Outside the hospital ward further heat loss should be prevented, e.g. by warm blankets
30 40
50 60 70
80 90
35.0 100 110 120
Time (min)
and the patient must be handled cautiously (e.g. no unclothing). The general principle is that rewarming should take place from the interior to avoid the ‘afterdrop’, the extra fall in core temperature, which takes place if the cold blood from the periphery is redistributed back into the core of the body. This may cause a sudden heart stop. Indirect cold injuries Cold climates also have indirect harmful effects on human health. Raynaud’s syndrome or white finger disease is mostly an idiopathic phenomenon, in which cold or even emotional exposure leads to cold, pale and numb fingers. Long-lasting vasospasms may lead to ulceration. Raynaud’s syndrome may also relate to smoking, previous frostbite, vascular diseases, abnormal plasma proteins or compression of thoracic nerves. The syndrome can be treated by vasodilating agents or by protecting hands from cold. Desensitization treatment (putting hands in cold water) is also often a good measure. Cold urticaria is a skin allergy caused by local or general cold. Usually a large wheal appears on skin exposed to cold. The wheal disappears after – h in a warm environment. In rare cases cold exposure causes angioedema (swelling of veins and tissues, which may be lifethreatening and calls for immediate treatment in hospital if the throat and respiratory pathways are affected). The main treatment includes avoiding
Chapter .
Physiologic responses to hot (and humid) environments
Physiologic mechanisms activated by heat Increased heat loss: • Vasodilatation, increased skin blood flow • Sweat secretion (evaporation) Decreased heat production: • Inertia • Decreased food intake
Heat acclimation 41.0 12
34
5
6 7 8 910
40.0 Tes (°C)
exposure to cold (water, air) and use of antihistamine drugs. Daily cold showers may also help, but the possible development of angioedema should be taken into account. Cold-induced increases in blood pressure and hemoconcentration and increased sympathetic activity are well-known risk factors for heart diseases and may explain the high mortality from cardiovascular diseases in winter mentioned above.
Subj. JBO
39.0 38.0 37.0 0
10
20
30 40 Time (min)
50
60
70
Fig. .. Esophageal temperature during exercise in °C dry heat till exhaustion for consecutive days (one subject). The endurance time increased from to min with acclimatization (from []).
hyperthermia. Performance is markedly hampered under these adverse conditions, as athletes are forced to lower their exercise intensity (to reduce heat production) or they will attain critically high body temperatures of – °C, which per se will cause fatigue [,] (see Fig. ..).
Cardiovascular changes in hot conditions Sweating The physiologic capacity for heat dissipation is closely linked to the ability to sweat. This depends on the size of the individual, on the physical fitness, and on the state of heat acclimatization. Maximal sweating rates may vary between and mL/h for a sedentary person, to about L/h in very well trained and heat-acclimatized individuals exercising in dry heat. The evaporation of L sweat removes approximately kJ ( kJ). However, in humid conditions the amount of sweat which can evaporate may be restricted (evaporation depends on the difference in water vapor pressure between skin and air). If the water vapor pressure difference is too small not all the sweat produced can evaporate; only the evaporated sweat removes heat, the rest drops off and is wasted []. Due to the physical limits for evaporation, heat loss is drastically impaired in hot humid environments, and exercise is often associated with advancing degrees of
The circulatory capacity also affects the ability to sustain exercise in the heat, and hence determines the upper critical temperature. The amount of blood needed for the transport of heat to the skin, Hskin, is expressed by the equation: Hskin = Q skin ◊ c ◊ (Tar - Tv ) where Q skin is blood flow to the skin in L/min, c the heat capacity of blood (approx. kJ/kg) and Tar - Tv is the temperature of arterial and venous blood, respectively, reaching and leaving the skin. If we substitute Tar with Tre, rectal or esophageal temperature, and Tv with Tsk, and rearrange the equation, we obtain: Q sk = Hskin c(Tre - Tsk ). In warm conditions the difference (Tre – Tsk) becomes smaller, thus the skin blood flow necessary to carry the heat to the skin increases. At rest and during mild to moderate exercise this extra skin blood flow is adequately supplied by an increase in cardiac output and a
Physical Activity and Environment
Dehydration If no fluid is ingested during prolonged physical activity, sweating leads to dehydration, loss of water from the body water compartments. This is a problem, especially in warm environments. Sweat also contains electrolytes, but in lower concentration than the body fluids. So after sweating the body becomes hypohydrated and hyperosmotic. Both hypohydration and hyperosmolality impair performance by effects on cardiovascular function and sweating [,]. Thus, each % loss of body weight by dehydration increases heart rate by – beats/min, and core temperature by
24 Cardiac output (L/min)
(a)
22 20 *† *†
18
*†
16 17 Two-legged blood flow (L/min)
(b)
16 15 14 13
† *†
12 11 9
Blood flow non-exercising tissues (L/min)
(c)
8 7 6 5 *†
4
*
3 (d) Fore arm blood flow (ml/100 g/min)
redistribution of blood flow (diminished renal and splanchnic flow). However, during more intense exercise or when hyperthermia is combined with dehydration, cardiac output is limited and skin tissue and active muscles must compete for the available blood flow. A limit is reached for the ability of the heart to supply blood both to the exercising muscles and to cover the thermoregulatory demand for skin blood flow. Under this condition, the core temperature increases, and the skin blood flow may be reduced (see equation). This is when the upper critical temperature is surpassed. Hot environments represent an additional load on the circulatory system. The temperature-induced vasodilatation and increased skin circulation result in redistribution of blood volume to the periphery, and a fall in central blood volume and reduced filling of the heart. This becomes even worse in the case of dehydration (see below) where plasma volume is reduced. The stroke volume decreases and heart rate is increased to maintain blood pressure. Depending on the severity of the exercise, a compensatory increase in cardiac output may take place. The competition for blood flow between the thermoregulatory need for skin circulation, and the metabolic demand for blood flow to the exercising muscles results firstly in a reduction in skin circulation, and in increased heat storage as mentioned above. But ultimately, with advancing dehydration, blood pressure and cardiac output become reduced, and the blood flow to the exercising muscles also falls (Fig. ..). The performance/endurance for continued exercise declines, resulting in exhaustion, which is caused primarily not by metabolic alterations but by hyperthermia [,,].
18 16 14 12 10 8 6 4 2
†
20
40
60
†
80 100 120 140
Time (min) Fig. .. Cardiac output and blood flows during dehydration and control trials (from []).
. °C during exercise. Also the loss of sodium in the sweat (– g NaCl per L sweat) can be a problem in prolonged exercise. This has to be taken into consideration together with the rehydration and food intake after exercise (‘miner’s cramp’, see Chapters . and .). With increasing dehydration performance is
Chapter . increasingly reduced, as a result of the reductions in the volume of circulating blood, and the rising core temperature. Severe dehydration during continued exercise leads to earlier fatigue due to hyperthermia; it may cause heat exhaustion or in extreme situations heat stroke (see below).
Heat injury When the body core temperature increases above the normal level, due to internal or environmental heat stress, clinical symptoms of heat illness may develop. These symptoms range from mild discomfort, swelling of the legs, dizziness or ortostatic syncope in the upright position, heat cramps and heat exhaustion, to the severest form of heat illness, heat stroke, which may be lethal. Heat exhaustion is usually the result of fluid loss from the vascular system with accompanying cardiovascular disturbances, such as reductions in skin and splanchnic blood flow and a tendency for a fall in blood pressure. Of note is the fact that the environmental temperature is not necessarily very high in conditions where an endurance athlete performing at high metabolic rates becomes heat exhausted. The upper critical temperature for a good marathon runner may be as low as °C (see Fig. ..). The treatment for heat exhaustion is to put the patient in a supine position, cool him or her, and supply ample water to drink. The heat exhaustion may develop into heat stroke, a potentially fatal syndrome, involving high core temperature, often but not always ceased sweating, unconsciousness, neurologic disorders, metabolic disturbances, cardiovascular failure with low blood pressure and weak pulse. This condition calls for immediate hospitalization and treatment with intravenous infusion and control of acid–base balance. Causes for the development of the heat stroke syndrome are not fully understood (Fig. ..). It appears that endotoxins (lipopolysaccharides, LPS) from Gram-negative bacteria in the gastrointestinal tract are liberated, because the intestines become permeable to LPS due to the heat-induced reduction in splanchnic blood flow. This may add a fever to the already high core temperature. Furthermore, a multitude of cellular dysfunctions/damages due to high temperature may be involved in the clinical picture. Several factors such as age, state of training, exercise level, state of
Case story 2.3.2 Copenhagen Marathon, heat exhaustion in temperate climate conditions A young student of physical education had prepared himself for the marathon; he had trained for several months and was well aware of the importance of keeping well hydrated. He had therefore planned to drink two cups of diluted ‘Isostar’ ( mL) each km, and arranged for his wife to follow him on bicycle to supply it. The air temperature was about – °C on a sunny day. All went well and as planned. After km he overtook a friend, who he started to compete with. This resulted in him spilling half the fluid he was handed the following – times, but he felt all right until he stopped after . km to get his ration. He drank, and started off again after his friend, but began to stagger. A physician who happened to be nearby had a look at him, but decided that he would be able to run the final m at a slower pace to complete his run. He ran on, but immediately fell to the ground and blacked out — and came to in the emergency ward, having . L isotonic fluid administered to him in drop infusion. His temperature was then still elevated.
hydration, heat acclimatization and effect of drugs play a role in the tolerance to heat stress [] (see Case story ..).
Prevention and treatment of heat injuries Procedures which improve conditions for heat loss and cardiovascular stability in warm conditions will be protective against heat injury. Since dehydration is a key factor in the development of heat illness, it is important to prevent dehydration by appropriate fluid intake. Water or isotonic fluid sufficient to replace the sweat loss should be drunk during ongoing exercise (see also Chapter .). Two problems arise: firstly, the
Physical Activity and Environment
HEAT Peripheral thermoreceptors
Sweat
SkBF
CO
BF spl, kid, M, fat
Continuing heat
Sweat
PBV
Fl & el
SkBF & V
CBV
TBV
CO BF spl, fat
CVP
Plasma osmolality
Endotoxemia
Tc
SkBF & V
Sweat
Cellular heat shock responses, spherocytosis, etc. Fig. .. Scheme of interacting sequences of events occurring from the beginning of exposure to hot environments to death from heat stroke. Arrows indicate (≠) increase or (Ø) decrease in the parameter. BF = blood flow (spl, kid, M, respectively, Splanchnic, kidney and muscle). CBV = central blood volume. CO = cardiac output. CVP = central venous pressure. DIC = disseminated intravascular coagulation. F1 & el = fluid and electrolytes. PBV = peripheral blood volume. SkBF = skin blood flow. Tc = core temperature. V = volume. (From [].)
Tc
CVP SkBF & V
Tc DIC, acidosis
Coagulative necrosis, other cellular death, cerebral hypoxia
Neural dysfunction
sense of thirst is not a good indicator of water deficit. Persons offered fluid to replace a sweat loss stop drinking before the deficit has been compensated for. This ‘voluntary dehydration’ must be overcome by encouraging persons exercising in warm conditions to drink more than they feel is enough. The other problem is the limitation in the rate of gastric emptying. Fluid is
DEATH
transferred from the stomach to the gut, where absorption takes place at a maximum rate of approximately –. L/h, while sweat rates during exercise in hot conditions may exceed L/h. This means that even with optimal fluid intake dehydration cannot be totally prevented during prolonged exercise such as marathon running or military activity in warm
Chapter . Table .. Changes in physical parameters with altitude above sea level (s.l.). Temperature and water content of air
Air pressure
Water content (at 100% saturation)
Air density
Altitude (m)
Atmospheric (mmHg)
PO2 (mmHg)
% of s. l. value
kg/m3
% of s. l. value
°C
g/L
% of s. l. value
0 2000 3400 5500 8800
760 600 500 360 250
159 125 105 75 52
100 79 66 50 33
1.12 1.01 0.87 0.70 0.50
100 90 78 60 45
30 17 +7 –7 –29
33.3 15.4 8.1 3.0 0.5
100 46 24 9 2
climates []. Sports organizations, coaches and physicians responsible for events in hot and especially humid climates should agree on rules for the cancellation of competitions if temperature and humidity exceed certain limits, e.g. °C, % relative humidity, to prevent heat illness [].
Acclimatization Acclimatization to heat is another important means of protection against heat stress. Stressful environments induce physiologic adaptive changes, which improve tolerance to the stress. When humans are exposed acutely to exercise in hot environments, their heart rate and core temperature increase more than under cool conditions, and their performance and endurance for prolonged exercise is reduced (Fig. ..). A prolonged stay in a hot climate, or repeated daily exposures in climatic chambers over a period of several days to weeks will induce physiologic changes, which include an increase in sweating rate, a lowering of resting core temperature and increased blood volume. These adaptations are beneficial for performance, since they lead to an increased evaporative heat loss, resulting in a lowering of the core and skin temperatures during work in hot environments [,]. Furthermore, the improved filling of the cardiovascular system results in a lower heart rate and improved endurance for exercise. However, in hot humid environments the improved sweating capacity does not help if the physical limits for evaporation of the produced sweat are exceeded.
High altitude Introduction Physical changes and their implications Exposure to high altitude is associated with a reduction in barometric pressure, by one-third at an altitude of m, by half at an altitude of m, and by about two-thirds at the altitude of Mount Everest ( m). There is an almost parallel decline in partial pressure of oxygen and air density. Furthermore, temperature declines approximately by degree per m of altitude. As a consequence of the decrease in temperature, the water content of fully saturated air decreases dramatically because of falling water vapor pressure (see Table ..). In addition, the thinner overlying atmosphere absorbs less and snowfields reflect more radiation. Therefore solar radiation, especially of short wavelength near the ultraviolet spectrum, is increased at high altitude and calls for special protection of skin and eyes. Table .. also shows that there are already considerable physical changes in the environment at the highest altitudes at which athletes compete or perform classic high-altitude training (– m). In brief, altitude can have the following principal effects on exercise performance. As long as maximum voluntary power output is not affected, it will enhance performance in short anaerobic events involving high speed because of decreased air resistance.
Physical Activity and Environment It will decrease performance in events which depend predominantly on aerobic capacity because of a decreased ambient P2. Running over distances longer than about m will be affected as demonstrated by the results of the Olympic Games held in Mexico City ( m) in . The lower water content and lower temperature of ambient air may affect performance by exacerbating exercise-induced asthma in athletes with bronchial hyperreactivity or asthma. At altitudes that are relevant for mountaineers (– m and higher) the danger of acute altitude illnesses (see p. ) and cold injuries (see p. ) will increase. This section will discuss in more detail acute adjustments and acclimatization to hypoxia, the effects of acute and chronic altitude exposure on aerobic performance, and the modalities and efficacy of highaltitude training. In addition, an overview of acute high-altitude illness is given. As cold injuries are not strictly related to hypoxia, they are discussed in a separate section.
Immediate adjustments and acclimatization to hypoxia The energy requirement and thus the O2 demand for performing a given task does not change with altitude. Because of the reduced partial pressure of oxygen, O2 loading of the blood is incomplete at high altitude. The reduced O2 content per volume unit of blood is compensated for at several levels. Ventilation. Ventilation increases immediately and continues to rise further over the first – days at a given altitude. This further rise is called ventilatory acclimatization. As a consequence of this arterial P2 rises considerably during this time. On the other hand, more CO2 will be blown off by the enhanced ventilation causing a relative increase of bicarbonate, i.e. a respiratory alkalosis. This is partially compensated for by increased renal bicarbonate excretion. This leads to a reduction in the blood buffer capacity []. Circulation. Cardiac output and heart rate are increased for a given submaximum workload. With acclimatization this increase declines but heart rate still remains elevated compared to sea level.
Blood. Oxygen-carrying capacity is increased per volume unit of blood, acutely by decreasing plasma volume and in the long range by increases in the number of circulating red cells, i.e. by increasing erythropoiesis through release of erythropoietin from the kidney. Furthermore, ,-diphosphoglycerate (,-DPG) increases in red cells and favors unloading of oxygen in the tissue. This effect may, depending on the altitude, be offset or even overridden by the respiratory alkalosis which favors loading of oxygen in the lung []. Muscle. There are no immediate adjustments in the muscle cell components for hypoxia. Training studies in hypobaric chambers suggest that acclimatization to altitudes below m may increase capillary density, mitochondrial density, aerobic enzymes and enzyme activities []. Furthermore, increase of myoglobin and other proteins accounts for the augmented buffer capacity of muscle tissue. At altitudes above m (Himalayan mountaineers) muscle mass, muscle fiber and oxidative capacity of muscle decrease [], a surprising finding, for which the low level of exercise intensity and insufficient nutrition may account.
Aerobic performance Maximum aerobic capacity V˙2 max decreases with acute exposure to high altitude by approximately % per m above an altitude of m. In highly trained athletes hypoxia-induced reduction of V˙2 max may be considerably greater (Fig. ..) and it can be detected at altitudes as low as m [,]. Thus, at elevations of – m at which altitude training is performed, athletes may have a considerably greater reduction of their aerobic capacity than the expected –%. This forces them to reduce the training intensity. This reduction shows, however, considerable interindividual variability []. Despite improved oxygen delivery and utilization with acclimatization the depressed V˙2 max increases little, if at all, with chronic exposure to hypoxia. This lack of improvement can in part be attributed to a reduction in maximal heart rate []. A young healthy mountaineer climbing at m without supplemental oxygen is left with less than one-third of his sealevel aerobic capacity. Expressed in O2 uptake he is at
Chapter . 5
5 * Lactate (mmol/L)
0 –5
% ∆VO2max
–10 –15
* Acute altitude
*
4 *
†
3
†
† Chronic altitude Sea level
2 * 1
–20
0 –10
–25 –30 –35 –40 –45 45
50
55
60
65
70
75
10
20 30 Time (min)
40
50
Fig. .. Arterial plasma lactate significantly increases at high altitude when exercising at the same absolute workload at · an intensity that elicited % of sea-level V 2 max on day and day at an altitude of m. With acclimatization lactate levels fall significantly but remain elevated compared to sea-level values. From [].
∆VO2maxnorm (ml/kg/min) · Fig. .. Individuals with a higher V 2 max show a greater loss · of aerobic performance (DV2 max) when exercising at a simulated altitude of m in a hypobaric chamber. From [].
the level observed in patients with severe heart failure ( mL/kg/min) and his rate of climbing is accordingly slow. The maximum power output of this individual is reduced to about . W/kg with maximal values of ventilation of L/min, with a heart rate of /min and with lactate of . mmol/L []. Despite an arterial oxygen saturation of only %, the ECG is normal. The reduction in maximum heart rate, presumably due to a down-regulation of a-receptors, may protect his heart from ischemia by reducing the maximum workload on the heart.
Submaximum aerobic performance At high altitude the same absolute submaximum workload elicits a higher ventilation, a greater cardiac output and thus a higher heart rate as well as a greater increase in plasma lactate than at low altitude. Acclimatization to high altitude improves submaximum performance as demonstrated by increased endurance time as well as a reduction of heart rate and plasma lactate (Fig. ..) for a given workload [,]. The fact that lactate is higher at a given submaximum exercise level while several studies found maximum lactate to
be reduced compared with exercise at sea level (see data from Mount Everest mentioned above) has been termed the ‘lactate paradox’. This phenomenon, for which there is no clear explanation, has been questioned by recent findings of unchanged maximum lactate levels during the Chacaltaya expedition. In summary, acclimatization to high altitude does not improve the reduced V˙2 max but it enhances performance at submaximum levels. This may help to explain why athletes competing at altitude must train and thereby acclimatize at this altitude prior to the competition. Furthermore, because of changes in the relationship between heart rate and workloads at altitude, it is necessary to adjust heart rate-based recommendations for training intensities.
Training at high altitude for sea-level competition The hypothesis that high-altitude training improves sea-level performance is based on the assumption of beneficial effects by acclimatizing to high altitude and/or hypoxia being an additional training stimulus. Accordingly, three concepts have emerged: • Live high — train high (classic high-altitude training). • Live high — train low (high-altitude houses or hypoxic tents).
Physical Activity and Environment • Live low — train high (training in hypobaric chambers or in normobaric hypoxia). The most important beneficial effect of altitude acclimatization for sea-level performance is the increase in erythropoiesis. Improvements of aerobic capacity after high-altitude training correlate with the increase in red cell mass (RCM). It appears that a significant increase in RCM only occurs when more than weeks are spent at an altitude equivalent to m. Interestingly, an exposure of – h at night at an FI2 of .% (equivalent to m) for consecutive nights while living and training in normoxia for the rest of the day did not increase RCM []. There are preliminary reports of an increase in RCM by about –% after living – h per day at normobaric hypoxia equivalent to an altitude of m for days suggesting that this time and altitude may be sufficient for stimulation of erythropoiesis. Specific ventilation does not change after altitude training indicating that ventilatory acclimatization has no advantage for sea-level performance. The effects of acclimatization on the hemoglobin–O2 affinity and on the plasma volume are rapidly reversible and most likely offer no benefit for sea-level performance. Increases of myoglobin and possibly another muscle protein (karosin) enhance the local buffer capacity of muscle tissue and overcome the potential disadvantage of reduced blood buffer capacity which is due to renal compensation of respiratory alkalosis. It has already been mentioned above that mountaineers living and exercising above altitudes of – m have a loss of muscle mass and a reduction in oxidative capacity. This is mostly a consequence of catabolism due to reduced food intake because of lack of appetite. Regularly exercising on a bicycle ergometer during a chamber study (Operation Everest II, described in reference []) could not prevent muscle loss. Training at high altitude may have several negative aspects like reduction in absolute workload, lack of adequate facilities or locations, unfavorable climate and sleep disturbance. These may offset the benefits of altitude acclimatization. Therefore, the concept of living high and training low has become popular although the evidence in favor of this approach for the elite athlete is at best circ*mstantial. One well-controlled study, published in German only, demonstrated a greater improvement of performance after classic high-altitude training [] and one equally well con-
trolled study found the same after living high and training low [] compared to sea-level training. These studies were performed in moderately well trained athletes (V˙2 max – mL/kg/min). There are no controlled data obtained in elite athletes that unequivocally demonstrate a benefit of either training modality. A recent investigation suggests that there is an individual response to training at high altitude that depends on how much erythropoiesis is increased and on the training intensity that can be maintained at high altitude []. Living in normoxia and training in a hypoxic chamber at simulated altitudes up to m leads to increases in myoglobin content, oxidative enzymes, capillaries and muscle fiber volume when training is performed at the same absolute workload as in normoxia. Thus, the beneficial effect can be attributed to more intense work rather than to hypoxia itself. Training at the same relative workload in hypoxia vs. normoxia also has no additional effects on endurance performance [].
Acute high-altitude illnesses Unacclimatized healthy individuals who ascend too fast to high altitudes are at risk of developing acute high-altitude illnesses. The faster they climb and the higher they go the greater the chances of developing a serious, possibly life-threatening illness. We distinguish between acute mountain sickness (AMS), an illness dominated by cerebral symptoms which can progress to overt cerebral edema (high-altitude cerebral edema, HACE) and high-altitude pulmonary edema (HAPE). AMS often also precedes the pulmonary form of high-altitude illnesses. There are distinct differences between these entities with regard to aspects of pathophysiology as well as prophylaxis and treatment with drugs (Table ..). Acute mountain sickness (AMS) frequently occurs within – h after rapid ascent to altitudes above – m []. It is characterized by headache, nausea or loss of appetite, fatigue, dizziness and insomnia. AMS usually resolves spontaneously over the next days when no further gain in altitude occurs. It may also progress to ataxia and clouded consciousness which are early signs of potentially lethal HACE []. The pathophysiology of this illness is poorly understood. While imaging techniques show cerebral edema when HACE is present, the cerebral changes accompa-
Chapter . Table .. Acute mountain sickness
High-altitude pulmonary edema
Occurrence
Altitude > 2000–2500 m
Altitude > 3000 m
Latency
6–12 h
1–4 days
Leading symptoms
Cerebral symptoms: • Headache • Nausea, vomiting • Neurological abnormalities
Pulmonary symptoms: • Cough • Dyspnea and decreased exercise performance • Rales
Pathophysiology
Low hypoxic ventilatory response Sodium retention Increased cerebral blood flow and permeability of blood brain barrier?
Exaggerated hypoxic pulmonary vasoconstriction
Pre-acclimatization and slow ascent to altitudes > 2500 m (average daily ascent rate: 300–500 m above 2000 m) Acetazolamide: in case of known susceptibility and rapid ascent
Nifedipine: in case of known susceptibility and rapid ascent
Prophylaxis
Exaggerated hypoxic pulmonary vasoconstriction
Therapy
Descent by at least 1000 m of height, supplemental oxygen In addition: Nifedipine
In addition: glucocorticoids Prognosis
• AMS: spontaneous resolution within 1–2 days • HACE: lethal without treatment, prolonged recovery of severe cases at low altitude
nying AMS are subtle and hardly detectable by conventional imaging techniques. There is a large interindividual variability regarding susceptibility to AMS. While usually less than % have AMS (defined as headache and one additional symptom) at an altitude of m, about –% have AMS after rapid ascent to m. For prevention it is important that the rate of ascent matches the degree of acclimatization and the individual tolerance. When symptoms occur, a day of rest should be taken. If this is not followed by improvement, one must descend. In severe and often rapidly progressive cases application of supplemental oxygen or treatment in a portable hyperbaric chamber and the administration of dexamethasone (– mg every h) should be given until descent is possible. Acetazolamide ( ¥ mg) can be taken for prophylaxis when slow ascent in susceptible individuals is not possible. High-altitude pulmonary edema (HAPE) presents after rapid ascent from low altitude within – days
Nifedipine: in case of known susceptibility and rapid ascent
• 50% mortality without therapy • Clinical recovery at low altitude within 1–2 days
[]. It is rarely observed below altitudes of m and after week of acclimatization at a particular altitude. In most cases, it is preceded by symptoms of AMS. Early symptoms of HAPE include exertional dyspnea, cough and reduced exercise performance. As edema progresses, cough worsens, and breathlessness at rest and orthopnea occur. Gurgling in the chest and pink frothy sputum indicate advanced cases. There is large interindividual variability in susceptibility to HAPE. Individuals with a proven history of HAPE have a % chance of developing this illness again when the exposure is similar compared to the last episode []. The clinical examination reveals cyanosis, tachypnea, tachycardia, and elevated body temperature, which generally does not exceed . °C. Rales are discrete at the beginning, typically located over the middle lung fields. Often, there is a discrepancy between the minor finding at auscultation compared with the widespread disease on the chest radiograph. In advanced cases, signs of concomitant cerebral edema,
Physical Activity and Environment
Fig. .. Chest radiograph with patchy alveolar pulmonary edema of a -year-old mountaineer with HAPE on admittance to hospital ( m) after evacuation by helicopter from an altitude of m (left side). Reduction of edema over h with bed rest and supplemental oxygen (right side).
such as ataxia and decreased levels of consciousness, are frequent findings. There are no characteristic findings in common laboratory examinations. Abnormal results may be due to accompanying dehydration, stress and preceding exercise. Arterial blood gas measurements of four cases of advanced HAPE at m showed a mean P2 of mmHg and a mean arterial oxygen saturation of %. These findings demonstrate the severity of this illness. In early cases, values around mmHg for P2 and % for Sa2 were observed at this altitude. Chest radiographs and CT scans of early HAPE cases show a patchy, peripheral distribution of edema (Fig. ..). Cardiac catheterization of untreated cases of HAPE at high altitude revealed normal wedge pressure and pulmonary artery hypertension (systolic pressure in the order of mmHg compared to mmHg in controls at m). This increased pressure precedes edema formation. Lowering pulmonary artery pressure by nifedipine is effective for treatment and prevention of HAPE. The prevailing hypothesis to explain increased capillary filtration pressure is inhom*ogeneous hypoxic vasoconstriction accounting for increased capillary pressure in areas of overperfusion. Recent investigations by bronchoalveolar lavage suggest that early HAPE is caused by a pressure-induced leak without increased permeability due to an inflammatory reaction. With the exception of the recommended drugs, the prevention and treatment of HAPE resemble those of AMS and are summarized in Table ... The fol-
Table .. How to avoid and treat high-altitude pulmonary edema. Prevention 1 Slow ascent for susceptible individuals (average increase in sleeping altitude of 300–350 m/day above 2000 m). 2 No ascent to higher altitude with symptoms of acute mountain sickness (AMS). 3 Descent when symptoms of AMS do not improve after a day of rest. 4 Under circ*mstances of high risk avoid vigorous exercise when not acclimatized. 5 Nifedipine: 20 mg slow release formulation every 8 h (or 30–60 mg sustained release formulation once daily) for susceptible individuals when slow ascent is impossible. Treatment 1 Descent by at least 1000 m of altitude (primary choice in mountaineering). 2 Supplemental oxygen: 2–4 L/min (primary choice in areas with medical facilities). 3 When 1 and/or 2 not possible: 20 mg nifedipine slow release formulation every 6 h. Portable hyperbaric chamber. Descent as soon as possible.
lowing case history demonstrates that HAPE can be a life-threatening illness from which one recovers rapidly at low altitude. It also demonstrates that a susceptible individual may continue mountaineering even as a mountain guide because HAPE can be avoided with adequate preventive measures (see Case story ..).
Chapter .
Case story 2.3.3 In the summer of a party of people led by two mountain guides ascended by cable car from low altitude to m to climb for several days at altitudes between and m. On the third day one of the mountain guides, who was years old, noticed unusual shortness of breath while climbing to m, which improved when descending to a hut at m. There his appetite was reduced, he had headache, felt weak and slept poorly. He did not want to leave a group of people with only one guide and accompanied the party on the next day to the Margherita Hut ( m). On this ascent, he could not keep up with the group above m altitude because of severe shortness of breath. He also noticed a dry cough. After he had fought his way up to the hut, he did not recover, was cyanotic and had considerable dyspnea at rest. There were rales over both lungs. He showed truncal ataxia but his consciousness was not clouded. Arterial blood gas analysis, measured by a research team working in the hut, demonstrated severe hypoxemia with a P2 of . mmHg, a P2 of . mmHg and a measured arterial oxygen saturation of %. He was immediately flown out by helicopter to a hospital at m where the diagnosis of HAPE was confirmed by chest radiography (see Fig. ..). At low altitude, the patient felt immediately bet-
Multiple choice questions The core temperature during exercise: a reaches a new level after min exercise b is increased during exercise in proportion to work intensity c rises in proportion to the relative workload of the individual d rises due to an insufficient heat loss e is higher in trained than in untrained athletes at the same work intensity. The ‘prescriptive zone’ is: a a temperature range where body temperature is independent of environmental temperatures
ter; blood examinations including sedimentation rate and a differential white cell count were normal. He was on supplemental oxygen overnight. When he left the hospital the next morning arterial blood gases without supplemental oxygen showed increased ventilation in order to achieve normoxemia: P2 . mmHg, P2 . mmHg (oxygen saturation %). He continued to work as a mountain guide and had a similar episode of HAPE at the same location on day after ascending from low altitude with only one night spent at m. Since then he pays attention to slow ascent (average rate of ascent – m per day above m) when staying for lengthy periods at altitudes above m. When slow ascent is not possible, he takes nifedipine, mg every h, during ascent until reaching the final altitude. With these measures, he is able to work normally as a mountain guide. He also accompanies groups in the Himalayas and in South America where he reached, without any problems, the top of Aconcagua ( m) after preacclimatizing by climbing the volcanoes in Ecuador (altitude between and m). Since he has had one further episode of threatened HAPE, at an altitude of about m, which he recognized so early that he was able to descend by himself.
b independent of the activity level c affected by the sweating capacity d the same as ‘comfortable’ temperature conditions e the interval in which shivering responses occur f reduced in water. In hot conditions: a maximal sweating rate is not so important for endurance performance b competition between muscle and skin blood flows causes an increase in core temperature c fatter individuals tolerate the heat better d the process of heat acclimatization leads to increased blood volume
Physical Activity and Environment e the air humidity has no effect on performance f sweat loss impairs exercise performance. Heat illness is prevented by: a warming up before physical performance b fluid intake during activity c fluid intake after prolonged activity d training without water for week e acclimatization to hot conditions. Cold exposure in humans leads to: a immediate shivering b increase in serum norepinephrine c loss of appetite d extravasation e increased serum FFAs. With regard to heat production: a it occurs mainly in the muscle b uncoupling proteins are proton channels c adult humans have no uncoupling proteins d specific dynamic action is associated with exercise e drugs increasing cAMP produce heat. With regard to heat loss and clothing: a radiation is the main avenue for heat loss in winter sports b IREQ index relates to temperature and wind c in winter sports the insulation of clothing is usually – clo units d frostbite begins to develop when WCI is over W/m2 e cold sensations acclimatize sooner than shivering. With regard to cold injuries: a ice crystals cause cold injuries b local ointments protect from frostbite c frostbite can be treated by fire d comatose and cold patients should be warmed by active moving. Immediate adaptive responses to high altitude are: a increase of red blood cell mass b decrease of plasma volume c increase of ventilation d increase of heart rate for a given workload e increase of muscle oxidative capacity. The following statements about the effects of high altitude on aerobic performance are correct: a V˙2 max decreases. b V˙2 max significantly increases with acclimatization. c Maximal heart rate increases with acclimatization.
d Heart rate for a given workload decreases with acclimatization. e An untrained individual has a greater decrease in aerobic performance than a well-trained individual. The following statements are correct regarding highaltitude training: a Training at high altitude improves performance at high altitude more than training at low altitude. b Training in a hypobaric chamber is more effective than training in normobaric hypoxia. c Increase in red cell mass is the principal factor for improvement of sea-level performance. d The changes of hemoglobin affinity for oxygen are important for improvement of endurance performance at low altitude. e Training at high altitude improves buffer capacity of muscle tissue. Acute mountain sickness (AMS): which statements are correct? a The most frequent symptom is vomiting. b When symptoms of AMS occur, a mountaineer must always descend. c Ataxia and decreased consciousness indicate progression to high-altitude cerebral edema (HACE). d Slow ascent is the major preventive measure. e The treatment of choice for HACE is descent, supplemental oxygen and glucocorticosteroids. High-altitude pulmonary edema (HAPE): which statements are correct? a An inadequate drop in performance accompanied by dyspnea and cough is an early sign of HAPE. b Lowering pulmonary artery pressure is the principle of treatment. c Acetazolamide has been shown to prevent HAPE. d Clinical recovery at low altitude occurs within or days. e An individual with a history of HAPE has a high probability of developing HAPE again under similar circ*mstances.
References Nielsen B. Olympics in Atlanta: a fight against physics. Med Sci Sports Exerc ; : –. Saltin B, Hermannsen L. Esophageal, rectal and muscle temperature during exercise. Med Sci Sports Exerc ; : –. Lind AR. A physiological criterion for setting thermal limits for everyday work. J Appl Physiol ; : –.
Chapter . Nielsen M. Die Regulation der Körpertemperatur bei Muskelarbeit. Skand Arch Physiol ; : –. Bittel JHM, Nonotte-Varly C, Livecchi-Gonnot GH, Savourey MJ, Hanniquit AM. Physical fitness and thermoregulatory reactions in a cold environment in men. J Appl Physiol ; : –. Wilber RL, Rundell KW, Szmedra L, Jenkinson DM, Im J, Drake SD. Incidence of exercise-induced bronchospasm in olympic winter sport athletes. Med Sci Sports Exerc ; : –. Ricquier D, Fleury C, Larose M et al. Contribution of studies on uncoupling proteins to research on metabolic diseases. J Intern Med ; : –. Danielsson U. Windchill and the risk of freezing. J Appl Physiol ; : –. ISO. Ergonomics of thermal environment — cold environments. , Geneva: International Standard Organisation. Thompson RL, Hayward JS. Wet-cold exposure and hypothermia: thermal and metabolic responses to prolonged exercise in rain. J Appl Physiol ; : –. ISO/TR-. Evaluation of cold environments — Determination of required clothing insulation (IREQ). , Geneva: International Standard Organisation. Bruck K, Baum E, Schwennike HP. Cold-adaptive modifications in man induced by repeated short-term cold exposures during a -day and -night cold exposure. Pflügers Arch ; : –. Leppäluoto J, Korhonen J, Hassi J. Habituation of thermal sensations, skin temperature and norepinephrine in men exposed to cold. J Appl Physiol ; : –. Mager M, Robinson SM. Substrate mobilization and utilization in fasting men during cold exposure. Bull New Jersey Acad Sci (symposium issue); –. Keatinge WR. The effect of repeated daily exposures to cold and of improved physical fitness on the metabolic and vascular responses to cold air. J Physiol ; : –. Scholander PF, Hammel TH, Lange Andersen K, Logning Y. Metabolic acclimation to cold in man. J Appl Physiol ; : –. Park YS, Rennie DW, Lee IS et al. Time course of deacclimation to cold water immersion in Korean women divers. J Appl Physiol ; : –. Young AJ, Myza SR, Sawka MN, Gonzalez RR, Pandolf KB. Human thermoregulatory responses to cold air are altered by repeated cold water immersions. J Appl Physiol ; : –. O’Brien C, Young AJ, Lee DT, sh*tzer A, Sawka MN, Pandolf KB. Role of core temperature as a stimulus for cold acclimation during repeated immersion in °C water. J Appl Physiol ; : –. Vuori I. Sudden death and exercise: effects of age and type of activity. Sport Sci Rev ; : –. Galloway SD, Maughan RJ. Effects of ambient temperature on capacity to perform prolonged cycle exercise in man. Med Sci Sports Exerc ; : –.
Sallis R, Chassay CM. Recognizing and treating common cold-induced injury in outdoor sports. Med Sci Sports Exerc ; : –. Hassi J, Mäkinen T. Frostbite: occurrence, risk factors and consequences. Int J Circumpolar Health ; : –. Paton B. A history of frostbite treatment. Int J Circumpolar Health ; : –. Berg U. Human power at subnormal body temperatures. Acta Physiol Scand ; : –. Nielsen B, Strange S, Christensen NJ, Warberg J, Saltin B. Acute and adaptive responses in humans to exercise in a warm, humid environment. Pflügers Arch ; : –. González-Alonso J, Teller C, Andersen SL, Jensen FB, Hylding T, Nielsen B. High body temperature causes fatigue during exercise in humans. J Appl Physiol ; : –. Nielsen B, Hales JRS, Strange S, Christensen JN, Warberg J, Saltin B. Human circulatory and thermoregulatory adaptations with heat acclimation and exercise. J Physiol (Lond) ; : –. González-Alonso J, Calbert JA, Nielsen B. Metabolic and thermodynamic alterations with dehydration-induced reductions in muscle blood flow in exercising humans. J Physiol (Lond) ; : –. González-Alonso J, Calbert JA, Nielsen B. Muscle blood flow is reduced with dehydration during prolonged exercise in humans. J Physiol (Lond) ; : –. Sawka MN. Physiological consequences of hypohydration: exercise performance and thermoregulation. Med Sci Sports Exerc ; : –. Hales JRS, Hubbard RW, Gaffin SL. Limitation of heat tolerance. In: Fregly MJ, Blatteis CM, eds. Handbook of Physiology, Section , Environmental Physiology. Bethesda MD: American Physiological Society, : –. Nielsen B, Krog P. Optimal fluid replacement during long lasting exercise in °C and °C ambient temperature. Scand J Med Sci Sports ; : –. Bender PR, McCullough RE, McCullough RG et al. Increased exercise Sa2 independent of ventilatory acclimatization at m. J Appl Physiol ; : –. Mairbäurl H, Schobersberger W, Oelz O, Bärtsch P, Eckardt KU, Bauer C. Unchanged in vivo P- at high altitude despite decreased erythrocyte age and elevated ,diphosphoglycerate. J Appl Physiol ; : –. Terrados N. Altitude training and muscular metabolism. Int J Sports Med ; : S–S. Hoppeler H, Ceretelli P. Morphologic and metabolic response to chronic hypoxia: the muscle system. In: Fregly MJ, Blatteis CM, eds. Handbook of Physiology, Section , Environmental Physiology . Oxford: Oxford University Press, : –. Koistinen P, Takala T, Martikkala V, Leppäluoto J. Aerobic fitness influences the response of maximal oxygen uptake and lactate threshold in acute hypobaric hypoxia. Int J Sports Med ; : –. Chapman RF, Stray-Gundersen J, Levine BD. Individual
Physical Activity and Environment
variation in response to altitude training. J Appl Physiol ; (): –. Gonzalez NC, Clancy RL, Moue Y, Richalet J-P. Increasing maximal heart rate increases maximal O2 uptake in rats acclimatized to simulated altitude. J Appl Physiol ; (): –. Sutton JR, Reeves JT, Wagner PD et al. Operation Everest II: oxygen transport during exercise at extreme simulated altitude. J Appl Physiol ; : –. Maher JT, Jones LG, Hartley LH. Effects of high-altitude exposure on submaximal endurance capacity of men. J Appl Physiol ; : –. Mazzeo RS, Bender PR, Brooks GA et al. Arterial catecholamine responses during exercise with acute and chronic high-altitude exposure. Am J Physiol ; : E–E. Ashenden MJ, Gore CJ, Dobson GP, Hahn AG. ‘Live high, train low’ does not change the total haemoglobin mass of male endurance athletes sleeping at a simulated altitude of m for nights. Eur J Appl Physiol ; : –.
Levine BD, Stray-Gundersen J. ‘Living high–training low’. effect of moderate-altitude acclimatization with low-altitude training on performance. J Appl Physiol ; (): – . Mellerowicz H, Meller W, Woweries J et al. Vergleichende Untersuchungen über Wirkungen von Höhentraining auf die Dauerleistung in Meereshöhe. Sportarzt Sportmed ; : –. Desplanches D, Hoppeler H, Linossier MT et al. Effects of training in normoxia and normobaric hypoxia on human muscle ultrastructure. Eur J Physiol ; : –. Johnson TS, Rock PB. Acute mountain sickness. N Engl J Med ; : –. Houston CS, Dickinson J. Cerebral form of high-altitude illness. Lancet ; II ( October): –. Bärtsch P. High altitude pulmonary edema. Med Sci Sports Exerc ; (): S–S. Loyd EL. Hypothermia and Cold Stress. London: CroomHelm, .
Chapter 2.4 Nutrition and Fluid Intake with Training LEIF HAM BRÆUS, STEFAN BRA NTH & ANNE RA BE N
Classical reference Ivy JL, Katz AL, Cutler CL, Sherman WM, Coyle EF. Muscle glycogen synthesis after exercise: effect of time of carbohydrate ingestion. J Appl Physiol ; : –. The effect of the time of ingestion of a carbohydrate supplement on muscle glycogen post exercise was examined. The authors investigated male cyclists who exercised continuously on a cycle ergometer at % V˙2 max interrupted by six -min intervals of % V˙2 max on two separate occasions. A % carbohydrate solution was ingested either immediately post exercise or hours post exercise. Interestingly, the glycogen synthesis rate after exercise was markedly higher for the group who received carbohydrate immediately after exercise compared with the group that received it hours after exercise. The slower rate of glycogen storage in the group receiving carbohydrate at a later time point occurred despite the fact that the response in plasma glucose and insulin to carbohydrate loading was similar in the two groups. The study was the first to show in humans that ingestion of a carbohydrate supplement immediately post exercise will result in the most optimal recovery of muscle glycogen storage.
Optimal nutrition for physical training and competition — a challenge for nutritional science In order to perform optimally during daily training as well as during competition, it is essential that an ath-
lete’s habitual diet contains enough of both required nutrients and fluid. An optimal nutrient and fluid status is also important to avoid injuries and to optimize the immune system. Not only nutrient composition, but also timing and frequency of food and fluid intake are critical for optimal performance. One of the reasons for the common idea that athletes need special diets might be based on the misconception that an increased energy turnover per se leads to increased needs for other nutrients. However, this is not necessarily the case. Increased physical exercise is essentially a question of increased energy turnover, while the turnover of essential nutrients is usually not related to energy turnover to such an extent that there is a need for increased intakes. Most studies of food habits have indicated that the nutrient density, i.e. nutrients per energy unit, is the same in low-energy consumers as in high-energy consumers. Thus the increased food intake in physically active individuals will automatically have an increased intake of essential nutrients. To what extent the intake of essential nutrients is a valid problem is consequently mainly due to two factors: (i) are the athletes in energy balance? and (ii) are they eating an optimal, nutritionally balanced diet according to recommendations? For recreational athletes this also means that there is no need for specific supplements or diets to cover their energy needs, as illustrated in Case story .. below. This may also be the case in elite athletes. However their often intensive training programmes in combination with short times for recovery between competitions may call for extra nutritional support.
Nutrition and Fluid Intake
Case story 2.4.1 Energy in long distance biking might be obtained by sport drinks and carbohydrate loading. -year-old, non-athlete male: body weight kg, height cm, BMI . kg/m2, body fat %, calculated BMR kJ, V˙2 max . L/min or . mL/kg/min. He participates in one of the classic Swedish sporting events (Vättern-rundan), a noncompetitive endurance biking race with no exact completion times or publication of results. The-km Vätternrundan is a physically taxing event, as it will take the ordinary participant – h of cycling to complete. Most cyclists start in the evening and thus cycle a large part of the Leg/ km Leg/ km Leg/ km Leg/ km Leg/ km Leg/ km Leg/ km Leg/ km Legs & / km + km
Energy turnover (kJ)
race throughout the night in the dark. The race comprises seven legs and nine stops where refreshments are available. At most stops blueberry soup, coffee, buns, and banana are available, but hot meals are offered after km (milk, sausage and mashed potatoes, banana) and after km (lasagne, milk). His mean speed was km per hour, total energy cost during the race was kJ (based on heart rate recording) and total energy intake from food and sport drinks during the race was kJ. His energy balance (in kJ) throughout the race is illustrated in this table. Note the essential energy (and fluid) supplement that is obtained from the sport drinks! Energy intake (kJ) + * + * + * + * + * + * + * + * * + *
Total km + * * From half bottle of sports drink consumed during each leg. The observed energy deficit ( kJ) corresponds to about g glycogen which very well might be available, especially if the subject has performed carbohydrate loading before the race. The case illustrates that it is possible even
Are requirement and recommended daily allowances equivalent to optimal nutrition? For each nutrient there is a range of intakes from minimal requirement to prevent nutrient deficiency diseases to toxic levels. Somewhere in between is what is defined as optimal intake. According to the original definition, requirement refers to the minimal nutrient intake needed in order to prevent nutritional deficiency diseases. The recommended dietary allowance is
Energy balance (kJ) – – + + – + – – – –
during energy-demanding endurance performances to cover energy needs by combining carbohydrate loading with optimal food intake during a race.
defined as the mean of the requirement for a special population group + standard deviations, thereby covering .% of the need of a normal population. In order to compare the requirement vs. an adequate intake some concepts are introduced, as illustrated in Fig. ... A better distinction between the concepts ‘requirement’ and ‘optimal intake’ of nutrients is urgently needed. The mere fact that a more optimal restitution post exercise is reached at a higher nutrient intake does
Chapter .
1.0
UL
RDA
1.0
AI 0.5
0.5
0 A
B C Observed level of intake
Risk of adverse effects
Risk of inadequacy
EAR
D
Fig. .. Schematic illustration of various concepts used to express requirement and optimal intakes of nutrients. AI, adequate intake; EAR, estimated average requirement; RDA, recommended dietary allowances; UL, tolerable upper limit. (Source: Dietary reference intakes, National Academic Press, Washington, ).
not necessarily mean that there is an increased requirement in athletes as such in order to counteract any potential nutrient deficiency. This further accentuates the need to differentiate between various activity periods, whenever discussing the concept of nutritional perspectives on nutrient turnover in athletes. The daily nutritional requirements of nutrients have very little in common with specific nutritional needs pre-exercise and during exercise for optimal performance, which might also on the other hand be quite different from the nutritional needs post exercise for optimal recovery. Thus an optimal restitution of protein balance in the muscle due to heavy physical exercise might call for increased protein availability in the postexercise period although there is still no risk of protein malnutrition on a normal diet.
Energy requirement vs. nutrient requirement Under normal conditions the body gives priority to covering its energy needs. In situations where its energy needs are not met, it will use all available energy-yielding substances in the food and body stores to cover energy requirements. This also means that the energy need essentially involves quantitative aspects of the dietary intake. The requirement for essential nutrients, i.e. protein, essential fatty acids, minerals and vitamins, is essentially related to fat-free mass and to a small degree to the extent of physical exercise. Thus nutrient requirement is related to age, sex
and body size and refers to a specific need for certain nutrients, involving qualitative aspects of the dietary intake. When the energy intake via the diet, i.e. exogenous energy, does not meet energy requirements, endogenous energy is released from the mobilization of energy stores in the body (glycogen in liver and muscle; fat from subcutaneous and adipose tissue; gluconeogenesis from muscle catabolism). Protein plays a two-fold role. There is (i) a specific nutritional role as source of essential amino acids for protein synthesis, i.e. building up, repairing and maintaining tissues; as well as (ii) a non-specific role as an energy-yielding nutrient. If energy needs are not met, protein will be used as an energy source, no matter whether protein needs are increased and not being met. It is consequently not possible to discuss energy and protein requirements separately. This is of special relevance when discussing nutritional problems in athletes.
Energy density vs. nutrient density The energy density of a diet refers to the amount of energy per weight or volume, while the nutrient density refers to the amount of nutrient in relation to energy, i.e. g/ MJ. Foods rich in fat and sugar have a high energy density, while their nutrient density is low. Persons with a high energy turnover, i.e. endurance athletes, may however cover their nutrient needs even on a diet with low nutrient density if they are in energy balance, while a low nutrient density may be detrimental in low-energy consumers. There are few examples, if any, where athletes consuming a normal diet in amounts relevant to cover their energy needs develop any objective signs of nutrient deficiency.
How to measure energy turnover Figure .. illustrates the various methods that can be used for studies of the various compartments in energy turnover in humans. Energy turnover in the body comprises a conversion of energy between various forms: mechanical energy as represented by physical exercise or muscular work; heat production, which is also called thermogenesis. Sooner or later energy conversions result in heat production, i.e. dietary-induced thermogenesis
Nutrition and Fluid Intake
Ergometers (e.g. bicycle, treadmill)
Direct calorimetry (e.g. room, suit)
Indirect calorimetry: Calculations (food tables)
Direct calorimetry Bomb calorimetry
Calculation (PAL)
Energy in Food intake
Energy out Tissue stores
Tissue stores
External work Heat
Body composition: Densitometry Anthropometry, e.g. skin fold Total water, e.g. bioimpedance, stable isotopes (D218O, 40K)
Losses (urine, faeces)
Indirect calorimetry:
Indirect calorimetry:
Respiratory (O2 /CO2) Doubly labelled water Heart rate Activity records
Calculations (chemical analysis) Direct Calorimetry: Bomb calorimetry
Fig. .. Schematic illustration of the various methods used in studies on energy turnover.
(DIT), work-induced thermogenesis. The efficiency of the body in converting chemical energy to mechanical energy, i.e. physical work, is the same in normal and well-trained individuals, being about %, the remaining % being heat; chemically bound energy, as in food and body stores of glycogen and fat, but also protein. Table .. lists the types of energy stores and their role in exercise as a source for conversion into mechanical energy, as well as differences between trained and untrained individuals. Energy turnover includes oxidation of biological substances, i.e. carbohydrate, fat, protein and alcohol, which yields heat. Energy turnover can thus be measured by analysing the heat produced as a result of the oxidation. This is usually called direct calorimetry and calls for advanced and sophisticated analytical methods, which are of little practical importance in field studies. Energy turnover is consequently usually estimated by means of indirect calorimetry based on
measuring consumption of oxygen or production of carbon dioxide as a result of oxidation of energyyielding substrates. As oxidation is related to blood circulation and indirectly heart rate, a common method of indirect calorimetry measurement, especially in athlete physiology, is based on heart beat registration. The individual relationship between heart beat frequency and oxygen consumption, which is related to physical capacity, can be estimated in the laboratory. It is then possible to estimate the total energy turnover during physical performances using portable heart frequency recorders.
Calculation of energy turnover based on basal metabolic rate (BMR) and physical activity level (PAL) The total energy turnover comprises basal metabolic rate (BMR) as well as the energy needed for daily life, i.e. characteristics of lifestyle including physical activity. Based on large population studies, equations have
Chapter . Table .. Energy stores, physical activity and training state. Energy stores
Role in exercise
Difference in trained vs non-trained individuals
Muscle glycogen
Important energy source, influences endurance at moderate-intensity exercise This energy source is used to a large extent in: (i) high exercise intensity (ii) short-term exercise (iii) untrained subjects (iv) high intake of carbohydrate in the diet
Training increases the content by approximately 100%
Liver glycogen
Maintenance of blood glucose.To a certain extent, circulating blood glucose is taken up and catabolized in the working muscle
Training increases the content by approximately 100%
Triglycerides in adipose tissue and muscle tissue
Free fatty acids are produced during breakdown of triglycerides Free fatty acids as an energy source are to a large extent used in: (i) low intensity exercise (ii) long-term exercise (iii) trained subjects (iv) high fat intake in the diet
Exercise increases muscle triglyceride content to twice as much, but the percentage of body fat (and absolute fat mass) in the body drops
Muscle protein
Energy deficit leads to increased muscle catabolism due to increased gluconeogenesis. NB Muscle represents > 20% of body energy stores in athletes
Energy deficit leads to more pronounced muscle catabolism in well-trained athletes with low body fat % than in-non-trained individuals with higher body fat %
Exercise: Calculate your own BMR Table .. Calculation of basal metabolic rate based on age, sex and body weight (W). From []. Men
Women
Age
MJ/24 h
kcal/24 h
MJ/24 h
kcal/24 h
0–3 3–10 10–18 19–30 31–60 > 60
0.255 W – 0.226 0.0949 W + 2.07 0.0732 W + 2.72 0.0640 W + 2.84 0.0485 W + 3.67 0.0565 W + 2.04
60.9 W + 54 22.7 W + 495 17.5 W + 651 15.3 W + 679 11.6 W + 879 13.5 W + 487
0.255 W – 0.214 0.0941 W + 2.09 0.0541 W + 3.12 0.0615 W + 2.08 0.0364 W + 3.47 0.0439 W + 2.49
61.0 W – 51 22.5 W + 499 12.2 W + 746 14.7 W + 496 8.7 W + 829 10.5 W + 596
been established in order to calculate BMR with reasonable accuracy based on anthropometric data (weight, length, age and sex) []. It has been postulated that for survival, -h energy
turnover represents about . times BMR, and for a sedentary lifestyle total energy turnover represents about . times BMR (Fig. ..). Various activities in daily life as well as during
Nutrition and Fluid Intake Activity 3600
Total energy requirement (kcal/day)
3000
Activity
HEAVY
2.10
MODERATE
1.78
LIGHT
1.58 HEAVY with desirable MODERATE with desirable LIGHT with desirable MAINTENANCE with 60 min walking/standing INACTNE out of bed SURVIVAL lying continuously
1.40 1.82 1.27 1.84 1.56 1.20 1.40 1.00 1.27 1.20
MAINTENANGE INACTIVE 2000 SURVIVAL BMR
1.00
BMR
1000
65 kg males
55 kg females
Fig. .. Energy turnover expressed as multiples of BMR [].
various forms of physical activities are expressed as multiples of BMR, often characterized as BMR factors [,] or metabolic energy turnover (MET) values (Table ..) [,]. The total energy turnover (ET) per h can then be calculated based on BMR with the addition of energy for various physical activities based on intensity and duration throughout the day. The relationship between the total energy turnover (ET) and BMR per h is an indicator of the physical
Exercise: Calculate your own PAL Calculate your BMR (as above). Keep a record of your physical activity throughout h: factor Energy Occupation hours BMR (kJ) e.g. Sleeping . BMR/ ¥ . Sitting . BMR/ ¥ . etc. Estimate total energy turnover per h (ET). Your PAL is calculated by dividing ET with BMR.
Table .. Examples of MET values for various athletic activities. From []. Athletic activity
MET value
Badminton, competitive Ballet dancing Basketball, game Bicycle ergometer 100 W Biking > 32 km/h Circuit training Fencing Golf, general Horseback riding, general Ice hockey Jogging, general Orienteering Running, cross-country Running 17 km/h Sailing (Laser) Scuba diving Skiing, cross-country Skiing, competition Soccer, match Squash Skating, competition Swimming, crawl Table tennis Volleyball, beach Weight-lifting, training Wrestling, one match
7.0 6.0 8.0 5.5 16.0 8.0 6.0 4.5 4.0 8.0 7.0 9.0 9.0 18.0 3.0 12.0 7.0 16.5 10.0 12.0 15.0 11.0 4.0 8.0 6.0 6.0
activity level (PAL) of the individual, thus expressing the lifestyle.
Is there a special nutritional problem in training athletes? Elite athletes represent a group of individuals with usually high energy turnover, who experience intensive physical stress. The high energy turnover results in emptying their glycogen depots and in increased fat and protein turnover over shorter or longer intervals. Thus their training and competition schedule dominate their daily life and call for specific energy and nutrient demands and meal patterns. The principle behind any dietary advice to athletes is that priority should be given to covering the energy needs in addition to compensating for fluid losses. It is furthermore essential that all essential nutrients, i.e. vitamins, minerals, essential amino acids and fatty acids, are
Chapter . consumed not only in adequate amounts, which is usually a minor problem, but also in balanced amounts; the latter might be jeopardized when using food supplements. The meal pattern should always be adjusted to training and competition schedules. However, the effect of physical exercise is not only related to energy turnover as such. Physical exercise also has an impact on substrate utilization and may help the individual to balance his/her body composition, metabolic regulation and homeostasis.
The protein debate In athletic physiology the question as to whether there is a special need for protein in athletes is an ongoing matter of controversy. Critical analyses of the background data, however, show that there are a lot of conflicting opinions. When discussing protein needs, we must be certain that the studies performed have not been influenced by problems with energy deficiency, i.e. that the energy needs are not met []. This is of special concern in athletes with a high energy turnover as the body gives priority to covering its energy needs even when protein turnover is increased. Although it has essentially been the strength athletes that have been engaged in the discussions regarding increased protein needs of athletes, it seems, rather, that protein requirement is in fact a problem of endurance athletes. An increased demand may be due to essentially three reasons. First, it is obvious that training leads to increased muscle mass, which may increase the protein requirement. Secondly, hard physical activity, especially endurance training, may lead to increased breakdown and muscle protein turnover. Thirdly, if energy needs are not met there is an increased gluconeogenesis from muscle protein, leading to muscle protein catabolism and negative nitrogen balance. Recent studies using stable isotope techniques [,] indicate that there seems to exist a compensatory reduction in leucine oxidation in the recovery phase after physical activity. This effect is most pronounced post exercise during fasting and might indicate a homeostatic response in order to preserve body protein. Furthermore, the effect of physical exercise on leucine oxidation seems to be reduced during feeding. This might indicate that increased leucine oxidation in the muscle might be compensated for by increased utilization of dietary
protein. Interestingly earlier results from short-term studies (– h) on protein turnover during physical exercise have not registered any compensatory reduction in leucine oxidation, as they have not continued their measurements long enough after the end of the physical exercise. Both Wolfe and Rennie and their collaborators in a series of papers over the last few decades have also shown that protein turnover is increased during exercise. Nevertheless this does not necessarily mean that protein need is increased. Butterfield and Calloway [] showed that physical activity improved protein utilization and in a recent review Rennie and Tipton [] even suggested that protein metabolism may become more efficient as a result of training.
What do we know regarding gender differences? Certain oscillations in the blood content of sex hormones are necessary in order for women to have a regular menstrual cycle. This also applies to female athletes, though they often have lower levels of these sex hormones than non-trained women [,]. This results in the absence of menstruation — amenorrhea — with the frequency related to exercise volume and intensity. Exercise-induced amenorrhea occurs in nearly % of female endurance athletes [] and in athletes for whom esthetics and low body weight are important (gymnastics, sports with weight categories, dancing). Increase in running volume from to km/week for more than year has resulted in amenorrhea in almost all women. The state of amenorrhea is, however, reversible and there are no indications of reduced fertility in former female elite athletes. Amenorrhea can be counteracted by a simple reduction in exercise volume. There are several indications that an insufficient energy intake influences the development of bleeding disorders. In ballet dancers it is a well-known fact that reduced food intake is associated with amenorrhea. Furthermore, cross-sectional studies have shown that long-distance runners who do not increase their food intake to balance their energy output have a higher prevalence of amenorrhea. Surprisingly, these women do not lose weight in spite of a low energy intake. This may indicate that reduced energy intake is neutralized by a reduction in resting metabolic rate compared with
Nutrition and Fluid Intake non-trained women and trained women with normal menstruation patterns. Measurements of hormones in the blood support these theories, and the absence of bleeding could be an energy-sparing mechanism in women. Underreporting of food intake may also explain why the energy intake is unusually low. The practical importance of the amenorrheal state with reduced plasma levels of sex hormones is a reduction in bone mineral content. In extremely welltrained female endurance athletes, a low bone mineral content close to the limit of fracture is often seen. In men also, intense exercise is known to cause a moderate reduction in sex hormones in the blood [], but it has not yet been clarified whether this has any practical relevance in connection to performance [a] and fertility or whether it relates to a reduced dietary intake. Tarnopolsky has discussed in a series of papers the potential gender differences in substrate utilization during endurance exercise [–]. During moderateintensity long-duration exercise he reported that female athletes showed greater lipid utilization and less carbohydrate and protein metabolism than equally trained males. In studies on substrate utilization and energy turnover in elite cyclists during a -h race we have not been able to show any gender differences in substrate utilization (Branth, Hambraeus et al. in press).
dicate a developing nutrient deficiency state. Physiologic parameters such as decreased muscle strength, prolonged nerve reaction time and reduced immune response, however, may indicate more serious disturbances as a result of deterioration of the nutritional state of an individual. Increased physical exercise is essentially a question of increased energy turnover, while the turnover of essential nutrients is usually not affected to such an extent that there is a need for an increased intake per se, provided the energy needs are covered. The debate as to whether the intake of nutrients in athletes is adequate is usually based on assessments of the dietary intake by various methods. Interestingly numerous food intake studies in elite athletes have been published based on dietary assessments where the energy intake is remarkably low and the discrepancy is obvious if the data are compared to calculated energy turnover from their training log. Thus the first step in analysing any possible nutrient deficiencies in athletes must be based on validation of reported dietary intakes. It is not scientifically relevant to draw any conclusions regarding the possible need for food supplements or increased requirement for specific nutrients in athletes as long as the energy needs are not being met by dietary intake.
Dietary recalls and/or records How to identify nutritional problems in athletes Assessment of nutritional status The nutritional status of an individual can be evaluated by various methods, i.e. anything from recording of dietary intake or analysis of physiologic parameters (i.e. body composition, physical capacity, immune defence system) to biochemical indicators (i.e. plasma levels of nutrients or endocrine response). Each of them will illustrate various stages in the nutritional status. While analysis of dietary intake will indicate potential risks of developing nutrient and energy deficiencies, changes in plasma levels of various nutrients or metabolites can be a result of physiologic adaptation to a changed nutrient balance as well as a serious indicator of nutrient imbalance. Likewise changes in body composition may represent an adaptive mechanism in the homeostatic regulation of metabolism, but also in-
There are several methods used for studies on dietary intake, both retrospective and prospective, based on anything from personal interviews, records and use of food frequency questionnaires to the double portion technique. Each of them has its pros and cons as illustrated in Table ... There is no single golden method for estimation of the dietary intake without error, and the goal of the study is of utmost importance when selecting the optimal method for dietary assessment. Furthermore, different types of errors have different effects in analysis and interpretation. Consequently, data collected by means of one dietary assessment in order to study the intake of one nutrient may not necessarily be as valid in evaluation of the intake of another nutrient. The retrospective methods comprise dietary interviews in order to describe dietary habits from a longerterm perspective. This calls for a skilled interviewer and is time consuming. They can also be based on
Chapter . Table .. Summary of various methods for dietary assessments. Method
Coverage
Advantage
Disadvantage
Dietary history
All food items or selected items
Long-term perspectives of dietary habits Individual data
Time consuming Skilled interviewer needed Memory demanding Quantitative data difficult to obtain Variations in dietary habits lost
24-h recall
All foods
Relatively rapid and simple Can be repeated Individual data
Selection of interview day critical Quantitative data difficult to obtain Skilled interviewer needed
Food frequency questionnaire (FFQ)
Only listed food items
Rapid and simple Easy to computerize Large groups covered by mail
Restricted number of food items Memory demanding No direct contact with interviewer
Food records
All foods
Individual data Intake during various days Quantitative data
Selection of day critical Dietary intake may be affected Needs resources Time consuming Collaboration necessary
Double portions
All foods
Exact data on nutrient content possible (not dependent on accuracy of food tables)
Dietary intake may be affected Resource demanding Collaboration necessary
repeated -h recalls. In this case it is essential to select various weekdays and training situations and also to be aware of seasonal variations throughout the year. The advantage of retrospective methods is that they do not usually interfere with the subjects’ eating habits, as he/she does not know beforehand that their dietary habits will be analysed. However, the results obtained depend on the skill of the interviewer and on the subject being able to recall his/her dietary intake. In order to cover larger number of individuals, food frequency questionnaires can be used. Such forms can be coded in order to simplify computer analysis. However, the selection of food items is limited, and furthermore there is little personal contact with the subject that would allow the reliability of the data recorded to be assessed. Prospective methods comprise the use of food records, based on weighing all food items consumed or estimated from menu records or by observation. This can be performed over one or several days, usually – days. In the latter case it is essential that the records are performed continuously. A -day food record kept over consecutive days is far more informative and
reliable than seven isolated -h records made over shorter or longer intervals. All prospective methods may have a more or less pronounced indirect impact on the dietary habits, as the subject is aware that they are being studied.
Validation of dietary assessments Dietary assessment methods will almost without exception result in an underestimation of energy intake. Energy turnover should consequently be evaluated on the basis of studies of energy expenditure based on calculated BMR with the addition of a relevant PAL factor, which is based on the lifestyle including physical activity, and only in exceptional circ*mstances on determinations of energy intake. The energy equation fulfils the first law of thermodynamics: energy cannot be created nor destroyed, it can only be transferred from one form to the other. Available energy from energy intake and tissue breakdown must balance energy turnover if body weight is stable and body composition unchanged over a certain length of time. Thus an objective and reliable reference against which to validate data obtained on dietary intake can be based on a com-
Nutrition and Fluid Intake parison between the observed or registered energy intake (EI) and the theoretical calculations of energy turnover based on calculated BMR with addition of a relevant PAL factor. In Case story .. the flow chart for the estimation of energy turnover is illustrated.
Four different situations of nutritional significance in athletes The mean intake of nutrients in athletes is of less importance and/or interest; rather nutritional problems should be divided into the following subheadings with regard to energy and nutrient intake: daily intake and food habits (e.g. energy balance, nutrient density); intake pre-exercise (loading phase) for optimal training effect or performance; intake during exercise (nutrient and energy maintenance) for optimal performance; intake post exercise (recovery phase) for optimal restoration of the energy and nutrient stores. Nutritional problems pre-exercise are dominated by the carbohydrate loading as discussed below and in Chapter .. During exercise the dominant problems are compensation for water and electrolyte losses and, if possible, energy turnover. Post-exercise nutrition should be directed towards the most rapid and efficient restoration of body stores and compensation for tissue damages.
Daily intake and food habits in athletes Interestingly numerous published food intake studies in elite athletes are based on dietary assessments where the energy intakes are remarkably low. If the data from their training logs are compared to calculated energy turnover from anthropometric data, the discrepancy is obvious and the use of various forms of compensation for energy adjustments have been proposed. Whether athletes have a tendency to reduce their BMR values as a compensation for insufficient energy intake is still an open question. An increased BMR would in fact have been expected, as both the lower fat content of an athlete’s body compared to that of an untrained individual and the excessive postexercise oxygen consumption (EPOC) should lead to an increased BMR. Data on energy intake from any dietary assessment in athletes who maintain a constant body weight, which does not exceed the minimal energy require-
ment based on BMR and a suitable PAL factor, cannot be considered accurate for analysis of the relationship between dietary intake and health (Case story ..). In case the data should be considered as representative in a long-term perspective, energy balance must have been obtained. It is thus recommended that a validation based on calculated EI/BMR ratios should be included in dietary surveys []. The data must then account for at least the minimal energy needed for sedentary life (BMR ¥ .), with the appropriate addition for physical exercise, otherwise they represent an underestimation. It is then necessary to find out whether the missing energy units are supplied by qualitatively identical dietary components or whether other sources of energy have been consumed and not recorded. Furthermore, to what extent can we assume that the underestimation of dietary intake is the same for all nutrients? An intake of about g carbohydrate/kg/day is generally recommended for athletes today (Table ..). This corresponds to a total carbohydrate intake of g per day in a -kg person or to % of total energy (60E%) if daily energy intake is MJ/day ( g carbohydrate- kJ). This is a considerable amount — both compared to the recommendations for the average population (– E% = – g at MJ/day) and compared to the average intake of the adult Danish population ( g/day) []. The energy need of an athlete will normally be greater than the energy need of a sedentary person. However, carbohydrates give a higher degree of satiety and feeling of fullness per kJ than fat []. Furthermore, g carbohydrate contains approximately half as many kJ as g fat ( kJ/g vs. kJ/g). It is therefore necessary to consume twice as much carbohydrate than Table .. Nutrient recommendations.
Carbohydrate Fat Protein
Average population * E%
Athletes E%
g/kg/day
55–60 max. 30 10–15
60–65** 20–25 10–15
c. 8 Not defined 1.2–1.7
E%, percentage of total energy. * From [90].
Chapter .
Case story 2.4.2 How to validate dietary assessment by comparing energy intake (EI) and energy turnover (ET) based on BMR and PAL including one practical example Step
Procedure Collect anthropometric data (age and sex, body weight, height)
Verify that body weight has not changed = energy balance Calculate energy intake (EI) from dietary assessment Calculate BMR according to FAO/WHO/UNU equation Analyse physical activity from training report and lifestyle (hours of sleep, sitting, walking, etc.) Occupation h BMR factor Energy(kJ) Sleep Cross-country skiing, training Sitting, reading, TV . Walking . Miscellaneous . Calculate total energy turnover (ET): (a) using BMR factors from physical activity record (see Step ) ET = kJ (b) using BMR factor for sedentary life (.) ET = kJ Calculate PAL factor based on: ET (Step a)/BMR(Step ) ET/BMR = . Compare estimated EI from dietary assessment ( kJ) with: (a) estimated BMR ( kJ) EI/BMR = . (b) estimated ET from theoretical calculations of BMR and PAL EI/(BMR ¥ PAL) = .
Comments The EI/BMR ratio is ., i.e. the energy intake only covers sedentary life. This is quite different from his PAL according to the lifestyle and training record (.). The difference between ET for sedentary life ( kJ) and that according to the dietary record ( kJ) is kJ which is energy available for training. Training intensity (MET = ) corresponds to ¥ = kJ/h. If this dietary assessment is correct it means that he would only be able to train for / = . h or min, if it is assumed that he is in energy balance. If on the other hand he is training for the h recorded in the physical activity diary his daily ET would be , i.e. the recorded EI ( ) would represent only % of ET. These
Example Male, years, weight kg, height cm Stable body weight kJ kJ/ h or kJ/h
values do not fit if he is maintaining his body weight and body composition. If he had been asleep in bed when not training, his ET would have been kJ. This would mean that his EI should represent a BMR factor of ., which is considered below survival needs. Another solution might be that he must reduce his BMR in order to maintain his body composition and energy balance and not develop a catabolic state. In this case he must reduce his BMR from to kJ/h, or % if the BMR factor of . is valid for his sedentary life when not training. The most probable reason for the discrepancy between ET and EI is an underevaluation of his dietary intake!
Nutrition and Fluid Intake
Case story 2.4.3 Energy balance in a 20-year-old tennis-playing female (weight 61 kg, height 165 cm) Her BMR calculated from anthropometric data was kJ/ h or kJ/h. Her energy intake (EI) based on dietary records was kJ. Occupation h BMR factor Sleep Tennis training Sitting, reading, TV . Walking . Miscellaneous . Total energy turnover (ET) using BMR factors Her PAL factor was: based on ET/BMR based on EI/BMR EI in relation to ET from physical activity records
Comments The EI/BMR ratio is ., i.e. the energy intake does not even cover her BMR. This is quite different from her PAL according to lifestyle and training record (.). A dietician (who obviously had no experience or knowledge of athletic physiology) had recommended a low-fat diet, using skimmed milk, low-fat margarine and low-fat yoghurt, and this female started to develop anorexia. Unfortunately this is an authentic case and not an unusual example of misinformation due to lack of
fat in order to obtain the same energy intake. Finally, the so-called nutritious and recommended carbohydrates, which also contribute vitamins, minerals and dietary fiber (starch-rich carbohydrates and fruit), are characterized by a large volume and water content. This type of carbohydrate is therefore much less energy dense than fat, which means that a larger volume of food intake is needed in order to obtain the same energy intake on a carbohydrate-rich diet than on a fat-rich diet. An athlete may therefore find that satiety occurs before the meal is finished and consequently that their intake of energy and carbohydrate is not adequate. Evidence of this also comes from the numerous
Her physical activity according to training report and lifestyle was as follows:
Energy (kJ) kJ . . . knowledge that dietary counselling for athletes should be different from that intended for the general public. Low fat diets with low energy density usually lead to difficulties for athletes with high energy turnover in covering their energy needs with reasonable amounts of food. Furthermore the risk factor for cardiovascular disease secondary to fat intake has little relevance for athletes with high energy turnover as long as they are in energy balance.
studies showing a spontaneous decrease in total energy and a reduction in body weight when a carbohydraterich diet is consumed ad libitum for weeks or months [b,,]. From Table .. it can be calculated that you have to eat . kg bread ( slices of rye bread or slices of wholemeal bread), . kg boiled rice or . kg apples, or drink – L of juice every day in order to obtain g carbohydrates per day. The volume problem of a very carbohydrate-rich diet can be managed partly through more frequent meals (six to eight per day), and partly by consuming some of the carbohydrates as concentrated carbohy-
Chapter . drates or fluids such as dried fruits, sugar-rich sweets, juice, energy drinks, glucose or maltodextrin (glucose polymer) solution. In order to obtain essential vitamins and minerals, it is, however, necessary to ensure a daily intake of the nutritious carbohydrates as well. This recommendation is particularly important for subjects with a low fat intake (often women). Since a very high intake of carbohydrates is recommended, the diets of athletes will mostly be based on vegetable food and hence the diet is likely to be semi- or totally vegetarian. It is difficult to design a vegetarian diet, especially a vegan diet (% vegetable), which is sufficient in essential amino acids, vitamins and minerals. The latter applies especially to iron, zinc, calcium and vitamins D and B12. In a lacto-ovovegetarian diet it is relatively easy to obtain essential amino acids, vitamin B12 and calcium, but iron intake is still a problem. This is primarily due to the fact that non-heme iron which is found in vegetables is more difficult to absorb than heme iron which is found in meat []. A vegetarian diet may reduce concentrations of sex hormones even when ideally balanced [,a], but the long-term effects on performance of a vegetarian diet have not been shown [a,].
Nutrient and fluid intake before training/exercise (loading phase) Carbohydrate The focus with regard to athletes’ diets has been on carbohydrate intake in particular, since the body’s glycogen stores are very limited. Although glycogen content is increased about two-fold in a well-trained
athlete compared with a sedentary person (Table ..), the glycogen stores are still a limiting factor for exercise endurance and intensity (see Chapter .). Compared with the fat stores, glycogen stores can supply energy for a few hours of medium-intensity work, whereas fat stores can supply energy for several days. It is also essential to remember that muscle protein also represents a substantial and potential endogenous energy source, constituting about % of the body’s total energy store in a normal individual, probably more in a well-trained athlete. Studies during the past century have also shown quite convincingly, that glycogen stores can be varied according to the dietary composition (Table ..) []. This is of great importance when heavy training takes place once or twice every day. In this case, the stores can be completely replenished if the diet is rich in carbohydrates. Therefore, the goal in dietary advice to athletes has first and foremost been to increase carbohydrate intake. However, it should always be remembered that a diet rich in carbohydrates which still does not meet energy needs is of little use. An increase in muscle and liver glycogen content and an improvement in performance have been seen after the intake of a relatively large carbohydrate meal (approximately g carbohydrate) – h before training compared with no intake [–]. Previous opinion was that high concentrations of insulin in the blood at the beginning of physical activity (as after intake of carbohydrate – min before training) were a disadvantage because blood glucose during training of medium severity might drop as a consequence of increased glucose absorption in the working muscula-
Table .. Size of glycogen stores on different diets. From []. Size of the glycogen stores Stores
Total weight
Mixed diet*
CHO-rich diet†
Fat-rich diet‡
Liver Muscle
1.2 kg 32 kg
40–50 g 350 g
70–90 g 600 g
0–20 g 300 g
CHO, carbohydrate. * 30 E% fat, 45–50 E% carbohydrate. † 70 E% carbohydrate, 10 E% fat. ‡ 20 E% carbohydrate, 50 E% fat.
Nutrition and Fluid Intake ture []. This risk is lower during intense muscular exercise of short duration (e.g. – min of rowing). Here the release of blood glucose-elevating hormones (counter-regulatory hormones), such as epinephrine, cortisol and growth hormone, is very powerful and can therefore match the extra glucose absorption in the muscle []. Several more recent studies have shown, however, that intake of glucose – min before training (cycling or running) does not result in reduced endurance capacity, sometimes even the contrary (for a review see []).
The glycemic index More recently, not only the amount but also the types of carbohydrate have been included in the dietary guidelines to athletes. The concept of glycemic index (GI) was introduced in in order to be able to classify carbohydrates according to the postprandial increase in blood glucose []: GI = [ blood glucose area of test food]
[ blood glucose area of white bread] ¥ 100 According to the GI method, carbohydrates can be divided into high, medium and low GI foods. In general, GI is low for foods high in fructose, which have a high amylose/amylopectin ratio, contain large starch particles, are minimally processed or are ingested with fat and protein. However, there is no general rule that complex carbohydrates have a low glycemic index. Thus potatoes may have a high glycemic index while some pasta products have a very low glycemic index []. The GI for some selected foods is shown in Table ... For a more extensive table, see Foster-Powell and Brand-Miller []. Some studies have suggested that low GI or slow carbohydrates should be preferred to high GI carbohydrate before exercise []. However, it seems that carbohydrate intake during exercise eliminates any difference in blood glucose, insulin, substrate oxidation and performance induced by pre-exercise carbohydrate intake [].
Table .. Carbohydrate content and glycemic index (GI)* (where known). From [–].
Glucose Sucrose Fructose Candy Cornflakes, unspecified Muesli, unspecified Liquorice Liquorice allsorts Biscuits, digestive Raisins Chocolate, milk White bread Rye bread, dark Wholemeal bread Rye bread, wholegrain Wine gums Soya beans† Boiled rice, brown† Boiled pasta† Corn Banana Fresh-boiled potatoes† Orange juice Apple/pear Soft drink and syrup Skimmed milk Tomato/cucumber
g/100 g
GI
100 100 100 98 83 71 78 83 66 78 59 51 48 49 49 79 34 25 25 23 21 18 10 13 10 5 6
138 89 31 – 115 96 – 82 93 – 100 89 99 58 – 20 96 45–66 80–87 79–84 80 67 53/47 – 46 –
* Compared to white bread = 100. † GI varies according to method of preparation and temperature during intake.
quate hydration and allow time for excretion of excess ingested water. Of special interest in this context is the fact that glycogen binds . g water per gram of glycogen. Thus during carbohydrate loading it is also essential to have an accurate fluid intake.
Nutrient and fluid intake during training/exercise (maintenance phase) See Case story ...
Fluid
Energy substrates
Fluid stores must be filled before exercise in order to prevent premature dehydration. About mL of fluid about h before exercise would promote ade-
The metabolic fuels used during exercise depend on the training duration and intensity, the training state of the athlete, the fuel availability and reserves in the
Chapter .
Case story 2.4.4 Emergy balance not protein deficiency is the problem in athletes -year-old girl, elite athlete, active mountain biker: body weight . kg, height cm, BMI ., body fat .%, BMR calculated kJ, V˙2 max mL/min ( mL/kg/min). She participates in a test training program involving cycling km at a mean speed of Intake before race Intake during race Losses during race Balance
Energy (kJ) –
Please note the pronounced negative energy balance! The protein balance does not represent a problem and it seems that she managed to maintain her fluid balance. (Fluid losses are
body, the previous diet and possible intake during exercise. In general, the use of carbohydrate as substrate increases with increasing exercise intensity and falls with increasing exercise duration (due to depletion of the glycogen stores). Conversely, fat utilization is higher at low exercise intensities (< % V˙2 max) and increases with longer exercise duration (> – h) []. The recommended carbohydrate intake is g carbohydrate/min, since this is the maximal rate of carbohydrate oxidation during exercise []. A -g/ mL glucose drink at a rate of about mL/h would be a compromise between fluid intake recommendations and intake rates typically achieved by athletes in competitive situations []. There seem to be no important differences between different moderate to high GI carbohydrate sources ingested during prolonged, moderate-intensity exercise (except for fructose which is very slowly metabolized) []. Furthermore, the food form (fluid vs. solid) seems to be of no importance either. Carbohydrate supplements have not been considered very relevant in exercise bouts lasting less than h. However, recent studies have shown that in intermittent or high-intensity exercise of < h, carbohydrate intake may also improve performance [].
km/h. Duration of race min. Breakfast before race contained juice, cereals, yoghurt, bread and butter, coffee. Intake during race: sports drinks, chocolate bars and bananas. The nutritional balance at the end of the race could be summarized as follows: Protein (g) +
Fluid (L) . . . +.
calculated based on weight differences and measurements of body water using bioimpedance.)
Protein Physical exercise leads to an increased protein oxidation in the muscle in absolute terms. However, the contribution of protein to energy turnover is remarkably reduced in relation to carbohydrate and fat. Food intake seems to reduce leucine oxidation during exercise []. The changes in substrate oxidation during exercise at -h energy balance during fasting and feeding is illustrated in Fig. ... A high protein diet seems to have a carbohydratesparing effect as the surplus of protein is converted through gluconeogenesis and contributes to endogenous carbohydrate which is then oxidized. Interestingly a high protein diet also seems to stimulate fat oxidation []. Both these effects might be due to increased glucagon levels in the blood on a high protein diet.
Fat The contribution of fat oxidation increases with improved training state []. But even for the welltrained athlete, the optimal situation during exercise is to maintain carbohydrate supply to the muscles, but slow the depletion of the glycogen stores by increasing the reliance on fatty acids and on glucose supplied from intake of carbohydrate.
Nutrition and Fluid Intake (b) 600
500
500
400
400
J/kg/min
300 200
200
0600
2100
carbohydrate fat protein
0600
Real time (clock hours)
1600 1730
0830 1000 1200
0600
2100
1600 1730
0830 1000 1200
0630
carbohydrate fat protein
0630
100
100 0
300
carbohydrate fat protein
Real time (clock hours) (d)
(c)
100
40
0600
2130
1600 1730
0630 0830 1000 1200
20 carbohydrate fat protein
Real time (clock hours)
60 40 20 0
2130
60
80
1600 1730
80
0630
% of energy expenditure
100
0830 1000 1200
J/kg/min
(a)
% of energy expenditure
Real time (clock hours)
Fig. .. Substrate utilization during exercise in -h energy balance studies at normal and high protein intakes [].
In order to reduce carbohydrate oxidation and spare glycogen stores during exercise, it has been suggested that fat also could be ingested before and/or during work. Medium-chain triglycerides (MCTs) have been investigated in particular, since they are rapidly absorbed and enter the circulation directly through the portal vein. MCTs are rapidly oxidized both at rest and during exercise, especially when ingested with carbohydrate [,]. Conflicting results have, however, been produced, showing either a negative effect, no effect or a glycogen-sparing and performanceenhancing effect of MCTs. Ingestion of g MCTs was found to contribute –% of energy expenditure, but to have no effect on muscle glycogen breakdown or carbohydrate utilization []. Conversely, a large dose of g MCTs was found to elevate plasma free fatty acid (FFA), decrease glycogen breakdown and increase performance in a time trial []. However, in another study a negative effect on performance was observed
after intake of g MCTs alone even though FFA levels were increased. Also the subjects reported gastrointestinal discomfort, which may have been the reason for the decreased performance []. A more recent study showed no effect of carbohydrate + MCT ingestion on time trials after h of constant-load exercise []. At present, data are therefore too conflicting to conclude whether MCTs should be used or not to enhance performance.
Optimal fluid intake During physical activity fluid is lost at a rate dependent on the degree of work intensity, temperature and humidity of the surroundings. Often athletes have a water loss due to sweating of – L/ h. For elite runners this may amount to .– L in warm surroundings. Studies have shown a tendency to drink too little (involuntary dehydration) since increased thirst during
Chapter . physical activity does not appear until the subjects dehydrate about % of their body weight. This should be viewed in light of the fact that even a dehydration of –% of body weight reduces performance because of compromised temperature and adjustment of cardiovascular regulation []. It is therefore very important that athletes drink at least as much fluid as they lose. A good rule today is to drink at least every min during a race. However, how much and what kind of fluid that can be consumed during exercise will vary for each individual and must therefore be decided individually during the actual exercise bout. It is consequently recommended that various kinds of fluids are tested during training in order to find the optimal solution and to try to estimate the water losses by recording body weight changes during the race. To what extent the glycogen-bound water is released and available for the homeostasis of water balance during endurance performance has to be further elucidated. The rate of gastric emptying for fluids depends on the volume and concentration. It is possible to empty c. mL/ h, but the amount is reduced during intense muscle activity (> % V˙2 max) and with high osmolality in the consumed fluid. The latter is especially important in exercise of longer duration (> – h). As long as the carbohydrate solution is –% it does not, however, affect gastric emptying rate. Newer carbohydrate types (e.g. the glucose polymer maltodextrin) permit an intake of % solutions. This is due to the fact that the osmolality is too low to affect the gastric emptying rate. During prolonged exercise (– h) the fluid should contain carbohydrates and a small amount of electrolytes, primarily in order to increase intestinal absorption of carbohydrate. Even though sodium is lost in sweat, there is no sodium depletion until several hours of work have been performed.
Nutrient and fluid intake after training/exercise (recovery phase) How soon post exercise? Muscle glycogen repletion occurs most rapidly just after exercise. This is due partly to increased glycogen synthase activity and high permeability to glucose, and partly to increased insulin action in the exercised muscle [,]. Hence, the rate of glycogen storage was
Table .. Examples of ‘pick-me-up’ food items for restoration of glycogen depot (all containing g carbohydrate). 1.5 L sport drink (7% carbohydrate) 0.9 L blueberry soup 2 bananas (peeled) 1.5 dL raisins 1 L orange juice 4 dL cereal mix (muesli) 10 bread slices (wheat) 4 dL oats 0.7 L fruit yoghurt (0.5% fat) 2 L low-fat milk (0.5% fat)
(0 g protein) (3 g protein) (4 g protein) (4 g protein) (10 g protein) (15 g protein) (17 g protein) (20 g protein) (25 g protein) (70 g protein)
found to be four times higher in the first hour after exercise than just h after end of exercise, when carbohydrate was consumed or h post exercise, respectively []. Carbohydrate should therefore be consumed as soon as possible after exercise. Protein consumed in combination with carbohydrate may increase postexercise glycogen synthesis more than carbohydrate alone, due to increased insulin concentrations [,] (Table ..). Recent studies indicate that protein post exercise in the form of protein hydrolysates and amino acid–carbohydrate mixtures [] will also optimize muscle protein recovery or even stimulate protein anabolism and increased muscle mass but this still has to be verified. Fluid intake in connection with exercise must at least compensate for the fluid lost during exercise. Weighing (without any clothes) before and after exercise will show the approximate fluid loss during exercise. The color of an athlete’s urine can also reveal whether overall fluid intake is sufficient.
Is there a need for a special diet post exercise? After moderate-intensity exercise with glycogen depletion, muscle glycogen content (like liver glycogen) is regenerated to a normal level in – days on a mixed diet and in approximately h on a carbohydraterich diet. Provided that the emptying of the muscle glycogen has been extensive and the following intake of carbohydrate is large, muscle glycogen will be regenerated to higher levels than before exercise (supercompensation). The type of carbohydrate probably plays its most
Nutrition and Fluid Intake important role in the postexercise diet. Thus, one study showed that the glycogen storage rate after glycogen-depleting exercise (.– h at % of V2 max) was higher h after intake of high GI carbohydrates compared to low GI carbohydrates []. Faster glycogen resynthesis with glucose compared to fructose has also been found during the hours after exercise. After h, however, no difference between the glycogen resynthesis was found after high or low GI carbohydrates. However, another study showed that after h a high GI diet increased muscle glycogen stores % more than a low GI diet []. If exercise takes place once or twice daily, it is therefore advisable to choose high GI carbohydrates after training. With exercise only once a day or less and a recovery period of more than h, the type of carbohydrate does not seem to be important for the training outcome, but this has not yet been completely clarified. A problem often encountered by athletes is a decreased appetite for up to – h after heavy exercise []. To overcome this problem, a carbohydratecontaining drink is advisable. In this way both fluid balance and muscle glycogen can be rapidly restored. It has not yet been clarified, though, if additional protein intake — resulting in a positive nitrogen balance — can be advantageous with respect to muscle building and performance. For most athletes, a sufficient protein intake will not be a problem. This implies, however, that the athletes are in energy balance and consume varied meals containing all the essential amino acids. In types of sport with frequent periods of energy deficiency during training (running, gymnastics, athletics, ballet) as well as for vegetarians (especially vegans), the diet may be low in proteins and insufficient with respect to essential amino acids []. Examples of complete protein combinations are: beans + rice, peas + corn, pulses + bread, cereals + milk or eggs, and potatoes + eggs or milk. One should also bear in mind that the bioavailability of vegetable protein from a fiber-rich diet is estimated to be % lower than the bioavailability of animal protein. Studies on the dietary intake of Kenyan runners by Christensen and collaborators [] were able to show, however, that the high carbohydrate and low fat intake, which was similar to that reported in endurance runners from other low-income countries, was suffi-
cient to cover energy as well as protein intake, including the need of essential amino acids, despite the diet being based on a small range of mainly vegetable food items.
The role of dietary supplements Is there a need for food supplements? Subnormal levels of one or more nutrients in body fluids cannot be taken as an indicator that there is a nutrient deficiency which calls for food supplements, unless the energy needs are covered. Several studies indicate that subnormal levels of nutrients can be restored by means of a well-balanced diet consumed in adequate amounts to cover energy requirements. The motivation for athletes to use supplements can be divided into various categories: use of supplements for optimal training effect, e.g. use of certain amino acids stimulating the release of growth hormone; supplements to be used during competition, e.g. use of bicarbonate to counteract acidosis; use of preparations for optimal restoration, e.g. creatinine for training effect at repetitive strength training; use of supplements to increase psychological capacity, e.g. B vitamins against agony, branched chain amino acid supplements to counteract central tiredness, antioxidants against muscle tissue damage. In all these circ*mstances there is a gray area between physiologic demands and doping effects, an issue which is still not resolved. There are also various forms and types of supplements. Complete supplements represent an alternative to conventional food which are often used in clinical dietetics for tube feeding of patients with gastrointestinal problems. These products may be used as ‘convenience foods’ for athletes who have problems fitting their meal pattern around their training schedule. Food supplements comprising vitamins and minerals are often used. It is, however, essential that they are balanced in a defined mixture, usually as a multiple of the recommended intakes. Otherwise there is a risk that imbalanced intakes will cause problems. Energy supplements, often drinks or cakes with high energy density, usually based on carbohydrate, are often used to cover high energy turnover. However, there is a
Chapter . potential risk of high energy density products leading to nutrient imbalance as a result of low nutrient density of the diet. Finally there are the ergogenic supplements which usually include megadoses of vitamins, minerals, stimulators (e.g. caffeine), and others (e.g. creatinine, Q, ginseng), in order to increase physical and mental capacity. In these cases we are also in the gray area between physiologic demands and doping effects. Excessive dietary intake of certain minerals and trace elements may impair the balance of other minerals due to interactions affecting intestinal absorption; e.g. zinc intake above mg per day impairs copper and iron metabolism and high iron supplementation impairs the uptake of other minerals, e.g. zinc. A high protein intake has also been reported to be deleterious for calcium, phosphorus, zinc and copper requirements.
Fat More recently, a renewed interest in fat-rich diets as an ergogenic aid has emerged. Thus, several studies have investigated whether fat oxidation can be increased and thereby glycogen breakdown prolonged during exercise if the athlete is habituated to a more fat-rich diet instead of the recommended carbohydrate-rich diet [–]. The overall message from these studies seems to be, however, that a fat-rich diet consumed for at least weeks does not improve performance or increase glycogen stores. On the contrary, a carbohydrate-rich diet still seems to be superior to a fat-rich diet. A daily intake of at least E% fat should be consumed in order to obtain enough essential fatty acids and fat-soluble vitamins in the diet. However, up to – E% fat would still ensure enough calories for carbohydrate and protein in the diet.
Protein Protein is also metabolized during exercise, although to a lesser degree than carbohydrate and fat as long as the athlete is in energy balance. Furthermore, sufficient carbohydrate stores and carbohydrate administration during exercise have a sparing effect on protein utilization. It is recommended that an endurance athlete should consume .–. g protein/kg body weight/day, while strength-training athletes should
consume .–. g protein/kg body weight/day [] although the scientific evidence for a raised protein requirement in the diet is questioned by others. At a total energy intake of MJ/day, where the protein intake corresponds to E%, this means an intake of g protein or . g protein/kg body weight in a -kg man, i.e. well above these recommendations. Most athletes even in their normal diet have > E% protein and a higher energy intake than MJ. Thus there is no need for extra protein supplements in their diet in order to cover a protein requirement of .–. g/kg body weight/day. Of greater interest is, however, to what extent a more optimal muscle protein restoration could be obtained if protein is given post exercise. This, however, still has to be further elucidated.
Minerals Minerals and trace elements constitute about % of the body. The dominant part is calcium phosphate in the skeleton, representing almost –% of body mass, while the trace elements constitute less than .%. As the latter play an essential role in the metabolic function of the body, trace elements represent essential nutrients which must be consumed regularly, albeit in small amounts. Today minerals and trace elements have been identified as essential, but recommended daily allowances (RDA) have only been established for seven of these: calcium, iodine, iron, magnesium, phosphorus, selenium and zinc. Intense physical exercise has been shown to increase the losses of minerals and trace elements in urine, sweat and feces to varying degrees. The magnitude of the losses is dependent not only on the type and intensity of exercise and individual homeostatic control, but also on the nutritional situation (nutrient intake and nutrient status of the individual). It is still an open question as to how to measure mineral status in an individual, as plasma levels are usually not appropriate indicators and may even be misleading due to the homeostatic regulation in the body. It is generally agreed that moderate physical activity does not adversely affect mineral status when recommended amounts of minerals and trace elements are consumed in a mixed diet with a normal nutrient density []. Diets with high energy density and low nutrient density (often called empty calories), i.e. high
Nutrition and Fluid Intake carbohydrate and/or high fat diets, may potentially lead to deficiencies of essential nutrients for some athletes with high physical activity. Other risk groups are those engaged in sports which favor low body weights, leading to restricted dietary intakes (e.g. gymnasts, endurance runners). Nevertheless, very few studies have so far indicated reduced physical performance due to trace element deficiencies, with the exception of iron-deficiency anemia.
Calcium Calcium is the most abundant mineral in the body, which contains about .–. kg. Approximately % of the body calcium is located in the skeleton, which serves as an important calcium depot, while the remaining % occurs as calcium ions of relevance for neuromuscular function. Severe hypocalcemia can cause serious muscle cramps and heart arrhythmias. However, there are no reliable data available concerning the potential effect of calcium supplementation in the treatment of muscle cramps in athletes. The homeostasis of calcium is tightly regulated by a complicated hormonal system in which vitamin D plays an important role. Peak bone mass is achieved by the age of – years. An inadequate calcium intake before this age, which is common in many young females, may lead to consequences later in life with osteoporosis and fractures. Weight-bearing exercises such as running and weight-lifting have been shown to increase peak bone mass, especially before puberty, but are probably not as important as calcium intake. A physically active lifestyle throughout life does however have a positive effect on bone mass and a lifelong adequate calcium intake of over mg/day reduces the risk for later osteoporosis []. A positive interaction between exercise and calcium has also been shown in young subjects but it seems likely that the calcium intake has to exceed mg, which many athletes do not achieve []. Athletes with stress fractures have been found to have low bone density associated with low calcium intake []. In contrast calcium supplements ( mg/day) given to military recruits did not prevent stress fractures []. In osteoporosis, prophylactic studies indicate that an effect is obtained only when more than mg are given in supplements. There
are no studies or other evidence that calcium supplementation could give athletes any physical performance benefits. On the contrary, excess calcium intake may inhibit iron absorption.
Iron The total content of iron in the body is – g. Iron is stored in the body bound to a protein, ferritin, and serum ferritin is considered to reflect total body iron stores. Transferrin is a transport protein in plasma and is usually only saturated with iron to %. The saturation decreases during iron depletion, but total transferrin content, often referred to as total iron binding capacity, is also increased during chronic infections and pregnancy, leading to a lower saturation. Serum iron is influenced by many factors including physical exercise and it is not considered as a suitable indicator of iron status of the individual. Iron occurs in two forms in the diet: in an inorganic form in vegetable sources, non-heme iron, as well as in an organic form, heme iron, from animal products, i.e. meat and blood products. The absorption of non-heme iron is relatively low and inhibited by, for example, bran, cellulose, pectin and phytic acid, while protein such as meat and ascorbic acid enhance absorption. Heme iron has a higher bioavailability and this is not influenced by antinutrients to the same extent. Iron supplements are widely used by athletes but gastrointestinal side-effects are common, which decrease compliance and make the treatment complicated. Low dose iron supplementation seems to be a good practice (approximately mg elemental Fe/day) []. The daily loss of iron is small (c. mg/day for men and mg/day for women — menses) because of an effective recycling system. In addition iron absorption increases when iron stores are depleted as occurs during growth and menstrual bleeding (up to mg/day). Hence, recommendations have been fixed at mg/day for men and mg/day for women, respectively. An increased incidence of reduced serum ferritin has been shown in many studies among athletes, where runners are most affected, especially females, but most types of training can affect serum ferritin concentration. However, most studies have shown that a low serum ferritin level without manifest anemia does not seem to affect performance capacity. Furthermore, low serum ferritin concentrations may only reflect a
Chapter . shift of iron from stores to functional compartments, e.g. myoglobin in muscle. Moreover, the widespread low or subnormal hemoglobin and hematocrit, often reported especially among endurance athletes, has been called ‘sports anemia’. However, in most cases this is probably caused by physiologic adaptation with expanding baseline plasma volume (dilution pseudoanemia) due to the repetitive acute loss of plasma volume during intense physical exercise []. In addition, intensive prolonged or muscle-damaging exercise evokes an acute phase response which, among other reactions, causes a fall in serum iron and rise in ferritin levels. This makes the interpretation of iron status in athletes difficult. Several suggestions have been proposed to explain how iron status can be affected by physical exercise, including increased gastrointestinal blood losses by hemorrhage erosions or ischemic colitis and/or reduced absorption. Hematuria occurs but is uncommon, and iron losses in the urine are small. Hemolysis due to erythrocyte rupture during strenuous training, especially running, where erythrocytes may be crushed within the foot, is also suggested as an explanation. There is also a possibility of increased red cell turnover and there might be increased red cell mass by training. Iron losses through sweat have been estimated to be –% of absorbed iron per day during h exercise and thus might be a problem for those with low iron intake and marginal stores []. The incidence of iron-deficiency anemia has not been shown to be high in athletes. Most studies have so far also shown that non-anemic iron depletion as well as iron supplementation does not seem to increase physical performance. However, some limited data suggest that female athletes with low ferritin values could benefit from iron supplementation [,] but this still has to be clarified. Increased iron intake by diet should always be the first choice. Three groups have, however, been identified to be at greater risk for developing iron deficiency: female athletes, distance runners and vegetarian athletes. Attention has, however, to be focused on the fact that excess iron appears to lead to oxidative stress and may therefore aggravate exercise-induced oxidative stress. It could also be deleterious for those with the genetic disease hemochromatosis []. Furthermore, excess iron intake may reduce uptake of other trace elements, in
particular zinc, and cause nutritional imbalances. Consequently iron supplementation to athletes should only involve small doses and should only be used when iron-deficiency anemia is properly documented by laboratory assessments [].
Zinc Zinc is a component of more than enzymes involved in carbohydrate, fat and protein turnover. They are necessary for the immune system as well as for the endocrine response and protection against free radicals. Zinc is of vital importance for metabolic turnover during physical exercise. About % of the zinc is intracellular; only .% of the total body content of zinc occurs in plasma while % is located in muscles. Thus the measurement of plasma zinc levels as an indicator of zinc status can be questioned. Zinc needs for athletes are still not clarified although exercise may result in increased zinc losses in sweat and urine []. There is, however, so far no evidence that zinc supplementation may enhance physical performance in humans. It has however, been suggested that zinc depletion could increase exercise-induced stress, e.g. decreased immune defence and muscle damage secondary to changes in membrane stability []. Zinc supplementation is common among athletes. However, zinc overdose (> mg) may impair immune function as well as iron and copper status [].
Magnesium Magnesium is involved in more than metabolic reactions of relevance for substrate turnover and utilization. It is also involved in neuromuscular, cardiovascular, immune and endocrine function, and has an antioxidant role. Magnesium deficiency has been shown to occur in a wide variety of clinical conditions associated with oxidative stress, e.g. cardiovascular disorders and diabetes, where magnesium supplementation may be beneficial []. In athletes it has been suggested that magnesium deficiency is a contributing factor to exercise-induced muscle cramps, but this is still not proven. Serum magnesium is a poor indicator of magnesium status and there are still no reliable methods available for evaluating magnesium status. Although magnesium is excreted in the sweat, even during profuse sweating the
Nutrition and Fluid Intake magnesium losses are relatively small, probably due to an effective redistribution of magnesium within the body, especially thanks to the homeostatic control of the kidney. There might, however, be increased magnesium turnover and urinary losses during long and intensive training periods and stress []. So far there are, however, no studies that show that magnesium supplementation is beneficial for athletes despite the fact that magnesium has an essential function in energy turnover in the body.
Chromium Although chromium is considered as an essential nutrient, its biologic role is still not fully understood. Strenuous exercise has been shown to increase urinary excretion of chromium markedly [], but whether this leads to a risk of developing chromium deficiency is not known.
Selenium Selenium functions as an antioxidant alone in the detoxification of heavy metals in the body and as a cofactor of the antioxidant enzyme glutathione peroxidase. Dietary selenium deficiency increases tissue oxidative damage and it seems that selenium has a sparing effect on tissue levels of vitamin E. However in experimental studies selenium deficiency does not impair endurance capacity in rats and supplementation in humans has no effect on physical performance []. Selenium has also been shown to be important for the immune system. This is of special concern in the Scandinavian countries, which have selenium-poor soils, and has led to specific programs to add selenium to fertilizers in Finland in order to increase the dietary intake of selenium. In this context it is of interest that it has been shown that selenium status in Swedish athletes is subnormal and lower than in Finnish athletes [].
Sodium As sodium plays an essential role in the regulation of fluid balance, prolonged strenuous exercise, especially in a hot environment, may result in acute sodium losses which lead to heat exhaustion or even heat cramps []. The daily intake of sodium is usually quite accurate and sodium replacement is seldom necessary during exercise. There is also an adaptation process in the
body during heat environment leading to less sodium losses in sweat and urine, but if the athlete is not acclimatized, losses of sodium and minerals in a hot environment may be considerable.
Vitamins Vitamins are essential nutrients which must be supplied on a regular basis. They are involved in many metabolic pathways, which often are stressed during intensive exercise, and include coenzymes essential in the metabolic system as well as antioxidants. Consequently it has been shown that a low vitamin status can reduce physical performance [] although, to date, no controlled studies have shown that vitamin supplementation increases performance. Exercise appears to increase the turnover and losses of some B vitamins. Some studies indicate that nutritional status is impaired in some active individuals with insufficient energy intake and/or poor nutrient density in their diet such that it is deficient in certain B vitamins, i.e. thiamine, riboflavin and vitamin B6.
Oxidative stress and antioxidants Oxygen is essential for human life and necessary for energy production, but in some forms it can be damaging to the body as reactive oxygen species (ROS): free radicals. The majority of ROS are produced in the mitochondrial electron transport chain during energy production. Physical exercise augments the production of free radicals and other forms of reactive oxygen species. End-products of oxidative damage are observed in the blood and tissues after acute intensive exercise as well as signs of decreased levels of antioxidants in some studies. Strenuous exercise may manifest an imbalance between the production of ROS and antioxidant defences, resulting in an oxidative stress situation in the body []. In fact there is some evidence which implicates ROS as an underlying cause of exercise-induced muscle fatigue and damage. During an acute bout of strenuous exercise the immune system is activated and produces a substantial amount of ROS, which may cause an inflammatory process. The immune system produces ROS to kill bacteria and viruses. During b-oxidation of large amounts of fat, as occurs during starvation, there is a substantial production of ROS; this also occurs during oxidation of amino acids through degradation of xanthine to uric
Chapter . acid. In addition there is a ROS production during the autooxidation of catecholamines []. The body has created an extensive protective system against these potentially damaging species, the antioxidant system. If the production of free radicals is large enough to overcome the antioxidant defence system, oxidative stress will ensue. Training seems to induce an adaptation with elevation of antioxidant protection through increased levels of the key antioxidant enzymes: the zinc-containing superoxide dismutase, iron-containing catalase and selenium-containing glutathione peroxidase. Training also seems to reduce signs of oxidative stress. Important dietary sources of antioxidants include vitamins C and E, carotenoids, zinc and selenium, whereas uric acid, bilirubin, ubiquinone (Q) and the thiol glutathione are important endogenous antioxidants. It is not yet fully known whether the body’s natural antioxidant defence system is sufficient to counteract the increase of free radical production during intense exercise. There is, however, evidence that antioxidant consumption increases during excessive prolonged exercise, but not to what extent. Some studies have reported that supplementation with antioxidants, such as vitamins C and E and thiol compounds (e.g. N-acetyl-cysteine and a-lipoic acid) might have some protective properties against tissue damage induced by oxidative stress []. Antioxidant supplements have, however, not been shown to increase performance. The balance between ROS production and availability of antioxidants plays a very important role in maintaining an intact immune system. Antioxidant deficiencies have been shown to impair immune function and supplementation has been shown to improve protection against infections in some studies. However, megadoses and unbalanced supplementation with antioxidants may be deleterious as they may cause autoxidation and increased tissue damage and suppress immune functions []. Thus recommendations for athletes should give priority to increasing the dietary intake of food items containing naturally occurring antioxidants, such as vegetables and fruits.
some of these are included in the list of doping drugs, such as caffeine (max mg/mL is allowed in urine) and alcohol. Among the (still) legal and most often used diet supplements are creatine, Q, antioxidants and ginseng. The daily need of creatine is approximately g/ day and it is covered through both the diet and the body’s own production (through the amino acids arginine and methionine). In the diet, creatine is found especially in meat (c. g/kg), fish and to a smaller extent in milk (– mg/L). If the intake of creatine is increased, the muscle tissue will reach a saturation limit after approximately days whereafter the surplus is excreted in the urine. An increased intake of creatine may have a positive effect, especially after shortterm explosive exercise []. Athletes who consume a well-balanced diet do not, however, need a creatine supplement. Q (ubiquinone or vitamin Q) works as an electrotransporter in the respiratory chain of the mitochondria where it is involved in the energy-producing processes. Furthermore, studies have shown that Q has antioxidative qualities. During physical activity, the content of Q in plasma lipoproteins is reduced. This may be due to an increased incorporation of Q into the heart and skeletal muscle, or because Q is used or excreted in the intestine. Q supplementation is known to have a positive effect on the heart muscle of patients with particular heart diseases, but no studies have yet shown that athletes who consume a varied diet need additional Q. Ginseng (Russian root) has been shown to have an ability to prevent tiredness and increase work capacity. However, there are also studies which have not been able to show this positive effect. In general, the effects of the diet supplements mentioned above have not been fully investigated for either possible positive qualities or toxicity, side-effects and long-term effects. Furthermore, the type of sport may influence the possible effects.
Practical dietary advice In training camps and abroad
Ergogenic substances A number of diet-related supplements have been credited with the ability to improve performance. Today
• In a training camp or at competitions it is not always possible to obtain the diet you are used to. It is therefore essential that you are prepared and plan in advance in
Nutrition and Fluid Intake order to keep to your normal dietary habits and meal order as far as possible. It is often possible to discuss the matter with your coach and to contact the hotel staff in advance to discuss your needs. • Bring your own food (raisins, bread, biscuits) and some nutritionally well-balanced convenient food items in suitable portions if you know in advance that the food may be of poor quality. If you do not get enough food, it may be necessary to eat food of poor nutritional value, such as chocolate, crisps and sweets. • Make sure that you consume plenty of bread together with the hot meal. It is always possible to get bread. Otherwise: insist on having bread! Pasta is another alternative that you can bring with you in order to get enough carbohydrate. • Make sure that there is plenty of food and ask for more if you do not feel full. • Make sure that it is possible to have a snack between meals, such as fresh fruit.
Important guidelines while abroad • Buy bottled water if the tap water is not drinkable, but be sure that the bottle has been carefully sealed by the factory. Boil the tap water whenever you are uncertain of its quality. • Never have ice in your drinks as it comes from tap water and may have been stored under less than hygienic conditions. • Do not eat dishes containing mayonnaise or egg. • Avoid eating fresh vegetables and raw fruits. Do not eat salad and cold mixed dishes. In a lot of countries, e.g. in Asia, the water is so polluted that bacteria in fresh vegetables may cause illness. Furthermore, avoid dishes which have been heated for a while and left to cool down. • Eat only fruits which have a ‘natural wrapping’, such as bananas and oranges, and peel them yourself. Otherwise peel the fruit (e.g. apples, pears) yourself carefully. Do not eat ‘ready-made’ fruit salad. • Do not eat ice-cream, or cakes with cream or filling, no matter how nice they look. • Be sure that meat, fish, egg and chicken dishes are thoroughly boiled or fried. Do not eat raw meat.
Summary Elite athletes represent a group of individuals with an unusually high energy turnover who experience inten-
sive physical stress, and who regularly increase their fat and protein turnover and empty their glycogen depots. Training and competition schedules dominate their daily life and call for specific energy and nutrient requirements as well as meal patterns. Many athletes, especially in endurance sports, have problems satisfying their energy needs through a conventional diet according to recommendations. The principle behind any dietary advice to athletes is that energy needs should be covered and fluid losses compensated for. All nutrients, i.e. vitamins, minerals and fatty acids, should be consumed in adequate and balanced amounts. The meal pattern should also be adjusted to the training/competition schedule. Furthermore, based on all available scientifically sound data the diet should take into account the specific demands that occur as a result of various physical and psychological stresses during training and competition. Special attention should also be given to the characteristics of each phase of training and competition within each specific type of athletic performance, i.e. strength as well as endurance sports. This may call for dietary counselling regarding diet composition, meal order and meal frequency as well as energy-rich food supplements. A high energy intake is no guarantee per se that the need for essential nutrients is being satisfied. Increased use of energy-dense food items (empty calories) leads to a diet with low nutrient density. The role of dietary intake for optimal performance can be divided into the following categories: (i) dietary habits in general (energy balance, nutrition density); (ii) intake of nutrients before competition (loading phase); (iii) intake of nutrients during performance (maintenance phase); and (iv) intake of nutrients after performance (recovery phase). Dietary recommendations for the general population may not be valid for elite athletes as a high intake of carbohydrate and dietary fiber leads to bulkiness. A low fat intake leads to problems in supplying energy needs. A high intake of PUFA and iron may lead to increased formation of free radicals and increased need for antioxidants. There are also various levels of motivation for the use of supplements: (i) for optimal training effect, e.g. amino acids stimulating growth hormone; (ii) use during competition, e.g. bicarbonate against acidosis; (iii)
Chapter . for optimal restoration, e.g. creatine for training effect at repetition; and (iv) to increase psychological capacity, e.g. B vitamins against agony, branched chain amino acids against central tiredness. Subnormal levels of one or more nutrients in body fluids cannot be taken as an indicator that there is a nutrient deficiency unless it is known that the energy needs are being adequately fulfilled. Subnormal levels of nutrients can usually be restored by means of a well balanced diet consumed in adequate amounts.
Multiple choice questions Resynthesis of muscle glycogen after prolonged endurance exercise depends on: a only complex carbohydrate being taken b intake of carbohydrate in a liquid form c immediate intake of carbohydrate after exercise d ensuring a high carbohydrate content in the food intake for the following h. With regard to an athlete’s diet it is important to: a have a high fat content in the diet b have a minimum intake of g protein/kg body weight/day c ensure obligatory administration of antioxidants d ensure that over % of the daily energy intake is from carbohydrate. With regard to energy intake during exercise it is correct that: a a solution with around % carbohydrate will provide the best source of carbohydrate during exercise b carbohydrate intake during exercise helps prolong endurance by emptying the glycogen stores at a lower rate c energy intake only plays a role during exercise if it lasts for more than h d fat intake will help improve fat combustion and therefore improve endurance. With regard to supplementation in regularly training individuals it is correct that: a all training female athletes will need iron implementation in order not to become anemic b magnesium deficiency can easily be detected by blood sample c extra administration of vitamin B will increase performance d vitamins C and E might have some protective properties against tissue damage from oxidative stress.
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responses to exercise in humans: influence of hypoxia and physical training. Am J Physiol ; : R–R. Hawley JA, Burke LM. Effect of meal frequency and timing on physical performance. Br J Nutr ; (Suppl.): S–S. Jenkins DJA, Wolever TMS, Taylor RH, Barker H et al. Glycemic index of foods: a physiological basis for carbohydrate exchange. Am J Clin Nutr ; : –. Björk I, Liljeberg H, Östman E. Low glucaemic-index foods. Br J Nutr ; (Suppl.): S–S. Foster-Powell K, Brand Miller J. International tables of glycemic index. Am J Clin Nutr ; : S–S. Thomas DE, Brotherhood JR, Brand JC. Carbohydrate feeding before exercise: effect of glycemic index. Int J Sports Med ; : –. Burke LM, Claassen A, Hawley JA, Noakes TD. Carbohydrate intake during prolonged cycling minimizes effect of glycemic index of preexercise meal. J Appl Physiol ; (): –. Romijn JA, Coyle EF, Sidossis LS, Gastaldelli A, Horowitz JF, Endert E, Wolfe RR. Regulation of endogenous fat and carbohydrate metabolism in relation to exercise intensity and duration. Am J Physiol ; : E–E. Hawley JA, Dennis SC, Noakes TD. Oxidation of carbohydrate ingested during prolonged exercise. Sports Med ; : –. Noakes TD. Fluid replacement during exercise. Exerc Sport Sci Rev ; : –. Jeukendrup A, Brouns F, Wagenmakers AJM, Saris WHM. Carbohydrate-electrolyte feedings improve h time trial cycling performance. Int J Sports Med ; : –. Forslund AH, El-Khoury AE, Olsson RM, Sjödin AM, Hambraeus L, Young VR. Effect of protein intake and physical activity on -h pattern and rate of macronutrient utilization. Am J Physiol ; (Endocrin Metab ): E–E. Hurley BF, Nemeth PM, Martain WH, Hagberg JM, Dalsky GP, Holloszy JO. Muscle triglyceride utilization during exercise: effect of training. J Appl Physiol ; : –. Massicotte D, Peronnet F, Brison GR, Hillaire-Marcel C. Oxidation of exogenous medium-chain free fatty acids during prolonged exercise — comparison with glucose. J Appl Physiol ; : –. Jeukendrup AE, Saris WHM, Schrauwen P, Brouns F, Wagenmakers AJM. Metabolic availability of medium chain triglycerides co-ingested with carbohydrates during prolonged exercise. J Appl Physiol ; : –. Jeukendrup AE, Saris WHM, Brouns F, Halliday D, Wagenmakers AJM. Carbohydrate (CHO) metabolism after ingestion of CHO and medium-chain triglycerides (MCT) during prolonged exercise. Metabolism ; : –. Van Zeyl CG, Lambert EV, Hawley JA, Noakes TD, Dennis SC. Effects of medium-chain triglyceride inges-
Chapter .
tion on fuel metabolism and cycling performance. J Appl Physiol ; (): –. Jeukendrup AE, Thielen JJHC, Wagenmakers AJM, Brouns F, Saris WHM. Effect of MCT and carbohydrate ingestion during exercise on substrate utilization and subsequent cycling performance. Am J Clin Nutr ; (): –. Goedecke JH, Elmer-English R, Dennis SC, Schloss I, Noakes TD, Lambert EV. Effects of medium-chain triacylglycerol ingested with carbohydrate on metabolism and exercise performance. Int J Sports Nutr ; : –. Maughan RJ. Fluid and electrolyte loss and replacement in exercise. J Sports Sci ; : –. Garetto LP, Richter EA, Goodman MN, Ruderman NB. Enhanced muscle glucose metabolism after exercise in the rat: the two phases. Am J Physiol ; : E–E. Price TB, Rothman DL, Taylor R, Avison MJ, Shulman GI, Shulman RG. Human muscle glycogen resynthesis after exercise: insulin-dependent and -independent phases. J Appl Physiol ; : –. Ivy JL, Katz AL, Cutler CL, Sherman WM, Coyle EF. Muscle glycogen synthesis after exercise: effect of time of carbohydrate ingestion. J Appl Physiol ; : –. Zawadzki K, Yaspelkis B III, Ivy J. Carbohydrate–protein complex increases the rate of muscle glycogen storage after exercise. J Appl Physiol ; : –. Van Loon LJC, Saris WHM, Kruijshoop M, Wagenmakers AJM. Maximizing postexercise muscle glycogen synthesis: carbohydrate supplementation and the application of amino acid or protein hydrolysate mixtures. Am J Clin Nutr ; : –. Van Loon LJC, Kruijshoop M, Verhagen H, Saris WHM, Wagenmakers AJM. Ingestion of protein hydrolysate and amino acid-carbohydrate mixtures increases postexercise plasma insulin responses in man. J Nutr ; : –. Kiens B, Raben AB, Valeur AK, Richter EA. Benefit of dietary simple carbohydrates on the early postexercise muscle glycogen repletion in male athletes. Med Sci Sports Exerc ; : . Burke LM, Collier GR, Hargreaves M. Muscle glycogen storage after prolonged exercise: effect of glycemic index of carbohydrate feedings. J Appl Physiol ; : –. King NA, Burley VJ, Blundell JE. Exercise-induced suppression of appetite: effects on food intake and implications for energy balance. Eur J Clin Nutr ; : –. Acosta PB. Availability of essential amino acids and nitrogen in vegan diets. Am J Clin Nutr ; : –. Christensen DL, van Hall G, Hambræus L. Food intakes in Kalenjin runners in Kenya: a field study. In: Sport Science in a Changing World of Sports, nd Annual Congress of the European College of Sport Science. Copenhagen, Denmark, – August : –. Lambert EV, Speechly DP, Dennis SC, Noakes TD. Enhanced endurance in trained cyclists during moderate
intensity exercise following weeks adaptation to a high fat diet. Eur J Appl Physiol ; : –. Pruett EDR. Glucose and insulin during prolonged work stress in men living on different diets. J Appl Physiol ; : –. Helge JW, Richter EA, Kiens B. Interaction of training and diet on metabolism and endurance during exercise in man. J Physiol ; : –. Lemon PWR. Effect of exercise on protein requirements. J Sports Sci ; : –. Armstrong LE, Maresh CM. Vitamin and mineral supplements as nutritional aids to exercise performance and health. Nutr Rev ; : –. Weaver CM. Calcium requirements of physically active people Am J Clin Nutr ; (Suppl.): S–S. Specker BL. Evidence for an interaction between calcium intake and physical activity on change in bone mineral density. J Bone Min Res ; : –. Myburgh KH, Hutchins J, Fataar AB, Hough SF, Noakes TD. Low bone density is an etiological factor for stress fractures in athletes. Ann Intern Med ; : –. Schwellnus MP, Jordan G. Does calcium supplementation prevent bone stress injuries? A clinical trial. Int J Sports Nutr ; : –. Beard J, Tobin B. Iron status and exercise. Am J Clin Nutr ; (Suppl.): S–S. Weight LM. Sport anemia: does it exist? Sports Med ; : –. Clarkson PM. Micronutrients and exercise. Antioxidants and minerals. J Sports Sci ; : –. Rowland TW, Deisroth MB, Green GM, Kelleher JF. The effect of iron therapy on exercise capacity of non-anemic iron deficient adolescent runners. Am J Dis Child ; : –. Yoshida T, Ido M, Chida M, Ichioka M, Makiguchi K. Dietary iron supplement during physical training in competitive distance runners. Med Rehab ; : –. Jenkins RR, Krause K, Schoufield LS. Influence of exercise on clearance of oxidant stress products and loosely bound iron. Med Sci Sports Exerc ; : –. Van Rij AM, Hall MT, Dohm G, Bray J, Porioes WJ. Change in zinc metabolism following exercise in human subjects. Biol Trace Element Res ; : –. König D, Weinstock C, Keul J, Northhoff H, Berg A. Zinc, iron and magnesium status in athletes. Influence on regulation of exercise induced stress and immune function. Exerc Immun Rev ; : –. Fosmire G. Zinc toxicity. Am J Clin Nutr ; : – . Begona MK, Moorkens G, Vertommen J, Noe M, Nève J, De Leeuw I. Magnesium status and parameters of magnesium. J Am Coll Nutr ; : –. Seelig MS. Consequences of magnesium deficiency on the enhancement of stress reactions: preventive and therapeutic implications. J Am Coll Nutr ; : –.
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Anderson RA, Bryden NA, Polansky MM, Deutster PA. Exercise effects on chromium excretion of trained and untrained men consuming a constant diet. J Appl Phys ; : –. Sen KC, Packer L. Thiol homeostasis and supplements in physical exercise. Am J Clin Nutr ; (Suppl.): S–S. Wang W-C, Heinonen O, Mäkelä A-L, Mäkelä P, Näntö V, Branth S. Serum selenium, zinc and copper in Swedish and Finnish orienteers. A comparative study. Analyst ; : –. Armstrong LE, Maresh CM. The exertional heat illness: a risk of athletic participation. Med Exerc Nutr Health ; : –. Manroe MM. Effects of physical activity on thiamine, riboflavin, and vitamin B requirements. Am J Clin Nutr ; (Suppl.): S–S. Li Li J. Antioxidants and oxidative stress in exercise. Proc Soc Exp Biol Med ; : –. Clarkson PM, Thompson SH. Antioxidants. what role do
they play in physical activity and health? Am J Clin Nutr ; (Suppl.): S–S. Niess AM, Dickhuth HH, Northoff H, Fehrenbach E. Free radicals and oxidative stress in exercise — immunological aspects. Exerc Immun Rev ; : –. Greenhaft PL, Casey A, Short AH, Søderlund K, Hultman E. Influence of oral creatine supplementation of muscle torque during repeated bouts of maximal voluntary exercise in man. Clin Sci ; : –. Sandström B, Aro A, Becker W, Lyhne N, Pedersen JI, Pórsdóttir I. Nordic Nutrition Recommendations. Nordiska Ministerrådet, Köpenhamn. Nord Livsmedel: . Møller A. The Composition of Foods, th edn. Copenhagen: Levnedsmiddelstyrelsen, . Jenkins DJA, Wolever TMS, Jenkins AL, Josse RG, Wong GS. The glycemic response to carbohydrate foods. Lancet ; : –. Jenkins DJA, Wolever TMS, Jenkins AL. Starchy foods and glycemic index. Diabetic Care ; : –.
Chapter 2.5 Ergogenic Aids (Doping) and Pharmacologic Injury Treatment ULRICH FRE DB E RG, TI MO S ÄPPÄ LÄ , RASMUS DA MS GAA RD & MI CHA E L KJ ÆR
Classical reference 5.0
L/min
Ekblom B, Berglund B. Effect of erythropoietin administration on maximal aerobic power. Scand J Med Sci Sports ; : –. The effect of subcutaneous injections of recombinant human erythropoietin (rhEPO) on the circulatory response to submaximal and maximal exercise was studied in healthy males. The study was the first to describe the ergogenic effect in well-trained humans of exogenous rhEPO. Seven weeks of rhEPO resulted in increased [Hb] from g/L to g/L and in parallel maximal V2 increased from . to . L/min (Fig. ..). The improvement in V˙2 max by rhEPO administration was similar to that obtained by acute elevation of [Hb] with red blood cell reinfusion. After stopping rhEPO administration V˙2 max gradually returned to the initial value over – weeks. Interestingly, systolic blood pressure at W increased after rhEPO treatment.
4.5 4.0
3.5 –2
2
4
6 Weeks
8
10
12
Fig. .. Maximal oxygen uptake before and after rhEPO administration in eight healthy young individuals.
found in an English sports lexicon, and included both the medical use and the moral implications. Gradually the term adopted a wider usage and in reference to sport, it became known as ‘doping’. In today’s sporting context, doping refers to the use by athletes of banned substances or methods that may enhance performance.
Doping and ergogenic drugs Ancient and modern drug use Introduction The use of prohibited ergogenic aids to enhance sporting performance is referred to as doping (Table ..). The word ‘dope’ arises from the Dutch word ‘doop’ which means sauce or cream. In South Africa the word referred to a drink that was used as a stimulant in religious ceremonies and during intensive hard work. In the word appeared for the first time in an English dictionary, referring to a mixture of opium and narcotics used in horses. In the term ‘doping’ was
In the third century Greek athletes prepared different mushrooms in the belief that it would enhance their performance. Similarly the Roman gladiators used stimulants for faster recovery after injury and chariot racers fed their horses ‘potent’ mixtures. Members of the Inca people chewed coca leaves before engaging in particularly intensive physical activities and Vikings have been said to eat fly agaric when fighting battles. Various stories about the use of different drugs by athletes emerge from the nineteenth
Ergogenic Aids and Pharmacologic Treatment Table .. Overall effect of ergogenic agents and procedures. Substances above the full line represent abandoned doping substances, whereas procedures and substances below the line represent legal or limited-legal approaches (caffeine below the allowed limit). Substance
Mechanism and effect
Blood doping Erythropoietin Anabolic steroids GH/IGF-I Beta-adrenergics Beta-blockers Amphetamine
· Hgb and V O2 max (10–15%) · Hgb and V O2 max (10–15%) Protein synthesis and strength (10–30%) Protein synthesis and strength (?) Protein synthesis and strength (5%) Central (5–10%) Central (3–5%)
Altitude Caffeine Creatine Bicarbonate
· Hgb and V O2 max (3–6%) Metabolism (5–15%), contraction (2–4%) Metabolism (3–5%), strength (10–20%) Neutralize acidosis (3–4%)
GH, growth hormone; Hgb, hemoglobin; IGF-I, insulin-like growth factor 1.
century when sport became more organized and sophisticated, reflecting the industrialization and urbanization of society; drugs included strychnine, nitroglycerine, opium, alcohol, coca leaves and caffeine. The majority of stories were related to cycling and other endurance sports. The events leading to a banning of drugs in sports are listed in Table ...
The Olympic Movement Anti-Doping Code The use of drugs to improve athletic performance is strictly prohibited in sports, mainly on the grounds of fair play and health. From an ethical and moral standpoint doping contravenes the fundamental principles of Olympism, sports as well as medical ethics and is thus forbidden. Furthermore, recommending, proposing, authorizing, condoning or facilitating the use of any substance or method covered by the definition of doping or trafficking therein is also forbidden. The International Olympic Committee (IOC) has considered the philosophy of control and the types of drugs to be classified as doping agents, and has established suitable methods for testing. These are included in the Olympic Movement Anti-Doping Code and may be changed by the IOC Executive Board. Legally
licensed athletes are bound by the regulations of their international federations. The regulations of the different federations vary in the details of their sanctions and restricted drugs. The IOC list of banned substances and methods consists of stimulants, narcotics, anabolic agents, diuretics and peptide hormones, masking agents, blood doping and manipulations (Table ..).
Doping agents and their function Substances used to increase performance can be classified according to the parameters they will influence, i.e. (i) increasing endurance and aerobic capacity, (ii) increasing muscle mass and strength, (iii) decreasing feelings of fatigue and nervousness and (iv) improving recovery processes (Table ..).
Stimulants (amphetamine, ephedrine, cocaine and caffeine) Substances belonging to this group range from the potent amphetamines to the weaker caffeine and ephedrine. The substances are called sympathomimetics and imitate the effects of the stress hormones epinephrine and norepinephrine. Amphetamines were synthesized first in and were initially commercially available as a nasal decongestant. They cause the release of excitatory neurotransmitters, such as dopamine, to stimulate the central nervous system (CNS). The main effects on the CNS include wakefulness, alertness and a decreased sense of fatigue, mood elevation, increased self-confidence and a decreased appetite. The physical effects include increased heart rate, redirection of blood flow from the gastrointestinal tract to the muscles, and an increased fat metabolism. Amphetamine carries a high potential of tolerance, i.e. dosage has to be increased after prolonged use to induce the same effect. Although several CNS-acting stimulants are suspected to be performance enhancing, amphetamine is among the few that has been evaluated scientifically and has been shown to improve performance by –% []. Ephedrine’s effect on the CNS is weaker than that of amphetamine and controlled studies on its effect are few. Evidently ephedrine has an energy expenditure enhancing effect which has been used in treatment of obesity, and thus could potentially — although this is unsubstantiated — lead to fat loss in athletes. Cocaine has not
Chapter . Table .. Chain of events finally leading to the banning of drugs in sport and the establishment of the independent World Anti-Doping Agency (WADA). 1896 The first recorded death was in 1896 when a cyclist,Arthur Linton, collapsed and died after finishing the first ever Paris Roubaix apparently after an overdose of strychnine
1963 The Council of Europe set up a Committee on drugs but couldn’t decide on a definition of doping.The first ever antidoping law was approved in France and 2 years later in Belgium
1904 The first near death in modern Olympics where a marathon runner,Thomas Hicks, was using a mixture of brandy and strychnine No specific date Most drugs involved alcohol and strychnine. Heroin, caffeine and cocaine were also widely used until heroin and cocaine became available only on prescription
1966 The first doping controls were carried out by FIFA during the World Championship in soccer in England
1930s Amphetamines were produced and quickly became the choice over strychnine.A wide use of amphetamine among soldiers was seen during the Second World War 1950s The production and use of synthetic testosterone explains the extreme improvements in weight-lifters from the Soviet team at the World Championship in 1954.Accordingly the potent effect of testosterone and synthetic derivatives such as dianabol became common knowledge 1952 One of the first noticeable doping cases involving amphetamines, which occurred at the Winter Olympics. Several speed skaters became ill and needed medical attention 1960 At the Olympics in Rome, Danish cyclist, Kurt Jensen, collapsed and died from an amphetamine overdose
been found to have any performance-enhancing effect in athletes. Although this drug could contribute to a subjective feeling of ‘doing well’, the effects on peripheral reflexes of cocaine could in fact impair performance. The effect on the CNS of amphetamine may lead to a distortion of the user’s perception of reality and impairment of judgement, which may cause an athlete to continue participation while injured or exhausted leading to worse injuries or collapse. Other acute sideeffects are headaches, insomnia, convulsions, halluci-
1967 The IOC took action after the death of Tommy Simpson (due to the illegal taking of amphetamines) in the Tour de France 1968 The IOC decided on a definition of doping and developed a banned list of substances.Testing began at the Olympic games 1988 At the Seoul Olympics, Ben Johnson tested positive for a banned anabolic steroid, was stripped of his gold medal and was suspended for 2 years 1999 The World Conference on Doping in Sport held in Lausanne on 2–4 February 1999 produced the Lausanne Declaration on Doping in Sport.This document provided for the creation of an independent international antidoping agency to be fully operational for the Games of the XXVII Olympiad in Sydney. Pursuant to the terms of the Lausanne Declaration, the World Anti-Doping Agency was established on 10 November 1999 to promote and coordinate the fight against doping in sport internationally
nations and paranoia and ultimately death due to ruptured blood vessels in the brain, heart attacks, heart rhythm abnormalities and heat stroke. Chronic sideeffects consist of dyskinesia, compulsive and repetitive behaviors, schizophrenia and death from ruptured blood vessels throughout the body. Caffeine, even in moderate doses (– mg/kg body weight) that do not exceed the accepted amount of caffeine in the urine, will result in improved performance. Earlier results indicated that the primary effect of caffeine was to stimulate an increase in circulating
Ergogenic Aids and Pharmacologic Treatment Table .. Performance-enhancing drugs. Performance aim
Ergogenic agent or method
Endurance
Erythropoietin Blood doping Hemopure/oxyglobin Caffeine
Strength (Body composition)
Anabolic steroids Growth hormone Insulin-like growth factor 1 Beta-adrenergic
Central fatigue Restitution (Nervousness) (Pain)
Amphetamine Ephedrine/cocaine Beta-blockers ACTH/cortisol Local anesthetics Glucose/insulin Alcohol
Anti-test
Effect 5–15%
10–30%
3–5%
Diuretics Probenecid/epitestosterone Human choriogonadotrophin Saline infusion
catecholamines which in turn mobilized free fatty acids (FFA) from adipocytes and improved muscular fat metabolism, sparing glycogen stores and improving endurance performance . However, more recently it has been shown that other mechanisms are also active, in that an enhanced performance effect of caffeine can be demonstrated in the absence of changes in catecholamines, and is found even in sports lasting only – min where fat metabolism does not play any major role. The effect has also been demonstrated in vivo in spinal cord injured individuals who underwent electrical stimulation of paralyzed muscle indicating that effects were local on the muscle rather than related to the brain, epinephrine or fatty acid mobilization [].
Beta-2 agonists These drugs are used for treatment of asthma (see Chapter .) and do not improve aerobic performance in lung-healthy individuals. However, it has been documented that b-agonists administered orally have an anabolic effect. Clenbuterol increases muscle hypertrophy and decreases fat deposition in animals, and several studies on b2-agonists in humans have shown increased strength gains [].
Beta-blockers Table .. The IOC list of prohibited classes of substances and methods. I Prohibited classes of substances A Stimulants B Narcotics C Anabolic agents D Diuretics E Peptide hormones, mimetics and analogs II Prohibited methods A Blood doping B Pharmacologic, chemical and physical manipulation III A B C D E
Classes of substances prohibited in certain circ*mstances Alcohol Cannabinoids Local anesthetics Corticosteroids Beta-blockers
By reducing sympathetic activity b-blockers cause a marked reduction in the maximal heart rate and thus reduce V˙2 max by –% which is clearly unfavorable in the case of any components of a sport that demand circulatory loading. On the other hand, b-blockers have been shown to cause an improvement in pistol shooting, ski jumping and musical performance of –% [].
Anabolic androgen steroids These substances, especially the hormone testosterone, are the doping substances most widely used for improving muscle mass and strength in association with regular training. Initially evidence for its effect was minor, due to the use of very small doses, but later studies have confirmed a significant effect. Body composition changes, with increased fat-free mass and reduced body fat. Some of this effect can be seen even without training, but is relatively more pronounced when added to resistance training [–]. Doses used
Chapter . Table .. Overview of anabolic steroids. Drug
Administration
Side-effects
Comments
Testosterone esters
i.m. (in water) Subling/derm (oil)
Some risk of hepatotoxic and lipid effects Androgenic effects
Very potent, cleared rapidly
Stanozolol
Oral
Low hepatotoxic risk Very little fluid retention
Cleared slowly
Oxandrolone
Oral
Low androgen risk Very little fluid retention
Regarded as potent with few side-effects
Nandrolone
i.m. (in oil)
Low androgen risk
Regarded as potent with few side-effects
are variable depending upon the drug type, but it is not uncommon to use – mg/day for men and – mg/day for women. A study of female body builders who all had trained for years showed that those who took anabolic steroids intermittently for around years had markedly more muscle mass than the control group. Furthermore, reports on former German Democratic Republic athletes who took anabolic substances for several years estimated that improvements in already well trained athletes were up to –% with regard to throwing events in track and field []. Interestingly, women performing running distances of , and m also gained up to –% improvement. Finally, in a well-controlled study, weeks of mg/week testosterone enanthate administered to healthy young males resulted in markedly enhanced muscle growth in the group that received the drug []. Drug users often use a mixture of steroids, or have preference for specific types of steroids, e.g. testosterone enanthate, nandrolone decanoate, stanozolol, oxymetholone or oxandrolone. This is due to differences in the profile of the various drugs with regard to effect vs. side-effects, especially anabolic vs. androgenic effects. Whereas some substances have a low androgen side-effect and are thus preferred by women users, other drugs are cleared more rapidly from the body, lowering the risk of being caught in a doping test (Table ..). In general the side-effects associated with androgen abuse are three-fold: (a) hepatotoxic effects; (b) androgenic and reproductive side-effects; and (c) other effects on lipid and carbohydrate metabolism as well as
Table .. Side-effects associated with intake of anabolic steroids in well-trained athletes ( mg testosterone daily over months). Data from Alen et al. Int J Sports Med ; : –.
ASAT (U/L) Testicular volume LH (IU/L) Sperm count (millions/mL) HDL cholesterol (mmol/L) LDL cholesterol (mmol/L) Hct (%)
Before
3 months
30 ± 3 19 ± 2 5.0 ± 2.4 55 ± 15 1.5 ± 0.2 3.1 ± 0.5 45 ± 2
46 ± 7* 13 ± 1* 2.5 ± 2.1* 2* 0.6 ± 0.1* 4.1 ± 0.9* 48 ± 2*
ASAT, aspartate aminotransferase; LH, luteinizing hormone; HDL, high-density lipoproteins; LDL, low-density lipoproteins; Hct, hematocrit.
psychologic effects. As substances are metabolized in the liver and are often used in high doses, it is clear that toxic parenchymal effects on the liver can occur, and elevation of aminotransferases is one of the first signs of anabolic substance abuse (Table ..) []. In addition, liver pathology such as cholestasis, blood cysts and primary liver tumors are observed. Suppression of sex hormones as well as testicular atrophy and infertility can be observed after only months of abuse, and although these effects are thought to be reversible after drug use ceases, good long-term studies of chronic abusers are lacking. Male athletes often take human chorionic gonadotrophin (hCG) in order to maintain endogenous synthesis of substances needed for spermatogenesis. Administration of large amounts of
Ergogenic Aids and Pharmacologic Treatment testosterone can in males result in formation of estrogen and thus development of gynecomastia, and many male abusers take estrogen antagonists to counteract this. In women androgenous side-effects lead to virilization including a deepened voice, increased facial hair and cl*toral hypertrophy []. Hair loss including balding has been observed in both female and male athletes. Likewise skin problems with acne appear in a dose-dependent manner in both sexes. Changes in blood lipid profile are seen rapidly after androgen intake commences, and interestingly the cholesterol profile after months of use seems more unfavorable than in untrained healthy individuals []. Likewise a dramatic change in insulin sensitivity has been seen, providing the basis for development of glucose intolerance. Good studies are, however, lacking with regard to reversibility, as well as to any later development of cardiovascular disease and/or type II diabetes. Psychologic side-effects have been difficult to assess, but studies have suggested an increase in psychologic pathologies such as anxiety, psychosis, irritability, aggression and violent behavior []. The exact mechanisms are not obvious but could be related to changes in neurotransmitter systems or hypogonadism.
Diuretics These substances are used in sports where body weight is important such as wrestling, boxing, light-weight rowing and horse riding, and weight loss of several percent has been observed overnight, resulting in unfavorable dehydration and subsequent reduced performance (see Chapter .). Previously, diuretics were also used for diluting the urine in order to pass doping tests, but today the determination of the urine mass weight has stopped this.
Human growth hormone (hGH) and insulin-like growth factor (IGF-I) Intake of growth hormone (GH) has been used for years in the belief that it has an anabolic effect on skeletal muscle. It has been demonstrated that GH administration in GH-deficient individuals can improve fat-free body mass and thus muscle, and animal studies have documented a GH-mediated stimulation of muscle hypertrophy. In spite of this, there have been no studies robustly documenting any muscle massincreasing effect of GH in addition to strength training
in either untrained or well-trained individuals []. What has been shown is an enhancing effect of GH on lipid oxidation and thus on body composition. Growth hormone administration results in several side-effects, in both the short and long term. Immediate sideeffects are fluid accumulation in the legs and carpal tunnel syndrome, whereas impaired glucose metabolism (glucose intolerance), hyperlipidemia and cardiomegaly can develop with long-term misuse. IGF-I has become used as a doping substance but no good experiments have documented any major effect of its administration in relation to muscle growth and performance.
Erythropoietin (rhEPO) The development of erythropoietin in recombinant form to use in patients with anemia has led to it totally replacing blood doping as the doping choice in endurance athletes. It has been demonstrated in both untrained and well-trained athletes with normal hematocrit and hemoglobin values that rhEPO can increase hemoglobin concentration, endurance performance, maximal aerobic power and arterial pressure during exercise [–]. Improvements by rhEPO administration are similar to those seen previously with blood transfusion, and it is thus likely that improvements in real sports performance are equally as good as those achieved by blood transfusion (see also Classical reference). It has been documented that performance in cross-country skiing and -km running has been shown to be increased by –% up to – days after blood transfusion. More recently it has been shown in monkeys that genetic engineering was able to produce erythropoietin in muscle and that hematocrit rose. Unfortunately, the increase in hemoglobin production led to a rise to unacceptably high levels. However, the finding points to the fact that genetic doping could very well be used in the future for other categories of doping substances. Another area of interest for doping attempts is the production of stable hemoglobin without erythrocytes from bovine blood (hemopure, oxyglobin) which is being developed for emergency cases involving blood loss. Use of this formulation is expected to provide higher oxygen uptake and delivery capacity in athletes, and is likely to become a used substance within the next few years.
Chapter . Legal substances or procedures In addition to the doping substances described above, it is clear that legal approaches can also result in performance enhancement. With regard to endurance, it has been documented that altitude training, especially if training is carried out at a moderate altitude (~ m) and the rest of the time is spent at a somewhat higher altitude (~ m), can result in some marginal improvement. Furthermore, the use of artificial low-oxygen ‘altitude’ houses has been shown to increase Hb concentration and hematocrit, if sufficient time is spent in hypoxia (> – h). The improvement is, however, not as large as that seen with rhEPO. The intake of bicarbonate has been shown to result in a small improvement in performance of events such as the -m run where both aerobic and anaerobic systems are heavily taxed. One of the most debated substances lately has been creatine (Cr), and its performance-enhancing effects. Research indicates that Cr supplementation (initially g/day followed by – g/day) can increase muscle PCr content in some individuals. Exercise performance involving short periods of extremely powerful activity can be enhanced, especially during repeated bouts of activity [], whereas performance in aerobic exercise is not influenced. Furthermore, it has been demonstrated that Cr results in increased improvement of muscle strength with strength training but the mechanism behind this has not been discovered []. So far there are no documented gastrointestinal, renal or muscle side-effects associated with Cr intake.
Doping analyses Doping analyses have been used for doping control in a variety of sports for some years now []. National and international sports associations and their antidoping authorities are responsible for the selection of the athletes to be tested, for maintaining the testing organization and for handing down judgements. Athletes are tested at competitions and during training (out-of-competition tests). To ensure the quality and reliability of testing, the protocol of sample collection is clearly specified and standardized. At present in most sports, only urine is collected from an athlete as a doping sample. The sample is divided between two glass bottles, each of which bears a distinguishable code. To guarantee the security of processing and stor-
age of the test samples, the bottles are sealed and transported to the laboratory in special containers. The analysis itself has to rely on an adequate sample collection. In some countries certified quality systems for doping control based on ISO- series standards and International Anti-Doping Arrangement (IADA) standards for doping control have been established already and in several other countries quality certification is in progress. Analysis in all official doping control tests is carried out exclusively in doping control laboratories accredited by the IOC, at present in the world. The laboratories follow the guidelines and procedures set by the IOC. The accreditation must be reapplied for each year. In the near future, WADA, founded by the IOC and nations throughout the world in , will take the leadership in organizing and harmonization of worldwide doping control.
Methods of detection The requirements of the IOC for the accreditation of doping laboratories include sophisticated instrumentation. Most of the methods are based on gas chromatography and sensitive and selective detectors. Development of analytic techniques and instrumentation has been fast in recent years allowing ever better resolution, identification and detection of smaller and smaller amounts of analytes with sufficient certainty. High-resolution and tandem mass spectrometry, liquid chromatography combined with mass spectography (HPLC/MS) with various configurations and even gas chromatography/combustion/ carbon isotope ratio mass spectrometry (GC/C/ CIRMS) are coming into routine use [–]. The IOC list of banned substances consists of numerous compounds with a wide range of chemical structures. The actual laboratory analysis consists of two steps: screening and confirmation analysis. From seven to nine separate analytic procedures are needed to cover all banned substances. After screening, all suspected samples are reanalyzed by gas chromatography/mass spectrometry (GC/MS) to provide fully reliable results. Some peptide hormones with large molecules such as human chorionic gonadotrophin (hCG) are still detected by immunoassays since sufficiently sensitive mass spectrometry methods are not yet available.
Ergogenic Aids and Pharmacologic Treatment However, if appropriately standardized and validated methods are used, investigators should be able to detect self-administration of hCG in men as reliably as anabolic steroids and testosterone are now being detected by mass spectrometry methods []. Reliability of the doping result is of crucial importance. The consequence of a false finding of doping in an innocent athlete is personal disaster. Therefore, the ratio of true-positive to false-positive doping results must be extremely high. The personal opinion of the author is that .% of the cases decided as ‘doping’ should be true positive. Because approximately doping tests performed annually in the whole world yield more than positive findings the application of the .% principle would lead to false positive tests of one or two non-users throughout the world each year. All tests used for doping control purposes should be well validated. The positive predictive value (PPV) of the test can be estimated by routine measures using Bayesian rule [] provided that the sensitivity and specificity of the test have been studied. The accurate value is, however, hardly ever obtained since the relative number of drug users has a marked effect on PPV. IOC requirements for doping laboratories guarantee that the reliability of the doping tests is high in general. This in no way precludes the existence of various uncertainties in the test results (or in judgements).
Testing of some doping agents of interest Non-physiologic agents Misuses of central nervous system stimulants, narcotic analgesics and b-blocking agents are all controlled at competitions only, and are easily controlled by the present analytic techniques, e.g. []. Sensitivities of the assays are nearly % for these agents, and analyses are reliable and specific. The ion mass spectrum indicative of the parent drug or its metabolite detected from the sample can be considered as a fingerprint of the banned substance in the body. Since stimulants, narcotics and b-blocking agents are allowed to be used during the training period for therapeutic purposes there is a risk for careless athletes of stopping the treatment too late before the competition to give sufficient time for elimination of the drug from the body. Such cases do not lead to sanctions and
Table .. Summary of urinary concentrations above which IOC-accredited laboratories must report findings for specific substances. Caffeine Carboxy-THC Cathine Ephedrine Epitestosterone Methylephedrine Morphine 19-Norandrosterone 19-Norandrosterone Phenylpropanolamine Pseudoephedrine Testosterone/epitestosterone ratio
> 12 mg/mL > 15 ng/mL > 5 mg/mL > 5 mg/mL > 200 ng/mL > 5 mg/mL > 1 mg/mL > 2 ng/mL in males > 5 ng/mL in females > 10 mg/mL > 10 mg/mL >6
in order to decrease this risk the IOC has set limits for urinary concentrations of e.g. ephedrine and ephedrine derivatives for which the laboratories declare the results as negative (Table ..). Similar to this, morphine positive samples are reported to doping authorities only when the urinary morphine concentration exceeds a certain limit. The rationale for this is that several unbanned antidiarrheals and narcotics, e.g. codeine, are metabolized in part into morphine. Ingestion of poppy seeds may also be the reason for the existence of small amounts of morphine in urine. Caffeine which is daily consumed in many beverages and foods belongs to the list of prohibited substances. The definition of a positive result depends on the concentration of caffeine in urine. This concentration may not exceed mg/L. The restricted level is only occasionally exceeded by common habitual intake []. In any case, excretion of caffeine into urine shows large interindividual variation due to several factors including differences in genetically determined enzyme profile [,]. Before doping sanctions based on urinary caffeine concentrations can be considered reliable much more research is needed. Anabolic steroid agents are used during the training period and therefore out-of-competition tests are of utmost importance to reveal the users. Conventional urine testing for anabolic steroids reliably identifies either the banned drug, its metabolites or both by GC/MS [,]. Increased knowledge of their metabolism has made it possible to select metabolites with
Chapter . long elimination half-lives and different from naturally occurring steroids for monitoring. On the other hand, the recent development of high-resolution equipment has lowered the detection limit for these agents. Accordingly, the number of anabolic steroidpositive findings has clearly increased over the last few years. Moreover, very small amounts of nandrolone metabolites, which may be physiologic in certain conditions (e.g. pregnancy) can be detected nowadays and the IOC has set the maximum allowable urine concentrations for these substances. It is well known that use of anabolic androgenic steroids has a long-term influence on the production and excretion of various endogenous steroids. In looking at methods of broadening the time window of detection of anabolic androgen use, the influence of these steroids on the hormone to hormone ratios derived from the measurement of several endogenous steroid hormones and metabolites (‘urinary steroid profile’) has been considered (see []). It has been shown that when appropriately calibrated the chemometric evaluation of urinary steroid profiles makes a distinction between control and user groups and may delineate androgenic steroid users directly from the routine screening procedure []. Validation of the procedure and confirmation of the results may be laborious. Further, the procedure is extremely vulnerable to exogenous manipulation. Therefore, steroid profile and chemometric methods are not in official use.
Physiologic agents There are two possible strategies for revealing doping with an agent which naturally occurs or may occur in some physiologic conditions in the human body. The more laborious way to find the solution is to make quantitative determinations of the agent itself, e.g. growth hormone (GH), and of a number of potential ‘markers’ of its effects. In the case of GH such markers could be e.g. insulin-like growth factor (IGF-I) and IGF binding proteins. Measurements should be made in the blood and urine. Samples should be taken in rest and exercise situations from healthy subjects with varying demography and athletes representing different sports. The results should be submitted to extensive statistic modelling and analysis to obtain reference values or indexes with sufficient reliability to reveal the
exogenous use of the agent. The second way is more challenging: attempt to set up a method which allows discrimination between the endogenous and exogenous molecule. The current assay methods for testosterone do not distinguish synthetic (exogenous) testosterone from physiologic (endogenous) testosterone. Detection of doping with testosterone is based on measuring the testosterone to epitestosterone ratio (T/E) in urine by GC/MS []. The T/E ratio in healthy males who have not used testosterone is usually lower than or around .. Athletes who have a urinary T/E ratio > are suspected of testosterone doping. The difficult aspect of the T/E test is that a small number of males have been found with T/E ratios in the range – in the absence of testosterone administration [] and a strict application of the T/E > criterion would falsely classify these subjects as testosterone users. Attempts to distinguish testosterone users from non-users in this population have included measuring the urinary ratio of testosterone to luteinizing hormone, measuring serum testosterone/hydroxyprogesterone ratio, carrying out the ketoconazole test, measuring different ratios of testosterone and epitestosterone sulfate and glucuronide conjugates as well as measuring several ratios based on testosterone precursors and metabolites. At present, sports authorities do not act on the basis of a single result T/E > , instead additional tests are carried out on the suspected athlete to follow the changes in the T/E ratio which has been to found to be relatively stable in healthy drug-free males. Not only may the current methodology applied to reveal testosterone doping lead to erroneous reporting of cases in which the T/E ratio > might be natural due to a physiologic or pathologic condition, it may also miss the cases with urinary T/E < in which exogenous testosterone, alone or together with epitestosterone and/or hCG, might have been used. Therefore assays for exogenous testosterone would be more reliable if identification of injectable testosterone esters, occurring in the body only after the use of testosterone preparations, were possible. Recently, a promising method utilizing HPLC/ MS analysis of serum testosterone esters has been published []. With further development a method might be adopted in sports doping control provided that blood samples will be allowed to be collected.
Ergogenic Aids and Pharmacologic Treatment The most promising approach for confirming the abuse of exogenous testosterone is based on gas chromatography/combustion/carbon isotope ratio mass spectrometry (GC/C/CIRMS) in which the changes in carbon isotope ratios (13C/12C) of urinary testosterone, its precursors and metabolites are detected []. Synthetic testosterone is derived from chemical sources whilst physiologic testosterone is of natural origin with a much higher carbon isotope ratio. Accordingly, decreased isotope ratio is indicative to a great extent of the use of exogenous testosterone. High costs may restrict the adoption of this method into routine use, as well as the lack of knowledge of the effects of dietary habits, variability of different pharmaceutical batches, etc. on the results []. The pregnancy hormone human chorionic gonadotrophin (hCG) has so far been measured by commercial immunoassays. According to the IOC recommendations hCG should be determined by two different immunoassays. Since hCG-like immunoreactivity occurs at low concentration in the plasma and urine of normal healthy males the analyses are quantitative in nature. Some uncertainties are included in the different immunoassays because hCG occurs in various molecular forms including the intact hCG heterodimer, its free a and b subunits, proteolytically cleaved forms and fragments, and these different forms cross-react to various degrees in immunoassays. Therefore, in each laboratory the assay procedure for urinary hCG has to be validated carefully in control and athletic populations before running the tests routinely. After the appropriate validation the selfadministration of hCG can be reliably detected [] provided that pregnancy or diseases associated with endogenous hCG production are excluded. Although human growth hormone (hGH) is easily measured by simple immunoassays the fact is that there are currently no valid methods of detecting its abuse. Based on quantitative determination of urinary hGH by immunoassays detection of hGH doping would be feasible provided that urine samples could be obtained in the basal states without exogenous intake []. The problem is that renal clearance of the hGH increases drastically during strenuous effort preventing relevant interpretation of the results. GH- is a European multinational research project, the aim of which is to produce an indirect method of revealing
hGH doping by measuring hGH, growth factors, IGF binding protein and connective tissue metabolites as potential markers []. As for testosterone, the 13C/ 12 C isotope ratios have been measured for natural hGH and commercial recombinant rhGH products in an attempt to differentiate endogenous and exogenous origins of the hGH by high-performance liquid chromatography/isotope ratio mass spectrometry (HPLC/IRMS) []. However, only one preparation studied differed markedly from natural hormone in its carbon isotope ratio. Further, the low renal clearance of GH reduces the applicability of this concept. The assay might work better with serum GH. So far, there are no reliable methods available to reveal the abuse of hGH. Erythropoietin (EPO) is a physiologic glycoprotein hormone involved in the regulation of erythropoiesis. The pharmaco*kinetics and pharmacodynamics of recombinant human EPO (rhEPO) are well clarified []. The produced rhEPO is hom*ogenous with respect to the peptide sequence of natural EPO, but rhEPO contains heterogeneous carbohydrate moiety and this difference in carbohydrate structure is an important factor for identifying the administration of exogenous rhEPO [] as is the consequent difference in electric charges of natural EPO and rhEPO detectable by electrophoresis [,]. At the Sydney Olympic Games a combination of an indirect method utilizing blood samples [] and a direct method utilizing urine samples [] was used for the first time in a preliminary manner to reveal the use of rhEPO. Validation of methods reliable for doping control purposes is in progress.
Pharmacologic treatment of sports injuries The objective for medical treatment of sports injuries is primarily to shorten the rest period by reducing inflammation and pain so active rehabilitation can start as soon as possible before the deconditioning rest period has seriously reduced the physical properties of the soft tissues. Medical treatment is therefore only an adjuvant therapy in the overall management of sports injuries. The main treatment is ‘active’ rest and gradual rehabilitation within the limits of pain. If you are not familiar with the principles of rehabilitation, do not use medicine in the treatment of sports injuries.
Chapter . The indications for using medicine in sports medicine are (i) pain control: simple analgesics (e.g. paracetamol), non-steroid anti-inflammatory drugs (NSAIDs) and weak opioids (e.g. tramadol) and (ii) inflammation control: NSAIDs and corticosteroids.
when in the acute phase of a viral illness [,]. Fever indicates an infection and sports activity must be stopped and temperature normalized before resuming sports activity.
Administration Simple analgesics and weak opioids Indications Analgesics can be used to a limited extent to reduce the pain in minor injuries when there is no risk of aggravating the injury by continuing the sports activity, for example hematomas under nails and excoriations. Of course analgesics can be used to reduce all forms of pain if the sports activity is stopped. Because of its few side-effects paracetamol is recommended.
Pharmacodynamics Paracetamol has an analgesic and antipyretic effect. Mode of operation is partly unknown but it seems probable that it has both a peripheral and central component.
Paracetamol – g – times daily by oral administration. Rectal administration gives a slower but longer effect.
Conclusion Because of the very few side-effects of paracetamol it is recommended as the drug of choice in treatment of pain without inflammation.
NSAIDs NSAIDs are widely used in sports medicine (i) to control pain, (ii) as anti-inflammatory agents that presumably allow early activity that speeds the healing process, and (iii) to decrease inflammation presumably to speed healing directly.
Indications Pharmaco*kinetics Ninety per cent is absorbed and maximal plasma concentration of paracetamol is reached after .– h after oral administration. The duration of effect is – h. Only % of paracetamol is absorbed by rectal administration.
Adverse events In contrast to weak opioids and acetylsalicylate derivatives paracetamol at the recommended dose has virtually no side-effects [a].
Contraindications Analgesics should never be used to allow an athlete to continue a sports activity when there is a risk of aggravating the injury. Paracetamol and other analgesics with antipyretic effects must never be used to reduce the body temperature before sports activity. Several viral infections can invade heart muscle and produce myocarditis. This risk of myocarditis is increased in strenuous physical activity during the acute phase of viral infection, and there are reports of spontaneous death and serious complications occurring in previously fit young adults who undertake vigorous exercise
Tendon injuries. Several randomized, placebocontrolled short-term studies of NSAID treatment in acute tendon injuries have been done. Healing was slightly more rapid and inflammation slightly decreased in treated patients compared with placebotreated patients in most studies [–], while no effect was found in other studies [,], and some studies showed increased instability and reduced range of motion []. Acute muscular injuries (strains and contusions). Only a few animal studies [,], and a single double-blind, placebo-controlled human study [] are available. Increased contractile force was found in the NSAIDtreated muscles early following the injury, but the treatment was associated with a delayed degradation of damaged tissue later on and a delayed muscle regeneration. Similarly, muscle regeneration appeared to be slowed by the NSAID treatment. The human study showed no beneficial effect. Myositis ossificans. One study showed that ossifications after non-cemented total hip arthroplasty appeared significantly less frequently in patients postoperatively
Ergogenic Aids and Pharmacologic Treatment treated with anti-inflammatory drugs []. No studies concerning athletes exist. Chronic muscle and tendon injuries. There is no convincing scientific support in literature for using NSAID treatment in chronic muscle and tendon injuries [,].
Pharmacodynamics NSAIDs have analgesic, antipyretic and anti-inflammatory effects. NSAIDs act by inhibiting the synthesis of prostaglandins, which are capable of mediating the inflammatory response following injury by the enzyme cyclooxygenase (COX). Two isoforms are now recognized. COX-, which is constitutively expressed, sustains the routine physiologic function of prostaglandins, including gastric mucosal protection. COX- is induced chiefly in response to pathologic processes, including pain and inflammation. Prostaglandins synthesized by the inducible COX- isoform mediate acute inflammatory responses in animal models. NSAIDs are non-isoform specific, inhibiting both the COX- and COX- isoforms. Since prostaglandins are involved in the maintenance of gastrointestinal (GI) mucosal integrity and since only the COX- isoform is present in the normal GI mucosa, the GI toxicity of NSAIDs has been proposed to result largely from inhibition of COX- activity. The therapeutic effects of NSAIDs may be primarily attributable to COX- inhibition. By selective inhibition of the COX- enzyme it is possible to reduce inflammation almost entirely without serious GI side-effects. A recent animal study [] indicates that a new isoform of the enzyme cyclooxygenase (COX-) has anti-inflammatory activity equivalent to or greater than that seen with steroids [] and can be an important part of the regeneration process.
Pharmaco*kinetics All NSAIDs are almost completely absorbed after oral administration and the half-life in the body (t 1/2) is from a few hours to more than day.
Adverse events Adverse GI effects are frequently seen in patients who are given NSAIDs and include dyspepsia, nausea and ulcer. The new selective COX- inhibitors are
largely free of serious GI side-effects. Serious adverse events are rare, but anaphylactic shock, nephritis and aplastic anemia are described. Only very few sideeffects are associated with the use of topical NSAIDs (allergy).
Contraindications In healthy athletes only allergy is a contraindication. Be careful with ulcer disease, hypertension and insufficiency of the kidney, heart and liver.
Administration Oral administration is recommended. A few placebocontrolled studies [–] all suggest that topical NSAIDs may indeed be significantly better than placebo in treating acute injuries although the blood concentration after topical administration will reach less than % of levels after oral or intramuscular administration []. There is no scientific support in literature for using intramuscular administration. No scientifically based conclusion as to the ideal time to start and the ideal duration of NSAID treatment can be drawn.
Discussion It remains controversial whether inhibiting the acute inflammatory response is of uniform advantage. Pain and disability following the injury are at least in part due to the inflammatory response. Decreasing the inflammation decreases the symptoms and may allow earlier rehabilitation. On the other hand, inflammatory cells are responsible for clearing away cell debris and necrotic muscle fibers. Without this phagocytic function healing, in particular regeneration, may not be able to begin. Studies involving anabolic steroids (which are not allowed in sport) and muscle injuries have found increased numbers of progenitor cells [a] and more rapid healing and restoration of force []. Interestingly, both studies found this was associated with an initial increase in inflammatory cells. This suggests that the initial inflammatory response is indeed a crucial part of the healing response. The future will show whether the new isoform of the enzyme cyclooxygenase (COX-) can be an important part of this regeneration process. Inhibiting the enzyme cyclooxygenase can theoretically result in a reduced spontaneous regeneration after an injury.
Chapter . Conclusions Although several clinical trials indicate that treatment with NSAIDs has some effect in sports injuries it is not clear that the difference between NSAIDs and placebo is clinically significant and clear-cut indications cannot be given. The indication for suppressing the acute inflammatory response is questionable. Theoretically it could reduce regeneration of the injured tissue. Adverse events after oral NSAIDs are common, but rarely serious. With this background it does not seem reasonable to recommend the use of NSAIDs routinely in acute muscle and tendon injuries. If treatment with NSAIDs is indicated, topical administration is recommended whenever possible. When systemic treatment is indicated it seems rational to use a COX- inhibitor because of the fewer side-effects although there is no documentation of the effect in athletes. If treatment with NSAIDs is misused as a ‘pain killer’ in order to send athletes back to full sport activity without rehabilitation and correction of training failures the medical treatment can indirectly result in a chronic injury.
Other pharmaceutical agents Systemic injected heparin has been used in the treatment of peritendinitis crepitans. At the moment there is little scientific basis for this treatment [] and the adverse events are so serious that the treatment cannot be recommended []. Local injections of polysulfated glycosaminoglycan [], one of the constituents of the base substance, and the protease inhibitor aprotinin [], have been used in the management of peri- and intratendinous pathologies. For these experimental treatments also there is currently little scientific basis.
Corticosteroids No legal treatment in sport has been so controversial as local injected corticosteroids. Intratendinous injection of corticosteroid has resulted in some animal studies in a directly deleterious effect on the tendon [–], and should be unanimously condemned. Obviously not all studies agree [–]. No proof of any deleterious effect of peritendinous injections exists in the literature [–]. Generally the literature concerning injection of local corticosteroids is very sparse and too many conclusions are based on poor scientific evidence.
Injection of corticosteroids is used in sports medicine: (i) to decrease acute inflammation in bursitis, tendovaginitis and peritendinitis; and (ii) to reduce the deleterious effect of chronic inflammation in chronic overuse symptoms.
Indications Arthritis. Intra-articular injected corticosteroid is one of the most widespread treatments in rheumatology. Placebo-controlled studies have proved the effectiveness of the treatment in arthritis [,]. Chronic tendinopathy. There are only very few randomized, placebo-controlled studies concerning the effect of local corticosteroids and chronic tendon injuries, but some effect has been recognized in the treatment of tennis elbow [,], rotator cuff tendinitis [] and plantar fasciitis []. Often the effect has been of short duration. Newer randomized, doubleblind, placebo-controlled studies [a,b] have shown a significant effect of ultrasound-guided peritendinous injection of long-acting corticosteroids in athletes with the most severe ultrasonography-verified jumper’s knee or Achilles tendinopathy. Despite having had symptoms for an average of 1/2 years % of the athletes were free of symptoms after months but only % were free of symptoms after months. The increased tendon diameter and the edema evaluated by ultrasonography were highly significantly reduced every week for the first weeks following an injection despite the fact that the tendons were never totally normalized after the maximum of three peritendinous corticosteroid injections. The high frequency of relapse of symptoms in the study can be explained by the very aggressive training involving starting running a few days after injection. Another explanation could be the degenerative changes in the tendon. Although there is only sparse documentation of inflammatory cells in biopsies from chronically affected tendons the significant reduction in edema and thickness of the treated tendons is most likely due to a reduction in the inflammatory process. The corticosteroid seems to reduce the inflammation and edema of the tendon, but steroid cannot, however, repair the degenerative changes. When maximal training intensity is resumed the degenerative changes will cause relapse of the inflammation. A third explanation of the relapse
Ergogenic Aids and Pharmacologic Treatment of symptoms could be the limited duration of the steroid effect. Peritendinitis. A retrospective study reported significant reduction in pain after corticosteroid injection for peritendinitis []. No controlled studies exist. Myositis ossificans. One article has reported seven cases demonstrating the beneficial effect of local corticosteroid injection in myositis ossificans []. No controlled studies exist. Bursitis. The effect of injected corticosteroid in bursitis is safe but sparsely documented []. Muscle strain. To date, there are no reported human or animal studies where corticosteroids have been injected locally into strained muscle.
Pharmacodynamics The mechanism of the anti-inflammatory action of corticosteroid is not completely understood, but corticosteroids inhibit both the early vascular phase of inflammation and the late inflammatory and regenerative phase. Corticosteroids seem to modulate the inflammation not only through an effect on prostaglandin production but also by modulating the cytokine activity in both the parenchymal tissue and the cellular components.
above mentioned study [a,b] where Achilles and patellar tendons were injected, nearly % had atrophy, which disappeared in most cases after months and in no cases caused embarrassing symptoms. Generally this atrophy seems to do little harm and recedes with time. Systemic effects from the corticosteroid are only a theoretical risk. Although locally injected corticosteroids are designed to be most effective where they are injected, a proportion of the substance penetrates to the bloodstream, and flushing, menstrual disturbances and fluctuations in blood glucose have been reported. Anaphylactic shock is a theoretical complication which doctors must be prepared to treat since cortisone allergy is a rare but possible form of allergy. Unintended injection in total or partial ruptured Achilles tendons is not unheard of [,]as the diagnosis can be difficult without ultrasonography and it is impossible to feel the erroneous intratendinous injection in degenerated tendons (see Figs ..–..). Unintentional damage to other structures is minimized when ultrasound-guided injections are used. The doping supervisors must be informed if the athlete is chosen for doping control during the weeks following an injection.
Pharmaco*kinetics Most preparations are microcrystallic suspensions of glucocorticoid esters. The less soluble the preparation the longer the duration of effect and the higher the risk of systemic effect. The long-acting corticosteroid triamcinolone has effects lasting for weeks.
Adverse events Introduction of infection is a possible adverse effect when using local steroid injection therapy. However, this risk can be almost completely eliminated by using a meticulous aseptic, no-touch technique, and by avoiding injections in areas with suspected infection. Atrophy of the overlying skin with telangiectasia and increased hyperesthesia or hypoesthesia and transparency or subcutaneous fat necrosis is often seen when subcutaneous structures are injected. In the
Fig. .. Athlete with jumper’s knee before injection. The erroneous placement of the needle inside the thick inflamed tendon is seen. The black arrows show the superficial border of the inflamed patellar ligament. The white arrows show the needle.
Chapter . Administration
Fig. .. The same athlete as in Fig. .. before injection. After correction the correct peritendinous placement of the needle is seen. The white arrows show the needle.
Dilute the corticosteroid with local anesthetic before the injection. The diluted solution decreases the risk of adverse effects, and the anesthetic-induced disappearance of pain helps to confirm the diagnosis. The literature on the comparative efficacy of different preparations, doses and number of injections is scanty [,]. Price et al. [] concluded in a double-blind study that more rapid relief of symptoms of tennis elbow was achieved with mg triamcinolone than with mg hydrocortisone and there was less need to repeat injections in the former group, and Vogel [] showed an increase in the tensile strength of tendons after corticosteroid injections, but repetition of injections progressively weakened the tendons, suggesting a relationship between cumulative dose and the adverse effect. Systemic treatment with corticosteroids is not allowed in sports and no studies in the literature find any beneficial effects of this treatment. Corticosteroids may also be delivered with phonophoresis or iontophoresis [,]. The literature is also unclear concerning the efficacy and potential side-effects when corticosteroids are used in this manner. These are common physical therapy modalities used especially to treat some of the most chronic problems in athletes, such as tendinopathy or bursitis.
Discussion
Fig. .. The same athlete as in Fig. .. after injection. The injection fluid is seen peritendinous. The white arrows show the peritendinous corticosteroid and local anesthesia.
Contraindications Avoid injection in areas with suspected infection. Active tuberculosis is an absolute contraindication. There is not enough practical or scientific experience with local injection with corticosteroids in children. Injecting children for sports injuries is almost never indicated.
Peritendinous injection of corticosteroids can be used as an adjuvant therapy of severe chronic tendon injuries. The main treatment is of course ‘active’ rest and gradual rehabilitation for several months within the limits of pain. Only when the injured structure is trained to withstand the maximal stress, should full sports activity be allowed. If the athlete does not follow the rules for graduated rehabilitation over several months after a chronic injury and returns to full sports activity before the weakened tissue is strong enough, there is of course a risk of rupturing the tissue. Incorrect rehabilitation is obviously the greatest risk in treating athletes with local corticosteroid injections. It is necessary to verify the diagnoses by ultrasonography (or MRI) and make the injection under ultrasonographic guidance especially when the big tendons are being treated (Achilles and patellar tendons and the
Ergogenic Aids and Pharmacologic Treatment plantar fascia). If there is no effect from one ultrasound-guided steroid injection there is no indication for a second (or third) injection. If there is a partial effect it might be reasonable to repeat the injection once or twice at –-week intervals.
Conclusions Local injection of corticosteroids seems to be an effective treatment in acute bursitis, tenosynovitis, peritendinitis, plantar fasciitis and (traumatic) arthritis even though the documentation is sparse. Performed where indicated, on the basis of an ultrasonography-verified diagnosis, ultrasoundguided peritendinous injection with a long-acting corticosteroid is safe and can be a powerful supplement to the basic rehabilitation of severe chronic tendon injuries when normal conservative rehabilitation has failed. If the treatment is misused to send athletes back to full sport after a few weeks the medical treatment can indirectly result in chronic injuries.
Summary Medical treatment is only an adjuvant therapy in the overall management of sports injuries. On the basis of a correct diagnosis and indication medical treatment can reduce the deconditioning rest period so that active rehabilitation can start as soon as possible before the physical properties of the soft tissues are seriously impaired. Before full participation in sports activities a period with gradual increased rehabilitation with respect for pain is necessary to reduce the risk of relapse of symptoms. Without this period of active rehabilitation medical treatment can be misused and increase the risk for chronic injuries. The use of ergogenic aids is subject to doping regulations, and urine analysis provides the basis for detection of several doping agents. In endurance sports use of erythropoietin (–% improvement) and in power sports anabolic steroids (–% improvement) is documented to improve performance but simultaneously to cause major side-effects.
d intra-articular injection e peritendinous injection. In chronic tendinopathy in the groin unalleviated by rest and graduated training it seems reasonable to try the following medical treatment: a paracetamol b weak opioids c heparin d NSAIDs e local injected steroid. Why should ultrasound be used when local steroid injection is planned? a For correct diagnosis. b To decrease the risk of unintended puncture of vessel and nerves. c To decrease the risk of erroneous intratendinous injection. d To decrease the risk of skin atrophy. e To allow evaluation of the effect of treatment. What are the documented risks after a peritendinous injection of corticosteroid? a Skin atrophy. b Tendon rupture. c Adrenal suppression. d Fat necrosis. e Unintended injection in other structures. What are possible facts concerning acute inflammation after injury? a It is necessary for clearing away cell debris and necrotic muscle fibers. b It is necessary for regeneration and healing. c It causes pain. d Treatment with anti-inflammatory drugs reduces the risk for myositis ossificans (after hip arthroplasty). e When left unchecked it can lead to a chronic situation and destruction of tendons and surrounding tissue resulting in ruptures of tendons, scar tissue and adherence.
References
Multiple choice questions a b c
Corticosteroids can be administered in sport as a: tablet suppository intramuscular injection
Clarkson PM, Thomson HS. Limits to research on drugs and sport. In: Reilly T, Orme M, eds. The Clinical Pharmacology of Sport and Exercise. Amsterdam: Excerpta Medica, : –. Graham T. The possible actions of methylxantines on various tissues. In: Reilly T, Orme M, eds. The Clinical Pharmacology of Sport and Exercise. Amsterdam: Excerpta Medica, : –.
Chapter .
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Mueller RK, Grosse J, Lang R, Thieme D. Chromatographic techniques — the basis of doping control. J Chromatogr B (Biomed Appl) ; : –. Aguilera R, Becchi M, Casabianca H, Hatton CK, Catlin DH, Starcevic B, Pope HG Jr. Improved method of detection of testosterone abuse by gas chromatography/ combustion/isotope ratio mass spectrometry analysis of urinary steroids. J Mass Spectrometr ; : –. Stenman U-H, Unkila-Kallio L, Korhonen J, Alfthan H. Immunoprocedures for detecting human chorionic gonadotropin. clinical aspects and doping control. Clin Chem ; : –. Pauker SG, Kassirer JP. Decision analysis. N Engl J Med ; : –. Tarnopolsky MA. Caffeine and endurance performance. Sports Med ; : –. Ullrich D, Compagnone D, Mûnch B, Brandes A, Hille H, Bircher J. Urinary caffeine metabolites in man. Age-dependent changes and pattern in various clinical situations. Eur J Pharmacol ; : –. Vistisen K, Poulsen E, Loft S. Foreign compound metabolism capacity in man measured from metabolites of dietary caffeine. Carcinogenesis ; : –. Catlin DH, Cowan DA, de la Torre R, Donike M, Fraisse D, Oftebro H, Hatton CK, Starcevic B, Becchi M, de la Torre X, Norli H, Geyer H, Walker CJ. Urinary testosterone (T) to epitestosterone (E) ratios by GC/MS. . Initial comparison of uncorrected T/E in six international laboratories. J Mass Spectrometr ; : –. Schänzer W. Metabolism of androgenic steroids. Clin Chem ; : –. Norli HR, Esbensen K, Westad F, Birkeland KI, Hemmersbach P. Chemometric evaluation of urinary steroid profiles in doping control. J Steroid Biochem Molec Biol ; : –. Schackleton CHL, Chuang H, Kim J, de la Torre X, Segura J. Electrospray mass spectrometry of testosterone esters: potential for use in doping control. Steroids ; : –. Abramson FP, Osborn BL, Teffera Y. Isotopic differences in human growth hormone preparations. Anal Chem ; : –. Saugy M, Cardis C, Schweizer C, Veuthey J-L, Rivier L. Detection of human growth hormone doping in urine: out of competition tests are necessary. J Chromatogr B (Biomed Appl) ; : –. Kickman AT, Miell JP, Teale JD, Powrie J, Wood PJ, Laidler P, Milligan PJ, Cowan DA. Serum IGF-I and IGF binding proteins and as potential markers of doping with human GH. Clin Endocrinol ; : –. Soullaird A, Audran M, Bressolle F, Gareau R, Duvallet A, Chanal J-L. Pharmaco*kinetics and pharmacodynamics of recombinant human erythropoietin in athletes. Blood sampling and doping control. Br J Clin Pharmacol ; : –. Choi D, Kim M, Park J. Erythropoietin. physico- and
Ergogenic Aids and Pharmacologic Treatment
a
biochemical analysis. J Chromatogr B (Biomed Appl) ; : –. Wide L, Bengtsson C, Berglund B, Ekblom B. Detection in blood and urine recombinant erythropoietin administered to healthy men. Med Sci Sports ; : –. Lasne F, de Ceaurriz J. Recombinant erythropoietin in urine. Nature (Brief Comm) ; : (): –. Garcia Rodriguez LA, Hernandez-Diaz S. Relative risk of upper gastrointestinal complications among users of acetaminophen and non-steroidal anti-inflammatory drugs. Epidemiology ; : –. Roberts JA. Viral illnesses and sports performance. Sports Med ; : –. Friman G, Ilbäck NG. Acute infection. metabolic responses, effects on performance, interaction with exercise, and myocarditis. Int J Sports Med ; : –. Blazina ME. Oxyphenbutazone as an adjunct to the conventional treatment of athletic injuries. Clin Med : . van Marion WF. Indomathacin in the treatment of softtissue lesions: a double-blind trial against placebo. J Int Med Res ; : –. Hutson MA. A double-blind study comparing ibuprofen mg or mg daily and placebo in sports injuries. J Int Med Res ; : –. Bahamonde SLA, Saavedra CH. Comparison of the analgesic and anti-inflammatory effects of diclofenac potassium versus piroxicam versus placebo in ankle sprain patients. J Int Med Res ; : –. Slatyer MA, Hensley MJ, Lopert R. A randomized controlled trial of pirioxicam in the management of acute ankle sprain in Australian regular army recruits. Am J Sports Med ; : –. Huskisson EC, Berry H, Strect FG. Indomethacin for soft-tissue injuries: a double-blind study in football players. Rheumatol Rehabil ; : –. Fredberg U, Hansen PA, Skinh¢j A. Ibuprofen in the treatment of acute ankle joint injuries: a double-blind study. Am J Sports Med ; : –. Obremsky WT, Seaber AV, Ribbeck BM. Biomechanical and histologic assessment of a controlled strain injury treated with piroxicam. Am J Sports Med ; : –. Almekinders LC, Gilbert JA. Healing of experimental muscle strains and the effect of non-steroidal antiinflammatory medication. Am J Sports Med ; : –. Reynolds JF, Noakes TD, Schwellnus MP. Non-steroidal anti-inflammatory drugs fail to enhance healing of acute hamstring injuries with physiotherapy. S Afr Med J ; : –. Kjaersgaard Andersen P, Sletgaard J, Gjerl¢ff C, Lund F. Location of ectopic bone and the influence of postoperative antiinflammatory treatment. Clin Orth ; : –. Adebajo AOP, Nash P, Hazleman BL. A prospective double blind dummy placebo controlled study comparing tri-
a
amcinolone hexacetonide injection with oral diclofenac mg tds in patients with rotator cuff tendinitis. J Rheumatol ; : –. Astrom M, Westlin N. No effect of piroxicam on achilles tendinopathy: a randomized study of patients. Acta Orthop Scand ; : –. Willoughby DA, Moore AR, Colville-Nash PR. COX-, COX-, and COX- and the future treatment of chronic inflammatory disease. Lancet ; : –. Willis D, Moore AR, Frederick R, Willoughby DA. Heme oxygenase: a novel target for the modulation of the inflammatory response. Nat Med ; : –. Russel AL. Pirioxicam .% topical gel compared to placebo in the treatment of acute soft tissue injuries: a doubleblind study comparing efficacy and safety. Clin Invest Med ; : –. Thorting J, Linden B, Berg R. A double-blind comparison of naproxen gel and placebo in the tretment of soft tissue injuries. Curr Med Res Opin ; : –. Ginsberg F, Famaey JP. Double-blind, randomized crossover study of the percutaneous efficacy and tolerability of a topical indomethacin spray versus placebo in the treatment of tendinitis. J Int Med Res ; : –. Dominkus M, Nicolakis M, Kotz R. Comparison of tissue and plasma levels of ibuprofen after oral and topical administration. Arzneimihelforschung ; : – . Beiner JM, Jokl P, Cholewicki J. The effects of anabolic steroids and corticosteroids on healing of a muscle contusion injury. Am J Sports Med ; : –. Sloper JC, Pegmm GD. Regeneration of crushed mammalian skeletal muscle and the effect of steroids. J Pathol Bacteriol ; : –. Larsen AI, Egfjord M, Jelsdorff HM. Low-dose heparin in the treatment of calcaneal peritendinitis. Scand J Rheumatol ; : –. Rydholm U, Rööser B, Lidgren L. Risk for severe hemorrhagic complication in heparin treatmeat of peritendinitis. Lähartidningen ; : –. Sundqvist H, Forsskahl B, Kvist M. A promising novel therapy for achilles peritendinitis. double-blind comparison of glycosaminoglycan polysulfate and high-dose indomethacin. Int J Sports Med ; : –. Capasso G, Testa V, Maffulli N. Aprotinin, corticosteroids and normosaline in the management of patellar tendinopathy in athletes: a prospective randomized study. Sports Exerc Injury ; : – –. Noyes FR, Nussbaum NS. Biomechanical and ultrastructural changes in ligaments and tendons after local corticosteroid injections. J Bone Joint Surg ; A: –. Kennedy JC, Baxter R. The effects of local steroid injections on tendon: a biomechanical and microscopic correlative study. Am J Sports Med ; : –. Kapetanos G. The effect of the local corticosteroids on the healing and biomechanical properties of the partially injured tendon. Clin Orth ; : –.
Chapter .
Phelps D, Sonstegard DA, Mathews LS. Corticosteroid injection effects on the biomechanical properties of rabbit patellar tendons. Clin Orth ; : –. Mackie JW, Goldin B, Foss ML, co*ckrell JL. Mechanical properties of rabbit tendons after repeated antiinflammatory steroid injections. Med Sci Sports ; : –. Matthews LS, Sonstegard DA, Phelps DB. A biomechanical study of rabbit patellar tendon: Effects of steroid injection. J Sports Med ; : –. McWhorter W, Francis RS, Heckmann RA. Influence of local steroid injections on traumatized tendon properties: a biomechanical and histological study. Am J Sports Med ; : –. Fredberg U. Local corticosteroid injection in sport. Review of literature and guidelines for treatment. Scand J Med Sci Sports ; : –. Read MTF. Safe relief of rest pain that eases with activity in achillodynia by intrabursal or peritendinous steroid injection: the rupture rate was not increased by the steroid injections. Br J Sports Med ; : –. Gudeman SD, Eisele SA, Heidt RSJ, Colosimo AJ, Stroupe AL. Treatment of plantar fasciitis by iontophoresis of .% dexamethasone. A randomized, double-blind, placebo-controlled study. Am J Sports Med ; : –. Luukkainen R, Nissilä M, Asikainen E, Sanila M, Lehtinen K, Alanaatu A. Periarticular corticosteroid treatment of the sacroiliac joint in patients with seronegative spondylarthropathy. Clin Exp Rheumatol ; : –. Price R, Sinclair H, Heinrich T, Gibson T. Local injection treatment of tennis elbow — hydrocortisone, triamcinolone and lignocaine compared. Br J Rheumatol ; : –. Day BH, Govindasamy N, Patnaik R. Corticosteroid injec-
tions in the treatment of tennis elbow. Pract Med ; : –. Petri M, Dobrow R, Neiman R. Randomized, doubleblind, placebo-controlled study of the treatment of the painful shoulder. Arthritis Rheum ; : –. a Pfeiffer-Jensen M, Fredberg U, Clemmensen D, Bolvig L, Jacobsen BW, Stengaard-Pedersen K. Pain assessment in inflamed tendons before and after placebo and local glucocorticoid treatment. Scand J Rheumatol ; S: . b Fredberg U, Pfeiffer-Jensen M, Bolvig L, Clemmensen D, Jacobsen BW, Stengaard-Pedersen K. Ultrasonographic visualisation and pain assessment of inflamed tendons before and after local glucocorticoid treatment. Arthritis Rheum ; : . Molloy JC, McGuirk RA. Treatment of traumatic myositis ossificans circ*mscripta: use of aspiration and steroids. J Trauma ; : –. Smith DL, McAfee JH. Treatment of non-septic olecranon bursitis. A controlled, blinded prospective trial. Arch Intern Med ; : –. Vogel HG. Correlation between tensile strength and collagen content in the rat skin; effect of age and cortisol treatment. Connective Tissue Res ; : –. Byl NN, McKenzie A, Halliday B, Wong TO, Connell J. The effects of phonophoresis with corticosteroids: a controlled pilot study. J Orth Sports Phys Ther ; : –. Martin DF, Carlson CS, Berry J, Reboussin BA, Gordon ES, Smith BP. Effect of injected versus iontophoretic corticosteroid on the rabbit tendon. South Med J ; : –. Ljungqvist R. Subcutaneous partial rupture of the Achilles tendon. Acta Orthop Scand Suppl : . Shields CL. The Cybex II evaluation on surgical repaired Achilles tendon ruptures. Am J Sports Med ; : –.
Part 3 Physical Activity: Health Achievements vs. Sports Injury
Chapter 3.1 Epidemiology and Prevention of Sports Injuries ROALD BAHR, PE KKA KANNUS & WILLEM VAN ME CHE L E N
Ekstrand J, Gillquist J, Liljedahl SO. Prevention of soccer injuries. Supervision by doctor and physiotherapist. Am J Sports Med ; : –. This study is recognized as the first randomized controlled trial (RCT) examining the effects of an injury prevention program in sports. Ekstrand and his coworkers used the classic four-sequence injury prevention approach in a series of studies. Firstly, they described the magnitude of the problem of soccer injuries in terms of their incidence and severity, demonstrating an incidence of . injuries per practice-hours and . per game-hours. Secondly, they described risk factors and injury mechanisms in their cohort. Among several factors identified in their first studies, the content of the warm-up the teams used appeared to be inadequate, previous injury and persistent instability was a significant risk factor for reinjury to the ankle and knee, and traumatic lower leg injuries occurred in players with inadequate or no shin guards. The two final steps in the injury prevention sequence, introducing measures that are likely to reduce the risk of injuries and evaluating the effect of these measures, were completed in the RCT described in this ‘Focus on Research’. Twelve teams ( players) in a male senior soccer division were followed for the first months of the and seasons. Between these two observation periods, the teams were allocated at random to two groups of six teams, one being given a prophylactic program and the other serving as control. The program was based on previous studies of
injury mechanisms. It comprised: (i) correction of training; (ii) provision of optimum equipment; (iii) prophylactic ankle taping; (iv) controlled rehabilitation; (v) exclusion of players with grave knee instability; (vi) information about the importance of disciplined play and the increased risk of injury at training camps; and (vii) correction and supervision by doctor(s) and physiotherapist(s). The six control teams had a mean of . injuries per month during the first months of , an incidence equal to the mean for all teams in the division during the same period in . After the introduction of the prophylactic program, the six test teams reduced the incidence to . injuries per month in , which was % less than in the control group (P < .). The most common types of soccer injuries, sprains and strains to ankles and knees, were all significantly re-
No. of injuries per month and team
Classical reference
4 Control teams (n = 6)
3
2
Test teams (n = 6)
All teams (n = 12)
1
1
2
3
4
1980
5
6
1
2
3
4
5
6
1981
Fig. .. In this landmark study, the injury rate was reduced by 75% through simple preventive measures.
Chapter . duced. Ekstrand and coworkers concluded that the prevention program, including close supervision and correction by doctors and physiotherapists, significantly reduces soccer injuries. This landmark study has served as a model in this research area, and most of the elements in their prevention program have been incorporated into the training program of Scandinavian soccer clubs.
Introduction A physically active lifestyle and active participation in sports and physical activity is important for all age groups. Reasons to participate in sports and physical activity are many, such as pleasure and relaxation, competition, socialization, and maintenance and improvement of fitness and health. However, sports participation also entails a risk for overuse injuries as well as acute injuries, which may even lead to death or permanent disability. In the following chapters the health benefits of exercise across the lifespan for both healthy and disabled persons are discussed. This chapter describes some current concepts regarding sports injury epidemiology, as well as the general principles for injury prevention research. The chapter will focus mainly on Scandinavian team sports and use examples from research performed in the region to describe the range of injuries that may be expected in this area. Also, these examples will illustrate some of the limitations that apply when interpreting research in this area. Finally, since potential injury prevention strategies may differ considerably between sports, it is not possible to describe practical preventive strategies for specific sports within the confines of the present chapter. However, some models will be presented and examples will be given from randomized controlled trials (RCTs) to illustrate the principles involved when trying to prevent injuries. These models may, in turn, be applied to the specific sport in question by the clinician. First, a different question will be addressed: do the health benefits of regular exercise outweigh the risk of injury and long-term disability, especially in highperformance athletes? Sarna et al. have studied the incidence of chronic disease and life expectancy of Finnish male world-class athletes[]. Finnish team members in the Olympic games, World or European championships or intercountry competitions from
to in track and field athletics, cross-country skiing, soccer, ice hockey, basketball, boxing, wrestling, weight-lifting and shooting were compared with a reference cohort of men selected from the Finnish Defence Forces conscription register, all classified as completely healthy at the time of induction to military service. The mean life expectancy adjusted for occupational group, marital status and the age at entry to the cohort was . years in endurance sports (longdistance running and cross-country skiing), . years in team games (soccer, ice hockey, basketball) and jumpers and short-distance runners from track and field, . years in power sports (boxing, wrestling, weight lifting, and throwers from field athletics), and . years in the reference group. The increased mean life expectancies were mainly explained by decreased cardiovascular mortality. These results are corroborated by a second study from the same group by Kujala et al. [] where they investigated the postcareer use of hospital care from all causes in the same groups based on national hospital discharge registry data. Compared with controls, the rate ratios for all-cause hospital care were lower in athletes from endurance sports, mixed sports (including endurance and weight training) and power sports compared with the reference group. The lower rate of hospitalization among athletes was largely explained by lower rates of hospital care for heart disease, respiratory disease and cancer. However, the rate of hospitalization for musculoskeletal disorders was higher in all groups of athletes than the control group. This may be partly explained by the increased risk of osteoarthritis in former elite athletes []. In other words, former elite athletes, particularly those in aerobic sports, live longer, and while they need less overall hospital care, they suffer more from frequent musculoskeletal problems. These health benefits cannot be attributed to their athletic career alone, but may in part be explained by the fact that elite athletes are healthier than the controls already at baseline (selection bias), and are likely to maintain a physically active lifestyle in later life. Also, it is important to keep in mind that the intensity of training and competition in sports has increased several-fold over the last two decades. This means that acute injuries as well as longterm musculoskeletal problems are likely be more prevalent and more severe today than > years ago.
Epidemiology and Prevention of Sports Injuries However, the benefits in terms of increased longevity and reduced morbidity due to reduced risk of cardiovascular disease in athletes may be even greater today, when contrasted to the gradually more sedentary lifestyle observed in the general population. Undoubtedly, there is an increased risk of shortand long-term musculoskeletal problems associated with physical activity, particularly in competitive sports. As sports medicine professionals and promoters of sports and physical activity from a health perspective, we have an obligation to make sports participation as safe as possible. In order to reduce the risk of injury associated with sports, it is necessary to use advances in the epidemiology of sports injuries as a basis for sports policy. In order to set out effective prevention programs, epidemiologic studies need to be done on incidence, severity and etiology of sports injuries. Also, the effect of preventive measures needs to be evaluated as they are introduced.
The sequence of prevention Measures to prevent sports injuries do not exist in isolation. They form part of what might be called a sequence of prevention [] (Fig. ..). First, the magnitude of the problem must be identified and described in terms of incidence and severity of sports injuries. Second, the risk factors and injury mechanisms that play a part in the occurrence of sports injuries must be identified. The third step is to introduce measures that are likely to reduce the future risk and/or severity of sports injuries. Such measures should be based on information about the etiologic factors and the injury mechanisms as identified in the second step. Finally, the effect of the measures must
1. Establishing the extent of the injury problem • incidence • severity
2. Establishing etiology and mechanism of sports injuries
4. Assessing its effectiveness by repeating step 1
3. Introducing a preventive measure
Fig. .. The sequence for prevention of sports injuries [].
be evaluated by repeating the first step, which will lead to so-called time-trend analysis of injury patterns. However, from an epidemiologic standpoint it is preferable to evaluate the effect of preventive measures by means of an RCT. Unfortunately, relatively few RCTs have been conducted in sports injury prevention studies [–].
The magnitude of the problem One way of getting an impression of the magnitude of the sports injury problem is by counting the absolute number of injuries. When these absolute numbers are compared with, for instance, the number of traffic accidents or the number of work-related injuries the relative extent of the sports injury problem can be revealed. Table .. shows data from selected communitybased studies from Scandinavia that describe the proportion of sports injuries as a percentage of the total number of acute injuries, as well as the distribution of injuries by sport. In these studies, between .% and .% of all acute injuries seen in an emergency room, casualty department or outpatient clinic setting are sports induced. A consistent finding across these studies is that in the total population, soccer is the number one sport in terms of the absolute number of injuries (Table ..). After soccer, other team games such as European team handball, volleyball, basketball and ice hockey also cause a significant proportion of the absolute number of injuries. Note that the proportions vary considerably between countries. A good example is ice hockey and skating injuries, which are common in Sweden and Finland, but rare in Norway. It is important to note that this injury pattern is a result of not only the risk involved when playing each of these sports, but also differences in participation rate for each sport. Soccer is a very popular sport in all of the Nordic countries, and ice hockey is very popular in Sweden and Finland, but not in Norway. This is reflected in concomitant differences in the number of injuries seen between these countries (Table ..). Consequently, these studies provide information about the magnitude of the sports injury problem and in particular which sports are responsible for the largest absolute number of injuries. They are therefore important from a public health perspective, but do not give estimates of injury risk.
Chapter . Table .. Total population distribution of sports-related injuries by sport. Selected studies conducted in an emergency room setting in Scandinavia have been included.
Soccer Handball Volleyball Basketball Ball games (unspecified) Ice hockey/bandy/skating Alpine skiing Cross-country skiing Skiing (unspecified) Horse riding Gymnastics Martial arts Cycling Orienteering Athletics Racket sports Motor sports Jogging and recreational walking Other No. of injuries (% of total injuries)
Lindqvist et al. [38]
Mæhlum & Daljord [39]
Ytterstad [40]
Sandelin et al. [41]
de Loës [37]
Motala, Sweden (pop. 40 000), 1983–84
Oslo, Norway (pop. 650 000), 1981–82
Harstad, Norway (pop. 22 600), 1985–93
Helsinki, Finland (pop. 800 000), 1978
Falköping, Sweden (pop. 31 260), 1984
39
25 7
45 11 7 4
2 11 12 4 2
3 7 7
24
42 5
23 19
5 6 5
11 7
6 2 1 4 1 3 3 1 10 993 (18.9%)
4 5
2 6
2 5 2 20 3434 (6.3%)
The only Scandinavian population-based study which takes time at risk into account and which therefore provides risk estimates is the one by de Loës and Goldies []. This study shows that the incidence rate is highest in ice hockey, horseback riding, team handball and soccer among men, and team handball and soccer among women. Similarly, Table .. provides similar data on absolute numbers of acute injuries among children and adolescents. Not surprisingly, since participation in sports is more prevalent among children than adults, it appears that sports participation causes a larger proportion of injuries in the younger population, between % and % in the Scandinavian studies. Similar to adults, soccer is the sport causing the most injuries among boys, except in Finland, where ice hockey dominates. Among girls a significant proportion of injuries
2234 (17.2%)
7 4 2493 (10%)
6 4 2
2 2 3 5 11 571 (18.1%)
is caused by team handball, horse riding and gymnastics. Again, this is a reflection of participation rates and not of the risk associated with each sport. In Scandinavia, team handball, horse riding and gymnastics are generally more popular among girls than boys. For true risk estimates it is necessary to collect information on exposure, and to compute incidence rates.
Sports injury incidence The most appropriate indication of the spread of disease in the population or in a section of the population is incidence. If one substitutes ‘sports injury or sports accident’ for ‘disease’, incidence can be defined as ‘the number of new sports injuries or accidents sustained during a particular period, in a particular population at risk (i.e. the number of newly sustained sports injuries per year divided by the population at risk)’. Incidence
Epidemiology and Prevention of Sports Injuries
Table .. Injury distribution by sport in children and adolescents. Selected prospective studies conducted in an emergency room setting in Scandinavia have been included.
Soccer Handball Basketball Volleyball Volleyball/basketball Ball games (unspecified) Ice hockey/skating Alpine skiing Cross-country skiing Ski jumping Horse riding Gymnastics Martial arts Swimming Running Athletics Roller skating Skateboard Baseball Other No. of sports-related injuries (% of total injuries)
Sahlin [42]
Sørensen et al. [43]
Kvist et al. [44]
Trondheim, Norway, 1985–86, age 5–14
Esbjerg, Denmark, 1988–92, age 6–17
Turku, Finland, 1980–82, age 6–15
Boys (%)
Boys (%)
Boys (%)
33 5
2 4 5 15 11 3 1 5 2 2
Girls (%) 13 30
3 7 6 7 6 6 6 1 2
Girls (%)
39 7 5
11 19 6
12
2
1 7
18 15
1 3 10
5 2
14
12
24
23
359 27%
399
3322 35%
2774
thus defined also gives an estimate of risk. If one multiplies the obtained figure by , one gets the incidence percentage rate []. Expressed in this way, sports injury incidence figures give insight into the extent of the sports injury problem in a particular population at risk. It is clear from this definition of incidence that incidence can only be assessed properly if clear definitions of both sports injury and of the population at risk are present. In many studies the incidence rate of sports injuries is usually defined as the number of new sports injuries during a particular period (e.g. year) divided by the total number of sports persons at the start of that period (population at risk). When interpreting and comparing incidence rates found in different studies it is important to know what definition of sports injury was used. Information on the comparability of the
Girls (%)
20
7
3 1
4 3
1 42 3 4
21 4 6
3
18 14
5 4 3
3 6 3
2 9
3 8
772 18%
352
populations at risk is also needed. It is clear that the methods used to count injuries and to count the population at risk will also influence sports injury incidence figures. Finally the length of the observation period has to be taken into account, since different lengths of observation periods will have a distinct influence on the incidences calculated. In terms of risk assessment another problem lies in the way incidence rates are expressed. In most cases, the number of injuries in a particular category of sports persons per season or per year is taken, or the number of injuries per player per match. In both examples no allowance is made for any differences in the actual exposure to injury risk (i.e. the number of hours of active play during which the sports person actually runs the risk of being injured). This is peculiar because this factor certainly has great influence on the
Chapter . risk of sustaining a sports injury. Incidence figures that take no account of exposure are therefore not a good indication of the ‘true’ risk one runs, nor can such incidence rates be used for a comparison of risk between different sports or between age and sex groups participating in the same sport. It would therefore be better to calculate the incidence of sports injuries in relation to exposure time (for example, per game-hours). This is commonly done in cohort studies, where a particular athlete population, e.g. one or several teams in a league, is followed prospectively. In this type of study it is often possible to collect detailed participation records for training as well as games to calculate exposure. Incidence is normally expressed as the number of injuries per player-hours. The equation of Chambers [], adapted by De Loës and Goldie [], can be used to calculate injury incidence taking exposure into account: injury incidence =
[(no. of sports injuries
year) ¥ 4 ]
[(no. of participants) ¥ (hours of sports participation week) ¥ (weeks of season year)]. Expressing incidence this way, as the number of injuries per athlete-hours, yields convenient numbers (usually between and ) and allows comparison between various sports, settings and populations. This method may have to be adjusted to particular research settings. When studying alpine skiing injuries it may be more valid to express incidence per days on ski (since exposure registration is often linked to lift pass sales) or, even better, to skiing distance. To this end, Rønning et al. have developed the distance-correlated injury index (DCI), expressing incidence as the number of injuries per km on skis []. This obviously requires the ability to record exposure through the actual use of ski lift passes and not only lift pass sales. Table .. shows the incidence rates for some team sports commonly played in Scandinavia. Although there is a limitation to the number of studies available in some sports, the trend seems relatively clear. Ice hockey is the game with the highest rate of injuries by far, in most studies – injuries per player-
hours during games. Ice hockey is followed by soccer with a match injury incidence of – per player-hours. There is only one study available from European team handball, showing an incidence slightly lower than soccer, and volleyball appears to have the lowest injury rate of the most popular Scandinavian team sports. There is no prospective study available from Scandinavian basketball, but other studies have shown rates just slightly higher than volleyball [–]. Table .. also shows other interesting trends. It appears that within a certain sport, competing at a high level increases sports injury risk and more injuries are sustained during matches than during training. This is primarily due to the higher intensity during matches, and most likely also due to the fact that athletes do not take the same risks when training with their teammates as they do in games. The high difference in injury rates between games and training seen in Swedish and Finnish elite ice hockey can be explained by the fact that the teams have an intense match schedule and mainly use their training sessions during the season for recovery and basic skill training purposes.
Methodologic issues When conducting (and also when interpreting the outcomes of) epidemiologic sports injury studies one is confronted with a number of methodologic issues. The first issue of importance here is the definition of sports injury. In general, sports injury is a collective name for all types of damage that can occur in relation to sporting activities. Various studies of incidence define the term ‘sports injury’ in different ways. In some studies a sports injury is defined as any injury sustained during sporting activities for which an insurance claim is submitted; in other studies the definition is confined to injuries treated at a hospital casualty or other medical department []. As shown in Table .., different injury definitions have been used in the Scandinavian studies. These definitions can be grouped into three categories: (i) time loss injuries, where the definition is usually that the player is unable to participate in the next match or training session because of injury; (ii) game interruption injuries, where the player has to interrupt the game or training session because of an injury; or
Table .. Injury incidence in selected team sports. Only prospective studies conducted in Scandinavia at the senior level for male teams have been included to allow comparison between sports. *Time loss: Player unable to participate in next match or training session because of injury; Interruption: Player has to interrupt game or training session; Medical attention: Player seeking medical attention for evaluation and/or treatment. Injury rate (per 1000 player-hours) Reference Soccer Arnason et al. [45] Drogset & Midthjell [46] Ekstrand [47] Lüthje et al. [48] Nielsen & Yde [49] Poulsen et al. [50]
Mölsa et al. [55]
Population
Sample size
Injury definition*
Total
Game
Training
Iceland, May–Sept 1991 Norway, late 80s, 17 months
5 of 10 div. I teams
84 players
Acute & overuse;Time loss
12.4 ± 1.4
34.8 ± 5.7
5.9 ± 1.1
Three div.VI teams
~ 75 players
13
27
3
12 div. IV teams All 12 div. I teams
180 players 263 players
16.9 11.3
7.6 1.8
One club, div. II & lower div.
34 div. II & 59 lower div. players 34 div. I & 59 lower div. players
Acute & overuse;Time loss or Interruption Acute;Time loss Acute & overuse; Interruption or Medical attention Acute;Time loss
Div. II: 18.5 Lower div. 11.9
Div. II: 2.3 Lower div. 5.6
Acute & overuse;Time loss
Div. I: 19.8 Lower div. 20.7
Div. I: 4.1 Lower div. 5.7
Finland, Jan–Oct 1993 Denmark, Jan–Nov 1986 Denmark, 1996, one year
Three teams, div. I & lower div.
Sweden, 1982–84, two seasons Sweden, 1984–85, 40 games Sweden, 1982–85, three seasons Finland, 1988–89, one season Finland, 1976–79 & 1988–89 & 1992–93 Sweden, 1986–90
One div. I team
24–25 players
Acute & overuse;Time loss
28.8
Swedish national team One div. I team
22–25 players
Acute;Time loss
79.2
24–25 players
Acute & overuse;Time loss
78.4
4 div. I teams & 3 div. II teams 3–7 div. I teams
21 players per team 17–22 players per team
Acute;Time loss
One div. I team
22–25 players
Acute & overuse;Time loss
Div. I: 66 Div. II: 36 1970s: 54 1980s: 55 1990s: 83 74.1
12 div. I teams
?
Acute & overuse;Time loss
53.0
36 teams, div. I–IV
286 players
Acute & overuse;Treatment
4.2
4.8
4.1
26 teams, div. I–II
273 players
Acute,Time loss
1.7
3.5
1.5
One club, div. II & lower div.
136 players
Acute & overuse;Time loss
2.8
5.7
2.1
One club, div. I & lower div.
127 players
Acute;Time loss
1.4
1.5 2.6
Petterson & Lorentzon [56] Tegner & Sweden, 1986–90, Lorentzon [57] one season Volleyball (indoor) Aagaard, Denmark, 1993–94, Scavenius & one season Jørgensen [58] Bahr & Bahr [29] Norway, 1992–93, one season Yde & Buhl Denmark, September Nielsen [59] 1985–April 1986 Handball Nielsen & Yde [60] Denmark, Sep.1985 — May 1986
Acute;Treatment
1.5
Epidemiology and Prevention of Sports Injuries
Ice hockey Lorentzon,Wedren & Pietilä [51] Lorentzon et al. [52] Lorentzon,Wedren & Pietilä [53] Mölsa et al. [54]
Country and period
Males: 13.3 Females: 13.8
Males: 2.4 Females: 0.7
Chapter . (iii) medical attention injuries, where the player has to seek medical attention for evaluation and/or treatment because of an injury. Differences in the injury definition used may partly explain the differing injury rates observed, but the study setting also plays a role. Apparently, all of the studies cited in Table .. have been performed in the same setting, by collecting injury and exposure information for the team through the coach, medical personnel or players directly. However, one should bear in mind that if a study is conducted in a setting where courtside medical support is readily available, using a ‘medical attention’ injury definition is likely to result in a higher injury incidence rate than a ‘time loss’ definition; in such a situation players are likely to seek medical attention for minor injuries not involving time loss. This may be the case in ice hockey, where medical staff is required to be present at all times during training and matches. Conversely, if a study is done in volleyball, where professional medical support is not as readily available, a ‘time loss’ definition is likely to result in a higher injury rate than a ‘medical attention’ definition. Players do not always seek medical attention for injuries, not even for time loss injuries. The results of various sports injury incidence surveys are not necessarily comparable, if the study setting differs. If sports injuries are recorded through medical channels (for instance through hospital emergency rooms or insurance records), a fairly large percentage of serious, predominantly acute injuries will be observed and less serious and/or overuse injuries will not be recorded. If such a ‘limited’ definition is used, only part of the total sports injury problem is revealed. This ‘tip-of-the-iceberg’ phenomenon is commonly described in epidemiologic research []. This problem is to a large extent found in sport injury epidemiology in the young where many overuse injuries are thought to be found, as well as ‘minor’ acute injuries. To make sports injury surveys comparable and to avoid the ‘tip-of-the-iceberg’ phenomenon as far as possible, an unambiguous, universally applicable definition of sports injury is the first prerequisite. This definition should be based on a concept of health different than that customary in standard medicine, and should for instance, take incapacitation for sports or school into account.
Research design The extent to which sports injury incidence and sports injury risk can be assessed depends not only on the definition of sports injury or the study setting, but also on the methods used to count injuries, to establish the population at risk and to verify that the sample is representative. Here proper research design comes into play. Injuries as well as time at risk can be assessed retrospectively or prospectively, using questionnaires or person-to-person interviews. However, prospective studies can, by closely monitoring exposure time and injury outcome, more accurately estimate the risk and incidence of sports injury according to the level of sports participation and type of exposure of an athlete. They are therefore superior to retrospective studies. One of the main problems of retrospective studies is the inherent recall bias of the subjects participating in such a study. A word should be said here about case studies. In sports medical journals clinical case series are commonly described. Conclusions are drawn from these case series regarding the incidence and the risk of sustaining sports injuries. However, case studies have the drawback that no information on the population at risk is available. Consequently, no valid conclusions can be drawn from case studies; neither with respect to sports injury incidence, nor with respect to injury risks []. Depending on the methods used the researcher will be confronted to a greater or lesser extent with phenomena such as recall bias, overestimation of the hours of sport participation [], incomplete responses, non-response, dropout, invalid injury description and problems related to the duration and cost of research. These factors will clearly affect the internal validity of a study. Special attention has to be paid to the method of assessing the population at risk and to ascertaining that the sample is representative. If the population at risk is not clearly identified it is not possible to calculate reliable incidence data. With regard to representative samples, consideration has to be taken of the fact that the performance of athletes in sports, and therefore the incidence of sports injuries, is highly determined by selection. Bol et al. [] recognized four different kinds of selection: (i) self-selection (personal preferences) and/or selection by social environment (parents,
Epidemiology and Prevention of Sports Injuries friends, school, etc.); (ii) selection by the sports environment (trainer, coach, etc.); (iii) selection by sports organizations (organization of competition by age and gender, the setting of participation standards, etc.); and (iv) selection by social, medical and biologic factors (socioeconomic background, mortality, age, aging, gender, etc.). All these issues should be taken into account in the study design or, if this is not possible, limitations must be readily acknowledged when interpreting the results.
predict a high frequency of future disability and functional impairment after an ACL rupture, an ACL injury is a much greater source of concern than an ankle sprain.
Duration and nature of treatment Data on the duration and nature of treatment can be used to determine the severity of an injury more precisely, especially if it is a question of what medical bodies are involved in the treatment and what therapies are used.
The severity of sports injuries A description of the severity of sports injuries is important in making a decision about whether or not preventive measures are needed, since the need to prevent serious injuries in a particular sport does not need to coincide with a high overall incidence of injuries in that sport. According to the literature the severity of sports injuries can be described on the basis of six criteria []. These criteria are briefly described below.
Nature of sports injuries The nature of sports injuries can be described in terms of medical diagnosis, e.g. sprain (of joint capsule and ligaments), strain (of muscle or tendon), contusion (bruising), dislocation or subluxation, fracture (of bone). It is the nature of the sports injury that determines whether assistance (medical or otherwise) is sought. The Abbreviated Injury Scale (AIS) has been developed as a direct measure of the severity of an injury based on patient status upon presentation in the emergency room, originally developed for motor vehicle accidents []. Recording of the nature of sports injuries enables those sports with relatively serious injuries to be identified. Information on which body part is injured can also give important information. As an example, studies from European team handball show that there is a high incidence of anterior cruciate ligament (ACL) injuries, especially among female players. Myklebust et al. [] and Strand et al. [] have found an incidence of . and . per playerhours for women during competition in Norwegian team handball, compared with . injuries per player-hours in soccer []. This means that the rate of ACL injuries in handball almost equals the rate of ankle sprains in volleyball [,]. Since one can
Sports time lost It is important for a sports person to be able to take up his or her sport again as soon as possible after an injury. Sport and exercise play an essential part in people’s free time and thus influence their mental well-being. The loss of sporting time is an important psychosocial factor. Also, for the professional athlete or the elite level team loss of sporting time is directly related to salary (or the opportunity to earn prize money or appearance fees) or to the relative success of the individual or his team. Thus, the length of sporting time lost gives the most precise indication of the consequences of an injury to a sports person.
Working or school time lost Like the cost of medical treatment, the length of working or school time lost gives an indication of the consequences of sports injuries at a societal level. Data on working or school time lost is used to compare the cost to society of sports injuries with that of other situations involving risks, such as traffic accidents.
Permanent disability The vast majority of sports injuries heal without permanent disability. Serious injuries such as fractures, ligament, tendon and intra-articular injuries, concussions, spinal injuries and eye injuries can leave permanent damage (residual symptoms). Excessive delay between the occurrence of an injury and medical assistance can aggravate the injury. If the residual symptoms are slight, they may cause the individual to modify his or her level of sporting activity. In some cases, however, the sports person may have to choose another sport or give up sport altogether. Serious physical damage can cause permanent disability, thus
Chapter . reducing or eliminating the individual’s capacity for work or school, or even death. When taking precautions, then, priority should be given to measures in sports where such serious injuries are common, even though the particular sport itself may be characterized by a low incidence of sports injuries and/or a low absolute number of participants. As an example, we have already mentioned the high incidence of ACL injuries in female team handball, which causes concern even if the total injury incidence in the sport is thought to be moderate. Ice hockey, in turn, represents a sport where the total incidence is high, and where even a high frequency of concussions and spinal cord injuries is seen [,].
Costs of sports injuries The calculation of the costs of sports injuries essentially involves the expression of the above-mentioned five categories of seriousness of sports injuries in economic terms. The economic costs can be divided into: (i) direct costs, i.e. the cost of medical treatment (diagnostic expenses such as X-rays, doctors’ fees and costs of medicines, hospital admission and rehabilitation); and (ii) indirect costs, i.e. expenditure incurred in connection with the loss of productivity due to increased morbidity and mortality levels (loss of school or working time and loss of expertise due to death or disability).
Conceptual models for the etiology of sports injuries Risk indicators for sports injuries can be divided into two main categories: internal personal risk indicators and external, environmental risk indicators []. This division is based on partly proven and partly supposed causal relationships between risk factors and sports injuries. However, merely to establish the risk factors for sports injuries, i.e. the internal and external factors, is not enough; the mechanisms by which they occur must also be identified. As can be seen in Fig. .. sports injuries result from a complex interaction of multiple risk factors of which only a fraction have been identified. Despite this multicausality many epidemiologic studies have concentrated on identifying single internal or external risk indicators from a medical, monocausal point of view, rather than from a multicausal point of view. However,
studies on the etiology of sports injuries require a dynamic model that accounts for this multifactorial nature of sports injuries, and that also takes the sequence of events eventually leading to an injury into account. One such dynamic model is described by Meeuwisse []. This model describes how multiple factors interact to produce injury (Fig. ..). In studies on the etiology of sports injuries this model can be used to explore the interrelationships between risk factors and their contribution to the occurrence of injury. Meeuwisse classifies the intrinsic or athlete-related factors as predisposing factors that are necessary, but seldom sufficient, to produce injury. In his theoretical model extrinsic risk factors act on the predisposed athlete from without and are classified as enabling factors in that they facilitate the manifestation of injury. It is the presence of both intrinsic and extrinsic risk factors that render the athlete susceptible to injury, but the mere presence of these risk factors is usually not sufficient to produce injury. It is the sum of these risk factors and the interaction between them that ‘prepare’ the athlete for an injury to occur at a given place, in a given sports situation. Meeuwisse describes an inciting event to be the final link in the chain of causation to sports injury and states that such an inciting event is usually directly associated with the onset of injury. Such events are regarded as necessary causes. The term injury mechanism is often used to describe the inciting event in biomechanical terms. Studies on the etiology of sports injuries tend to focus on factors proximal to the injury event (i.e. the inciting events) and tend to neglect factors more distant from the injury event (i.e. the intrinsic and extrinsic risk factors), thereby revealing only a small fraction of the factors and events that lead to sports injury. Although understandable, focusing on inciting events may lead to overweighing the importance of such events in the etiology and prevention of sports injuries. If in etiologic studies distant factors are studied it usually concerns intrinsic, person-related risk factors. These factors are relatively easier to measure than extrinsic risk factors. A multifactorial model like the model of Meeuwisse should be used to study the etiology of sports injuries. Although there are a fair number of studies available documenting the incidence, severity and injury profile of most major sports, we have very little information available on risk factors and injury mechanisms. As
Epidemiology and Prevention of Sports Injuries
Athlete Physical factors, e.g.: • body composition • health • physical fitness • skills
Load, e.g.: • type of sport • recreation • game/practice competition
Psychosocial factors, e.g.: • aims • risk taking • coping with stress • motivation
Sports behaviour: • attitude • social influence • self-efficacy/barriers
Physical factors, e.g.: • accommodation • weather • objects of handling • sports materials (of others) Fig. .. Risk indicators for sports injuries and determinants of sports and preventive behavior [].
Personal sports materials, e.g.: • protective materials (shinguards, braces) • instrumental materials (racket, stick, club) • other materials (shoes, clothing)
Human factors, e.g.: • team mates • opponent • referee • coach • spectators
Sports situation
Age
Exposure to extrinsic risk factors
Flexibility Intrinsic risk factors
Predisposed athlete
Inciting Susceptible event athlete
Injury
Previous injury
Fig. .. A dynamic, multifactorial model of sports injury etiology []. (Reprinted with permission from Clinical Journal of Sports Medicine, Lippincott, Williams and Wilkins) [].)
Somatotype
already mentioned, most studies have focused on single risk factors. And although the inciting event may be the most obvious causative factor in the chain of events leading to an injury, this has been neglected or at best
Risk factors for injury (distant from outcome)
Mechanism of injury (proximal to outcome)
described in broad terms in most studies. For instance, describing an ACL injury as a non-contact or contact injury does provide meaningful information, but leaves us far from having a complete understanding of
Chapter . the injury mechanism. Also, in most studies information on injury mechanisms has been collected using questionnaires given to the injured athlete, often weeks after the injury occurred. Recall bias is an obvious problem using this approach, but another important limitation is that injuries often happen in a split second, and the athlete is not always aware of what really happened. When completing a questionnaire, the information collected probably reflects the sum of what the athlete perceived and remembered, plus what he has been told by the coach, team mates or spectators. In future studies, more detailed information on injury mechanisms can probably be obtained by systematic examination of video recordings of injuries. Also, such systematic evaluation should not be limited to some biomechanical description of, e.g. knee motion, but should also describe the events leading up to the injury. This is especially important in team sports like soccer or team handball, where application of sport science methods may provide a better understanding of the chain of events preceding an injury.
When health is part of attitude one may suppose that healthy motivation is a combination of the perceived severity of the health risk, the perceived susceptibility to the health risk, and the effectiveness of the preventive behavior.‘Social influence’ is the influence by others; directly by what others expect, indirectly by what others do (modelling). ‘Social influence is often underestimated as a determinant of behavior. It can lead to behavior that conflicts with previous attitudes. Most sports situations are social situations.‘Selfefficacy-cum-barriers’ stands for the determinant whether one is able to perform the (desired) behavior. It involves an estimation of ability, taking into account possible internal (e.g. insufficient skill, knowledge, endurance) or external barriers (e.g. resistance from others, time and money not available, etc.). Self-efficacy is people’s perception of their ability to perform the behavior, and barriers are the real problems they face in actually performing the behavior.These determinants should be accounted for when trying to prevent sports injuries.
Sports behavior
A model for sports injury prevention
When trying to prevent sports injuries one should realize that participation in sports is a form of behavior. Usually the introduction of preventive measures implies a change or modification of behavior of the athlete. It may very well be that the desired preventive behavior conflicts with the actual sport behavior, for instance because it is believed by the athlete that the preventive behavior will affect sports performance negatively. When introducing preventive measures and when evaluating the effect of such measures it is therefore necessary to have knowledge of the determinants of both sports and preventive behavior. Many models are used to explain preventive behavior. In general these models include three sets of determinants: (i) knowledge and attitude; (ii) social influence; and (iii) barriers and self-efficacy [] (see Fig. ..). These determinants can be described as follows: ‘Attitude’ refers to the knowledge and beliefs of a person concerning the specific consequences of a certain form of behavior. An attitude is the weighing of all consequences of the performance of the behavior, as seen by the individual. Health is only seen as one of the considerations, and is often an unimportant one.
Given the limited information available on risk factors and injury mechanisms, it comes as no surprise that very few studies are available on injury prevention. Only RCTs on sports injury prevention can be found in the literature [–,]. However, strategies for injury control have been developed from other energy exchange areas, particularly from research on motor vehicle accidents. One such model, the so-called Haddon matrix [], is actually a family of matrices varied to suit the area it is applied to, in this case sports injuries (Table ..). As shown in Table .., the matrix has two dimensions. The first dimension is based on the fact that processes that naturally divide into three stages precede the end results of damaging interactions with environmental hazards. These three stages can be labeled the ‘precrash’, ‘crash’ and ‘postcrash’ phases. For the sports injury application the second dimension of the matrix can be divided into at least three factors, ‘athlete’, ‘equipment’ and ‘environment’. A considerable host of literature illustrates the practical application of such matrices to the study of motor vehicle crashes and their results []. Table .. lists a num-
Epidemiology and Prevention of Sports Injuries
Table .. Haddon’s matrix applied to sports injury prevention. Precrash
Crash
Postcrash
Athlete
Skills Neuromuscular control
Training status Falling technique
Rehabilitation
Environment
Floor friction Game rules
Safety net
Medical coverage
Equipment
Shoe friction
Tape/brace Ski bindings Shin guards
First aid equipment Ambulance
ber of injury control measures that may be effective in sports.
Precrash measures The precrash phase includes measures designed to prevent a potentially dangerous situation to occur at all. An example from the motor vehicle accident area would be four-lane highways built to avoid head-on collisions. In sports, examples of athlete-related precrash measures include increasing the skill level of an alpine skier to prevent falls or improving neuromuscular control around the knee or ankle to prevent the athlete from landing without proper alignment. Examples of precrash environmental measures include modifying the friction of the playing surface (too high may lead to twisting injuries to the lower extremity, too low may lead to slipping and falling injuries) or rule changes to avoid dangerous plays (e.g. checking from behind in ice hockey to avoid injuries to the spine, or a red card for tackling from behind in soccer). Equipment-related precrash measures include modifying shoe friction or cleat length to the playing surface and weather conditions. Several RCTs have applied precrash measures or actions to examine the efficacy of the intervention on occurrence of sports injuries. One of the very first was the study of Ekstrand et al. (for a detailed description, see ‘Focus on Research’ above): the study showed that by a multifactorial prevention program the injury rate in soccer could be reduced by % []. Since the program was multifactorial, it remains unclear which parts of the program were effective and which were
not. Jakobsen et al. investigated whether a multipart preventive program would decrease the number of injuries among long-distance runners []. The program consisted of a health examination, instructions on proper warm-up and stretching, selection of wellfitting running shoes, individually tailored running programs, and easy access to medical treatment. As a result, the risk of injury decreased % in competition, while no change was seen in training-induced injuries. Again, the effectiveness (or ineffectiveness) of any single action in the program remains unclear. Van Mechelen et al. examined, in turn, the effect of warm-up, cool-down and stretching on injuries of recreational long-distance runners, but could not find any effect []. This conclusion was recently supported by Pope et al. who studied the effect of pre-exercise stretching on risk of lower-limb injury in male army recruits []. Wedderkopp et al. investigated whether a program consisting of balance-board training and careful warming-up activities could reduce the high risk of lower-limb injuries in European team handball among girls []. The program was effective, since the risk of injury was reduced by more than % in the intervention group. This was the case for injuries occurring during games as well as practice. Recently, Heidt et al. examined the effect of a preseason conditioning program on the rate and severity of injuries in adolescent female soccer players aged – years []. The week program combined sports-specific cardiovascular conditioning, plyometric work, sport cord drills, strength training and flexibility exercises to improve speed and agility. After the playing season, % of the
Chapter . players randomized to the training program had sustained injuries, compared to % of those in the control group.
Crash measures The crash phase includes measures designed to protect the athlete from being injured, even when there is an accident. Examples of crash measures from the area of traffic accidents include seat belts and air bags to protect passengers from being injured in collisions, and use of safety helmets in cyclists. Athlete-related crash measures mainly focus on the physical preparation of athletes to allow them to withstand the forces involved when a collision or a fall occurs. Athlete-related crash measures could involve, for example, a general strength training program or falling techniques. Environmental crash measures include safety nets to avoid falling alpine skiers from flying into the crowd or soft mats protecting gymnasts who fail a dismount or fall down from apparatus. There are many examples of equipment-related crash measures in sports, possibly because they are the most obvious to consider, or because there is a potential sales profit involved. Equipment-related measures include release bindings for alpine skiing, helmets for various sports, taping and braces for ankles and other joints, shin guards for soccer players, eye guards for squash and racquetball, and visors for ice hockey. Examples of crash measures in sports traumatology (as tested in RCTs) include knee and ankle injuries. Sitler et al. () showed that it was possible to reduce the risk of medial collateral ligament injuries of the knee in defensive American football players by the use of a prophylactic knee brace []. For ankle injuries, similar results have been obtained by balance-board training [] and semirigid ankle stabilizers [,]. The risk of ankle sprains in particular in players with previous injuries could be reduced by these measures.
Postcrash measures Postcrash measures are designed to minimize the damage resulting from an injury and the risk of reinjury (which is a strong risk factor for sports injuries), and mainly relates to the chain of medical treatment provided after an injury. Postcrash measures in sports may include the training of athletes and coaches to provide adequate on-field first aid, providing adequate
medical services during sports events (personnel and equipment), including quick evacuation procedures to a hospital in the case of severe injuries, and adequate rehabilitation programs for injured athletes before they return to competition. Unfortunately, in sports medicine there are no examples known of effective postcrash measures that have been tested in RCTs.
Practical application of the Haddon matrix The Haddon matrix may be applied to any sport, thereby providing a means for identifying and considering, cell by cell: (i) prior and possible future resource allocations and activities, as well as the efficacies of each; (ii) the relevant research and other knowledge — both that already available and that needed for the future; and (iii) the priorities for injury countermeasures, judged in terms of their costs and their effects on undesirable injury results.
Summary The outcome of research on the extent of the sports injury problem is highly dependent on the definitions of ‘sports injury’, ‘sports injury incidence’ and ‘sports participation’. The outcome of sports epidemiologic research also depends on the research design and methodology, the representativeness of the sample, and on whether or not exposure time was considered when calculating incidence. The severity of sports injuries can be expressed by taking six indices into consideration. The etiology of sports injuries is highly multicausal. This fact, as well as the sequence of events leading to a sports injury, should be accounted for when studying the etiology of sports injuries and when trying to prevent them. Finally, one should take determinants of sports and preventive behavior into account in attempts to solve the sports injury problem.
Multiple choice questions Is the risk of post-career musculoskeletal problems increased in former elite athletes? a Yes. b No. Which of the following factors are important to take into account if you want to compare the magnitude of sports injuries between different sports? a The total number of injuries. b The training level of the athletes.
Epidemiology and Prevention of Sports Injuries c The number of athletes involved in the sport. d The severity of injuries sustained. e All of the above. Which of the following team sports has the highest incidence of injuries during games? a Soccer. b Team handball. c Volleyball. d Ice hockey. e Basketball. Which of the following team sports causes the highest number of injuries in Scandinavia? a Soccer. b Team handball. c Volleyball. d Ice hockey. e Basketball. Ankle tape and braces are commonly used to prevent ankle sprains in sport, and their preventive effect has been investigated in some clinical studies. What is the result from these studies? a Using ankle braces prevents ankle sprains. b Using ankle braces prevents ankle sprains, but their effect is most pronounced in players with former ankle injuries. c There is no protective effect of using ankle braces.
References Sarna S, Sahi T, Koskenvuo M, Kaprio J. Increased life expectancy of world class athletes. Med Sci Sports Exerc ; : –. Kujala UM, Sarna S, Kaprio J, Koskenvuo M. Hospital care in later life among former world-class Finnish athletes. J Am Med Assoc ; : –. Roos H, Lindberg H, Gardsell P, Lohmander LS, Wingstrand H. The prevalence of gonarthrosis and its relation to meniscectomy in former soccer players. Am J Sports Med ; : –. van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med ; : –. Ekstrand J, Gillquist J, Liljedahl SO. Prevention of soccer injuries. Supervision by doctor and physiotherapist. Am J Sports Med ; : –. Jakobsen BW, Kroner K, Schmidt SA, Kjeldsen A. Prevention of injuries in long-distance runners. Knee Surg Sports Traumatol Arthrosc ; : –. Pope RP, Herbert RD, Kirwan JD, Graham BJ. A randomized trial of preexercise stretching for prevention of lowerlimb injury. Med Sci Sports Exerc ; : –.
Sitler M, Ryan J, Hopkinson W et al. The efficacy of a prophylactic knee brace to reduce knee injuries in football. A prospective, randomized study at West Point. Am J Sports Med ; : –. Sitler M, Ryan J, Wheeler B et al. The efficacy of a semirigid ankle stabilizer to reduce acute ankle injuries in basketball. A randomized clinical study at west point. Am J Sports Med ; : –. Surve I, Schwellnus MP, Noakes T, Lombard C. A fivefold reduction in the incidence of recurrent ankle sprains in soccer players using the Sport-Stirrup orthosis. Am J Sports Med ; : –. Tropp H, Askling C, Gillquist J. Prevention of ankle sprains. Am J Sports Med ; : –. van Mechelen W, Hlobil H, Kemper HCG, Voorn WJ, Jongh DHR. Prevention of running injuries by warm-up, cooldown, and stretching exercises. Am J Sports Med ; : –. Wedderkopp N, Kaltoft M, Lundgaard B, Rosendahl M, Froberg K. Prevention of injuries in young female players in European team handball. A prospective intervention study. Scand J Med Sci Sports ; : –. de Loes M, Goldie I. Incidence rate of injuries during sport activity and physical exercise in a rural Swedish municipality: incidence rates in sports. Int J Sports Med ; : –. Walter SD, Sutton JR, McIntosh JM, Connolly C. The aetiology of sport injuries. A review of methodologies. Sports Med ; : –. Chambers RB. Orthopaedic injuries in athletes (ages –). Comparison of injuries occurring in six sports. Am J Sports Med ; : –. Ronning R, Gerner T, Engebretsen L. Risk of injury during alpine and telemark skiing and snowboarding. The equipment-specific distance-correlated injury index. Am J Sports Med ; : –. Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of literature. Am J Sports Med ; : –. Colliander E, Eriksson E, Herkel M, Skold P. Injuries in Swedish elite basketball. Orthopedics ; : –. Yde J, Nielsen AB. Sports injuries in adolescents’ ball games: soccer, handball and basketball. Br J Sports Med ; : –. Zelisko JA, Noble HB, Porter M. A comparison of men’s and women’s professional basketball injuries. Am J Sports Med ; : –. Klesges RC, Eck LH, Mellon MW, Fulliton W, Somes GW, Hanson CL. The accuracy of self-reports of physical activity. Med Sci Sports Exerc ; : –. Bol E, Schmickli SL, Backx FJG, van Mechelen W. Sportblessures onder de knie. Papendal. Amsterdam, Holland: NISGZ publication , . van Mechelen W. The severity of sports injuries. Sports Med ; : –. Haddon W. Advances in the epidemiology of injuries as a basis for public policy. Pub Health Rep ; : –.
Chapter . Myklebust G, Maehlum S, Holm I, Bahr R. A prospective cohort study of anterior cruciate ligament injuries in elite Norwegian team handball. Scand J Med Sci Sports ; : –. Strand T, Tvedte R, Engebretsen L, Tegnander A. [Anterior cruciate ligament injuries in handball playing. Mechanisms and incidence of injuries]. Tidsskrift for Den Norske Laegeforening ; : –. Bjordal JM, Arnly F, Hannestad B, Strand T. Epidemiology of anterior cruciate ligament injuries in soccer. Am J Sports Med ; : –. Bahr R, Bahr IA. Incidence of acute volleyball injuries: a prospective cohort study of injury mechanisms and risk factors. Scand J Med Sci Sports ; : –. Bahr R, Lian Ø, Karlsen R, Øvrebø RV. Incidence and mechanisms of acute ankle inversion injuries in volleyball — a retrospective cohort study. Am J Sports Med ; : –. Molsa JJ, Tegner Y, Alaranta H, Myllynen P, Kujala UM. Spinal cord injuries in ice hockey in Finland and Sweden from to . Int J Sports Med ; : – . Tegner Y, Lorentzon R. Concussion among Swedish elite ice hockey players. Br J Sports Med ; : –. Meeuwisse WH. Assessing causation in sport injury: a multifactorial model. Clin J Sport Med ; : –. Kok G, Bouter LM. On the importance of planned health education. Prevention of ski injury as an example. Am J Sports Med ; : –. Heidt R, Sjr Sweeterman LM, Carlonas RL, Traub LA, Tejkulve FX. Avoidance of soccer injuries with preseason conditioning. Am J Sports Med ; : –. Ekstrand J. Soccer injuries and their prevention. Thesis, Linköping University, . de Loes M. Medical treatment and costs of sports-related injuries in a total population. Int J Sports Med ; : –. Lindqvist KS, Timpka T, Bjurulf P. Injuries during leisure physical activity in a Swedish municipality. Scand J Social Med ; : –. Maehlum S, Daljord OA. Acute sports injuries in Oslo: a oneyear study. Br J Sports Med ; : –. Ytterstad B. The Harstad injury prevention study. the epidemiology of sports injuries. An year study. Br J Sports Med ; : –. Sandelin J, Kiviluoto O, Santavirta S, Honkanen R. Outcome of sports injuries treated in a casualty department. Br J Sports Med ; : –. Sahlin Y. Sport accidents in childhood. Br J Sports Med ; : –. Sorensen L, Larsen SE, Rock ND. The epidemiology of
sports injuries in school-aged children. Scand J Med Sci Sports ; : –. Kvist M, Kujala UM, Heinonen OJ et al. Sports-related injuries in children. Int J Sports Med ; : –. Arnason A, Gudmundsson A, Dahl HA, Johannsson E. Soccer injuries in Iceland. Scand J Med Sci Sports ; : –. Drogset JO, Midthjell K. [Injuries among soccer players in lower division clubs]. Tidsskrift for Den Norske Laegeforening ; : –. Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: a prospective study. Med Sci Sports Exerc ; : –. Luthje P, Nurmi I, Kataja M et al. Epidemiology and traumatology of injuries in elite soccer: a prospective study in Finland. Scand J Med Sci Sports ; : –. Nielsen AB, Yde J. Epidemiology and traumatology of injuries in soccer. Am J Sports Med ; : –. Poulsen TD, Freund KG, Madsen F, Sandvej K. Injuries in high-skilled and low-skilled soccer: a prospective study. Br J Sports Med ; : –. Lorentzon R, Wedren H, Pietila T. [The occurrence of injuries in first class ice hockey]. Läkartidningen ; (–): . Lorentzon R, Wedren H, Pietila T, Gustavsson B. Injuries in international ice hockey. A prospective, comparative study of injury incidence and injury types in international and Swedish elite ice hockey. Am J Sports Med ; : –. Lorentzon R, Wedrén H, Pietelä T. Incidence, nature and causes of ice hockey injuries. Am J Sports Med ; : –. Molsa J, Airaksinen O, Nasman O, Torstila I. Ice hockey injuries in Finland. A prospective epidemiologic study. Am J Sports Med ; : –. Molsa J, Kujala U, Nasman O, Lehtipuu TP, Airaksinen O. Injury profile in ice hockey from the s through the s in Finland. Am J Sports Med ; : –. Pettersson M, Lorentzon R. Ice hockey injuries. a -year prospective study of a Swedish elite ice hockey team. Br J Sports Med ; : –. Tegner Y, Lorentzon R. Ice hockey injuries. incidence, nature and causes. Br J Sports Med ; : –. Aagaard H, Scavenius M, Jorgensen U. An epidemiological analysis of the injury pattern in indoor and in beach volleyball. Int J Sports Med ; : –. Yde J, Nielsen AB. [Epidemiologic and traumatologic analysis of injuries in a Danish volleyball club] Epidemiologisk og traumatologisk analyse af skader i en dansk volleyball-klub. Ugeskr Læger ; : –. Nielsen AB, Yde J. An epidemiological and traumatologic study of injuries in handball. Int J Sports Med ; : –.
Chapter 3.2 Exercise as Disease Prevention ILKKA VUORI & LA RS- B O ANDE RS E N
Classical reference Nilsson BE, Westlin NE. Bone density in athletes. Clin Orth Rel Res ; : –. Commensurate with the fact that osteoporosis may be caused by inactivity, physical exercise is used clinically for its prevention and cure. There is, however, no convincing evidence that exercise will actually increase the bone mass in pathologic cases nor that physical exercise should in any way influence the bone mass in man. Some circ*mstantial evidence may be extracted from the positive relationships between body weight and bone mass in women and between weight bearing and bone density in rats. The objective of the present study was to evaluate the influence of physical activity on bone mass in healthy young men. The bone density was evaluated in male athletes and compared to healthy age-matched non-athletes (Fig. ..). The athletes had significantly denser bone in the distal end of the femur than the non-athletes. Within the group of athletes there was evidence that sports activities including heavy loads on the lower limbs were associated with higher bone density. Also in the athletes, the dominant leg had a denser femur. Among the controls, those who regularly exercised had a higher bone density than those who did not.
Introduction Exercise has been claimed to be healthy since ancient times. However, scientific evidence for specific health benefits of exercise began to accumulate only about years ago. Since then the amount and quality of information on the potential for exercise in disease prevention has increased greatly. The latest comprehensive review covering this topic at large is the Report of the Surgeon General [], but a large number of nar-
rative reviews, meta-analyses and critical systematic Cochrane reviews on more limited topics have been published since then. This chapter presents a short overview of the evidence of the potential value of physical activity in prevention or slowing down of the development of non-communicable diseases. Table .. gives an evidence-rated list of these conditions. This review is limited to those conditions that are prevalent in the population and in which there is strong or at least moderate evidence of preventative effectiveness of physical activity supported by evidence that offers plausible biologic mechanism(s) related to the etiopathogenesis of the diseases.
Cardiovascular disease Over the last five decades cardiovascular disease (CVD) has been the most common cause of death in the Western world. Inside the EU, % of all deaths are attributed to CVD and this is almost twice as many as all cancers put together []. CVD rates have decreased during the last few decades in Western countries especially in men below the age of years [,]. This development is in contrast to the Eastern European countries, where CVD rates have increased. The positive trend in the Northern European countries parallels a positive change in CVD risk factor levels [,]. The most common cardiovascular diseases are ischemic or coronary heart disease (CHD) and stroke. CHD and thrombotic stroke are characterized by a gradual development of atherosclerosis that obstructs the vessels supplying the heart and brain, respectively, with blood. Atherosclerosis development is influenced by many factors. Although there is genetic predisposition, most risk factors are modifiable. The probability of developing CHD can to a large extent be predicted
Minerals (g/cm3) — first leg
Chapter . 0.4
Athletes
0.3
0.3
0.2
0.2
0.1
0.1
0.1
Non-athletes
0.4
0.2
0.3
0.4
0.1
0.2
0.3
0.4
0.3
0.4
3
Minerals (g/cm3) — left leg
Minerals (g/cm ) —
0.4
Athletes
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0.1
0.2
0.3
0.4
Non-athletes
0.1
3
Minerals (g/cm ) — right leg
from the risk factor levels. The three traditional risk factors are smoking, high blood pressure and abnormal blood lipid levels. Other risk factors also predict risk of CHD. Currently there is evidence to conclude that physical inactivity is about as strong but even more prevalent a risk factor for CHD as the other major risk factors. Furthermore, physical activity modifies most of the other risk factors in a positive direction, i.e. type diabetes, hypertension, hypercholesterolemia, fibrinogen and obesity, and protects against a number of other diseases including osteoporosis and some cancers [].
Epidemiologic studies of CVD The first good study showing that physical inactivity was associated with CVD was published in []. In the early studies, subjects were classified according to their physical activity at work. At that time this made sense, because most of the physical activity people were engaged in was job related, but this has changed since. In another large population study was initi-
0.2
Fig. .. Left–right and preference–non-preference side relationships of bone density.
ated []. This study was based on detailed information of self-reported physical activity. Paffenbarger and Hyde found that age-adjusted CHD rates were % higher among sedentary compared to physically active alumni from Harvard. Many different physical activity variables were assessed, i.e. walking, stair climbing, recreational sports, vigorous sports and total energy expenditure. All physical activity variables predicted future CHD, and higher rates were found among the less physically active. More than a hundred studies have been published, and the methods of assessing different types and intensities of physical activities have been refined in the later studies. Morris et al. [] analysed the importance of the frequency of participation in vigorous aerobic activities []. Those who most frequently participated in vigorous aerobic activities only experienced one-third of the myocardial infarctions of the sedentary group (RR = .; % confidence interval (CI) .–.). Further, a dose–response relationship was found between the four groups analysed. Morris et al. did not
Exercise as Disease Prevention
Table .. The health benefits of regular physical activity (adapted from []). The table is based on a total physical fitness program that includes physical activity designed to improve both aerobic and musculoskeletal fitness. Physical activity benefit Fitness of body Improved heart and lung fitness Improved muscular strength/size Osteoporosis Helps build up bone density Prevention of osteoporosis Treatment of osteoporosis Osteoporotic fractures Prevention of fractures Arthritis Prevention of arthritis Treatment of arthritis Improvement in life quality/fitness Low back pain Prevention of low back pain Treatment of low back pain Blood cholesterol/lipoproteins Lower blood total cholesterol Lower LDL-cholesterol Lower triglycerides Raised HDL-cholesterol High blood pressure Prevention of high blood pressure Treatment of high blood pressure Diabetes Prevention of NIDDM Treatment of NIDDM Treatment of IDDM Improvement in diabetic life quality Weight management Prevention of weight gain Treatment of obesity Maintenance of weight loss Cardiovascular disease Coronary heart disease prevention Regression of atherosclerosis Treatment of heart disease Prevention of stroke Asthma Improvement in life quality Digestive diseases Prevention of gallstone disease
Surety rating
**** **** **** *** ** ** * ** **** ** ** * * *** *** **** **** **** *** * *** **** ** *** **** ** *** *** ***
Physical activity benefit Cancer Prevention of colon cancer Prevention of breast cancer Prevention of uterine cancer Prevention of prostate cancer Infection and immunity Prevention of the common cold Improvement in overall immunity Improvement in life quality with HIV infection Psychological well-being Elevation in mood Buffering of effects of mental stress Alleviation/prevention of depression Anxiety reduction Improvement in self-esteem Nutrition and diet quality Improvement in diet quality Increase in total energy intake Cigarette smoking Improvement in success in quitting Sleep Improvement in sleep quality Children and youth Prevention of obesity Control of disease risk factors Reduction of unhealthy habits Improved odds of adult activity Special issues for women Improved total body fitness Improved fitness while pregnant Improved birthing experience Improved health of fetus Improved health during menopause Elderly and the aging process Improvement in physical fitness Countering of loss of heart/lung fitness Countering of loss of muscle Countering of gain in fat Improvement in life expectancy Improvement in life quality
**
**** Strong consensus, with little or no conflicting data. *** Most data are supportive, but more research is needed for clarification. ** Some data are supportive, but much more research is needed. * Little or no data support.
Surety rating
**** ** ** ** ** ** *** **** *** **** **** **** ** *** ** *** *** *** ** ** **** **** ** ** *** **** ** *** *** **** ****
Relative risk
Chapter . 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0
1st
2nd
3rd
4th
5th
Quintiles of physical activity Fig. .. Age-adjusted rates of cardiovascular disease (CVD) events in quintiles of physical activity index among female nurses (from []).
find the same protective effect against CHD with physical activity at moderate intensities, but this has convincingly been shown in other studies. Most studies only include men, but a few recent studies have included large cohorts of women [,]. Manson et al. [] analysed CHD rates in female nurses in relation to different types of physical activity. A dose–response relationship was found over all quintiles (Fig. ..). After multivariate adjustment for all the measured risk factors the estimate was still .. Just as convincing, and graded, a relationship was found between quintiles of kilometres walked per week (RR = .; % CI .–.). In an analysis of walking speed, those with a walking speed above miles/h experienced . the CHD rate of the slow walkers after exclusion of women who participated in vigorous sport. In a recent study from Copenhagen, Andersen et al. found half the mortality rate in the physically active compared to the sedentary []. The study included more than subjects and half of them were women. The same relative risk was found in both genders and all age groups. Those who participated in sports had only half the mortality rate of the moderately active, and those who did not cycle to work had a % higher mortality rate even after adjustment for other types of physical activity and other CHD risk factors. A number of studies have analysed the effect of changes in physical activity habits. These studies are important because they exclude the possibility that the
lower CHD rate among the physically active is caused by a selection bias at baseline. Healthier people may be more likely to participate in physical activity. Further, it is important to elucidate whether it can be too late to start to exercise to obtain health benefits and lower the risk of CVD. At least five studies have analysed the effect of changes in physical activity or aerobic fitness against either all-cause mortality or CVD [–]. Paffenbarger et al. found a graded, dose–response relationship between changes in physical activity in men in relation to all-cause mortality, adjusted for baseline physical activity level. Subjects who increased their energy expenditure by more than kcal/week experienced less than half the mortality rate of subjects who decreased their level similarly. The studies from Copenhagen included more than men and women, and a similar dose–response relationship was found in those who decreased physical activity most, having a CHD rate of three to four times the rate of those who increased most [a]. Blair et al. [] studied the effect of changes in fitness. Genetics play a role in a subject’s fitness level and in fitness-related fat and carbohydrate metabolism that in turn are related to risk of developing atherosclerosis. Those who belonged to the lowest quintile of fitness had an age-adjusted mortality rate that was five times the rate of the most fit []. This difference could theoretically be caused by a link between genes for fitness and genes for health parameters even if the most plausible explanation is a difference in physical activity levels, and the current fitness level most likely reflects the past few months’ physical activity. However, an increase in physical fitness level can only be caused by an increase in aerobic physical activity or a decrease in body weight, which can be adjusted for. It is therefore interesting that Blair et al. found that those who were unfit at the first measurement and fit at a second measurement years later had only half the mortality rate of those who were unfit both times []. There is consensus that there is a large preventive potential in increasing physical activity in the population. This is caused by a large decrease in incidence rates in people adopting a more active lifestyle, but also by the fact that the prevalence of physical inactivity is very high in the population. In a recent study, Haapanen-Niemi et al. [] collected data from
Exercise as Disease Prevention
Table .. Prevalence, adjusted relative risks and population attributable risks for coronary heat disease deaths among Finnish men aged - years according to the different risk factors. From []. Lowest values
Highest values
Risk factor
Prevalence
RR
PAR (%)
RR
PAR (%)
Physical inactivity (3 h/w) Smoking Elevated cholesterol (> 6.5 mmol/L) Hypertension (SBP > 160 mmHg) Obesity (BMI > 30 kg/m2) (BMI > 27 kg/m2)
71% 43% 26% 15% 15% 37%
1.4 1.3 1.4 1.4 1.2 1.2
22.1 9.5 9.4 5.7 2.9 6.9
1.9 2.4 2.0 2.2 1.4 1.4
39.0 32.9 20.6 15.3 5.7 12.9
BMI, body mass index; PAR, population attributable risk; RR, relative risk; SBP, systolic blood pressure.
different published studies on Finnish men and calculated the population-attributable risk (PAR) of CHD for different risk factors (Table ..). The cut-off points for risk may be arbitrary and can be discussed, but the relative risk between groups are calculated from the same cut-off points, and if cut-off points are changed the RR changes too, leaving the calculated PAR at almost the same level. Highest and lowest values are calculated on data from different studies. Even if these kinds of calculations include several inaccuracies and uncertainties and do not take into account the fact that it is not realistic to change risk levels in all subjects at risk, it is obvious that there is a great preventive potential in behavioral change in physical activity habits.
Stroke There are two types of stroke, hemorrhagic and thrombotic, which only partly have the same etiology. A thrombotic stroke is caused by clot formation (atherosclerosis) and is therefore caused by the same risk factors as CHD. A hemorrhagic stroke is a bleeding event and one of the main risk factors for this is high blood pressure. Only few epidemiologic studies separate these two conditions even if risk factors partly differ and physical activity may act differently on these two types of stroke. Systolic blood pressure can increase during maximal isometric contractions to more than mmHg and this type of physical activity may therefore be a risk factor for hemorrhagic stroke.
However, intensive isometric contractions increase lipoprotein lipase activity [] which is favorable in terms of protecting against atherosclerosis. During dynamic exercise almost no change is found in transmural blood pressure in cerebral arteries and this type of exercise may therefore have a different effect on the risk of stroke. These differences may explain varying outcomes from the published studies. In the Surgeon General’s Report [], studies of physical activity and stroke were reviewed. Most studies included less than endpoints, and in eight of them an inverse association was found between physical activity and stroke. The report concluded that there was not yet consensus about the effect of physical activity on risk of stroke. Since , a number of good studies have been published [–]. Gillum et al. [] followed subjects who experienced more than strokes. They found a dose–response relationship between physical activity and low incidence of stroke with a relative risk of two in the sedentary. Lee and Paffenbarger [] analysed the association between physical activity and stroke in former Harvard alumni who had strokes. The relationship was somewhat U-shaped, with subjects expending between and kcal/week having only half the risk of the sedentary. This activity level equals the international recommendations of min accumulated physical activity a day. The most active did not exceed the sedentary in risk. Only a few studies include women, but in the Copen-
Chapter .
Osteoporosis and related fractures Osteoporosis is characterized by low bone mass and microarchitectural deterioration of bone tissue. These changes lead to enhanced bone fragility and increased risk of fractures. Osteoporosis as such without fracture is usually symptomless and the diagnostic criterion is bone mass. The most commonly used indicator of bone mass is areal bone mineral density (BMD, g/m2), which can be measured accurately by dual-energy Xray absorptiometry (DXA). Bone density accounts for –% of the variance in ultimate bone strength. The diagnostic criterion for osteoporosis is BMD at least . standard deviations (SD) and for osteopenia (low bone mass) –. SD below the mean of young adult women []. One SD is usually around –% of a given BMD value. Osteoporosis is most commonly related to aging. The rate of bone loss varies largely between individuals and by site. At the femoral neck BMD is decreased on average by SD at the age of and by . SD at the age of (Fig. ..). By the age of , an estimated % of white women are osteopenic and % are osteoporotic []. Fracture risk increases .- to -fold for each SD fall in BMD. Nearly % of women years of age and older suffer from hip fracture during their later years, and for vertebral fracture the corresponding figure is –%. Prevention of osteoporosis can be defined as preventing BMD from dropping lower than . SD below the mean for young adult women. Two factors determine the amount of bone later in life: the bone mass accumulated during youth (peak bone mass) and the subsequent rate of bone loss. Peak bone mass and the rate of bone loss are thought to be equally important in determining bone mass at the age of . Although genetic factors are the most powerful determinants of
bone mass, at least % of it is determined by modifiable factors, physical activity being one of them.
Physical activity and bone mass Physical activity can influence bone mass by causing compressive or bending loads on bone. If these are sufficiently strong, they can cause a temporary deformation, strain, in bone. As a result, primary and secondary responses occur that stimulate bone formation. The purpose of the increased bone formation can be thought to act as part of a homeostatic mechanism that aims to keep deformation of bone due to mechanical loading within narrow limits in order to avoid damage of the bone structure. Low loading leads to decreased bone formation and increased resorption (Fig. ..). Physical activity can substantially increase peak bone mass in youth and it can deter significantly bone loss with aging. Cross-sectional studies in athletes suggest that intensive sports training for many years can increase bone mass at the loaded sites by –% [], even over % []. These findings are not due to selection bias (individuals with strong bones or with bones that respond unusually well to physical loading would become superior athletes), as shown by studies comparing the bones of the right and left extremities of athletes practising unilateral sports such as tennis []. However, these very high bone mass values are seen
Proximal femur BMD change from PBM (%)
hagen City Heart Study women experienced strokes []. The physically inactive had % higher risk of stroke compared to the physically active. In conclusion, the evidence of physical activity as protection against stroke is less than for CHD, but it is likely that moderate physical activity has a protective effect. However, it is much more doubtful if highintensity physical activity has a positive effect and isometric contraction may even increase the risk of hemorrhagic stroke.
0 –5 –10 –15 –20 Trochanter Femoral neck Ward's
–25 –30 –35 –40 20
30
40 50 Age (years)
60
70
80
Fig. .. Average bone mineral density (BMD) change from peak bone mass (PBM) at different areas of the proximal femur, trochanter, neck, and Ward’s triangle in women. (From [], with permission.)
Net rate of bone response (Resorption) (Formation)
Exercise as Disease Prevention
Decreased loading
Normal activity
Increased loading
Stress/strain stimulus
Reference stimulus
Fig. .. Hypothetical relationship between the applied stress or strain stimulus and the net rate of bone resorption or formation. (From [], with permission.)
30
BMC difference (%)
25 20 15 10 5 0 >5
3–5
0–2
1–5
6–15
> 15
Before menarche (years) After menarche (years) Controls
Fig. .. Benefit of mechanical loading with respect to bone mineral content (BMC) in growing girls. The BMC of the playing arm (humeral shaft) of the subjects was about two times greater if the girls started playing at or before, rather than after, menarche. The bars represent the % confidence intervals. (From [], with permission.)
only in athletes who have begun systematic training before puberty. It has been shown that bone responds maximally to physical loading during prepuberty and puberty and much less before and after those few years (Fig. ..) [,]. Studies on non-elite athletes and physically active young subjects show bone mass values –% greater than those in their sedentary counterparts. Training studies on young subjects have
resulted in bone mass increases of a few per cent. The high bone mass that has been attained by athletic training or other physical activity cannot be maintained without continuous activity. It seems, however, that less activity is required to maintain the high bone mass or at least a substantial part of it than the amount needed to gain it [–]. However, it seems that much or most of the high peak bone mass attained by athletic training is lost before reaching old age [–]. In adulthood a substantial increase of bone mass by exercise has not been observed, but in premenopausal women physical activity can maintain the bone mass and in postmenopausal women regular exercise can substantially decrease loss of bone. In quantitative analyses of published studies this effect was on average about % per year in favor of the exercising subjects [,] and it is mainly due to decreased rate of loss of bone in the exercisers. Importantly, in randomized controlled trials the size of the effects was only about half of that observed in non-randomized studies []. The beneficial effect of exercise has been observed in both pre- and postmenopausal women and in both the proximal femur and the lumbar spine. On the basis of the size of the effect of exercise on bone mass it can be estimated that regular physical activity can prevent the development of osteoporosis until even very old age in women who have average or somewhat low bone mass in middle age. However, currently available methods for applying physical loading are not sufficiently effective to compensate for low bone mass. In addition to prevention of age-related osteoporosis, physical activity is important also in prevention of bone loss in conjunction with injuries and surgical operations. Permanent osteopenia or even osteoporosis may develop if immobilization is long and complete or if the functional results remain poor and loading of the affected body part remains insufficient [,]. The effectiveness of physical activity as an osteogenic stimulus is determined by its characteristics in relation to causing strain in bone. These strainrelated characteristics are weight-bearing, magnitude of force, rate of application of force, number of cycles of force (repetitions), and pattern of distribution of force in the bone (variability of movements). Table .. shows a descriptive assessment of these characteristics in a number of sports. In sports with beneficial loading characteristics such as tennis and squash bone
Chapter . Table .. Assessment of the loading characteristics of the different sports in which bone measurements of female athletes have been made []. Loading characteristics Sport
Weight-bearing
High-magnitude
High-impact
Repetitive
Varied
Strength sports Body-building Power-lifting Weight-lifting
xxx xxx xxx
xxx xxx xxx
x x xx
x x x
x x xx
Endurance sports Running Orienteering Speed skating Cross-country skiing Rowing Cycling Swimming
xx xx xx xx x x 0
x x x x x x x
xx xx xx x x x x
xxx xxx xxx xxx xxx xxx xxx
xx xx xx x x x x
Speed and power Aerobic dancing Ballet dancing Gymnastics Figure skating Basketball Soccer Volleyball Squash Tennis
xxx xxx xxx xxx xxx xxx xxx xxx xxx
xx xx xx xx xx xx xx xx xx
xxx xxx xxx xxx xxx xxx xxx xxx xxx
xxx xx xx xx xx(x) xx(x) xx xx xx
xxx xxx xxx xxx xxx xxx xxx xxx xxx
Assumption: duration of exposure is sufficient. xxx, high, broad; xx, medium; x, low, limited; 0, none.
mass at the loaded sites has been found to be high as compared with sports with weak loading characteristics and with referents (Fig. ..) []. Quantitative analyses of results of clinical trials agree well with these cross-sectional observations and strongly support the notion that only high-intensity activity significantly influences bone mass except possibly in osteoporotic subjects. Both endurance or aerobic and dynamic strength or progressive resistance training as well as impact and non-impact exercises have been found effective and thus far no definite differences in the effectiveness between the types of training have been found in quantitative analyses, possibly due to small number of studies in some categories. Static exercises and slow movements do not influence bone
mass in normal subjects. Also movements that are repeated in a similar fashion even in large amounts, e.g. walking, are weak or insufficient loading stimuli for healthy young and middle-aged subjects. However, smaller loading can be osteotrophic for weakened bones. Thus, walking has been found effective in osteoporotic subjects []. Data are not sufficient to reach firm conclusions as to the required number of loadings in one session, but on the basis of animal experiments it is likely to be only a few regarding stimulation of a small bone site. However, in order to stimulate sufficiently large bone sites, the total number of loadings from different directions has to be quite large. The optimal frequency of training sessions is likely to be a few times a week. The duration of training that is toler-
Exercise as Disease Prevention
(a) 20 P < 0.001 P < 0.001 Difference (%)
15 P < 0.05
P < 0.01 P < 0.05
10 5 0 –5 –10
Fig. .. Relative difference in weightadjusted bone mineral density (BMD) at the most loaded lower limb sites of different female athlete groups (n = –) and a physically active reference group (n = ) compared with that of the sedentary reference group (n = ). (a) Proximal tibia BMD and (b) calcaneus BMD. The grouping of the athletes was based on the specific bone-loading characteristics of the respective sports. The bars indicate the % confidence intervals. (From [], with permission.)
Difference (%)
(b) 30 25 20 15 10 5 0 –5 –10
P < 0.001 P < 0.001 P < 0.05
Weight lifters
P < 0.01
Speed skaters Cyclists Squash Aerobic Physically active players dancers Orienteers Cross-country skiers referents
High-magnitude High-impact loading loading
able to ordinary subjects should be more than half a year in order to begin to see its effects. During the postmenopausal years physical activity in combination with estrogen replacement therapy is more effective in maintaining bone mass than estrogen alone, but without the influence of estrogen physical activity is hardly effective []. The effects of physical activity on bone geometry, internal architecture and material properties have not yet been thoroughly studied. The few published observations suggest that physical loading can lead to increased diameter and strength of bone [,]. These kinds of changes may substantially influence the breaking strength of bone without marked changes in bone mass or areal density. Physical activity can also be detrimental to bone. Large amounts of intensive training for prolonged periods such as seen in military training and in competitive athletes can lead to stress fractures and osteopenia. The mediating mechanisms of development of os-
P < 0.001
Repetitive loading
Non-weight Normal, bearing high-level physical activity
teopenia are complicated and not completely understood, but one mechanism is disruption of normal ovarian function that leads to inhibition of the production of gonadotrophin-releasing hormone by the hypothalamus and to decreased estrogen content in blood. These athletes have oligo- or amenorrhea and gradually bone mass decreases or in young athletes peak bone mass remains low. As a consequence, the risk of stress fractures increases but it is not definitively known whether the risk of osteoporosis is also increased [,]. In addition to hormonal disturbances low body mass and, frequently, eating disorders can contribute to athletes’ osteopenia.
Physical activity and prevention of osteoporotic fractures The lifetime risk of having at least one osteoporotic fracture is greater than % for women. This includes a lifetime risk of approximately % for vertebral fractures, % for hip fractures, % for wrist frac-
Chapter . tures and % for humerus fractures []. Most vertebral fractures occur without trauma, solely as a result of osteoporosis. Most wrist and hip fractures are caused by a combination of mild or moderate trauma, usually a fall from a standing level, and osteoporosis. Thus, prevention of falls or decreasing their severity is an important part of prevention of osteoporotic fractures. Falls are common among elderly people. Each year, approximately % of community-dwelling older people fall at least once and –% fall twice or more. Although less than % of falls among older adults lead to bone fracture, multiple falling in particular is clearly an indicator of increased risk of fracture. Established risk factors for falls include older age, impaired balance and orthostatic hypotension, lower-extremity muscle weakness, decreased reaction time, impaired vision and cognition, decreased lean body mass and overall impaired mobility. Also several factors related to use of medications and alcohol, environment and the acute situation influence the risk of fall and its seriousness []. Physical activity may influence the risk of fall and its consequences through several mechanisms. The most likely effects are mediated through musculoskeletal and neuromuscular systems and can be measured by performance in strength, balance, coordination, postural stability, gait and mobility. Review of the currently published studies [] revealed that randomized controlled exercise trials aiming at decreasing the risk of falls have produced inconclusive results. No exercise modalities have shown to be consistently effective in reducing risk for falls, but balance and strength training exercise programs have shown promising results in recent studies. Most case-control studies of physical activity and hip fracture have shown a –% reduction in odds of fracture among women engaging in moderate physical activity vs. control. Most prospective studies on the topic have found –% smaller risk in physically active as compared with sedentary subjects. The consistency, magnitude of effect and diversity of populations across these studies strongly suggest that a physically active lifestyle can help reduce the incidence of hip fractures in the population. It is unclear whether physical activity is associated with risk of osteoporotic fractures at sites other than the hip. It is important to notice that es-
pecially in subjects with impaired movement abilities physical activity may also increase the risk of falls and consequently osteoporotic fractures. On the basis of the current evidence a pertinent message to older people would be to recommend a physically active lifestyle including a variety of customary tasks performed in a safe environment and requiring moderate amounts of muscle strength, balance, coordination and mobility. More studies are needed before evidence-based recommendations for specific exercise regimens tailored for various population groups can be given. It seems obvious, however, that physical activities that maintain and improve both muscle strength and abilities for a wide variety of physical tasks are favorable in terms of both bone strength and risk of falls.
Physical activity and low back pain Low back pain is pain, muscle tension or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica). About % of low back pain cases are non-specific, not attributable to recognizable pathology. The poorly defined pathophysiology and mechanism of pain explain to a large degree the difficulties of prevention and treatment of low back pain. Low back pain is a common disorder, the lifetime incidence being around –%. Most cases are resolved within – weeks and % recover by weeks []. However, in a follow-up study nearly one-third of cases had not recovered completely in year [,], and recurrence of low back pain is very frequent with rates of up to % in the year following the initial episode. The origin and mechanisms of low back pain are not exactly known, but it seems that the symptoms originate from tissue injury or inflammation and from the resulting irritation, nociception []. This in turn causes increased muscular tension in order to decrease movements that cause pain. Thus, trunk muscles are an important element related to low back pain syndrome, and these muscles have a decisive role in protecting back structures from excessive mechanical loading. Physical activity might relate to the development of low back pain as a provoking or preventing factor. Heavy physical work, frequent bending, twisting, lifting, pulling and pushing, repetitive work and static
Exercise as Disease Prevention postures as well as reduced muscle strength in back, abdominal and thigh muscles, reduced endurance in back muscles, hypermobility in the lumbar column and hypomobility of hip joints are commonly listed, activity-related risk factors for low back pain []. The theoretical rationale for the role of physical activity (PA) in the causation or prevention of low back pain includes the following ideas: (i) PA can induce acute and repetitive subclinical or more severe injuries in the back structures; (ii) higher strength of the muscles of the back and trunk could protect the back from injury or minimize the effects of injurious events; (iii) higher endurance of the trunk muscles helps to maintain motor control due to less fatigue in various tasks thus decreasing the risk of high loading of spine structures or occurrence of malfunctions and consequently development of injury; (iv) better flexibility may decrease the risk of injury especially during lifting and bending activities; (v) good motor skills decrease the risk of injury in various tasks; and (vi) good general or aerobic endurance helps to counteract fatigue and development of injury []. Additional suggested mechanisms include improved circulation to the back structures and improved mood that would influence favorably sensitivity to pain []. In addition, PA may influence the development or the course of low back pain episodes in indirect, unspecific ways, e.g. through influences on body mass, mood, perceptions and motivation, and by decreasing or abolishing the effects of physiologic deconditioning due to inactivity or hypoactivity. Current scientific evidence on the role of physical activity in provoking or preventing low back pain can be summarized as follows. Prolonged, repetitive, heavy physical activity at work or in sports can cause low back pain in susceptible individuals, but the ultimate contributory role of injury is not known. The most commonly practised leisure-time physical activities have not been found to increase the risk of low back pain. Strong evidence indicates that physical activity can have a preventive effect on low back pain and is currently the only effective tested modality for this purpose [,]. However, all studies do not show physical activity to be effective for prevention of low back pain. Further, the characteristics of an effective exercise program have not been defined. It is worth noting, however, that trunk muscle endurance in some
cross-sectional studies and endurance training of these muscles in controlled trials has been associated with positive preventative findings [].
Overweight and obesity The most commonly used measure to define overweight and obesity is body mass index (BMI, in kg/m2). Currently the most widely accepted cut-off point for overweight is BMI ≥ . and for obesity BMI ≥ . BMIs in the range of .–. indicate only overweight, but not obesity. BMIs ≥ . assume that persons categorized at this level are obese, i.e. overweight because of excess adiposity. Overweight and obesity constitute an important health problem because of two reasons. First, the risk of a number of somatic disorders as well as psychological and social consequences increases sharply with increasing overweight and obesity [–]. However, part of the increased morbidity and mortality associated with increased BMI may not be due to excess fat per se but to physical inactivity and low fitness associated with and probably causally related to overweight and obesity [,]. Secondly, overweight and obesity are very common and increasingly prevalent conditions in European as well as in other populations, nearly one in three EU citizens being overweight and one in being obese []. Regulations of body fat mass and body weight are extremely complicated phenomena, but in essence they are functions of energy intake by eating and energy expenditure by resting metabolism and various forms of physical activity (Fig. ..). Overweight and obesity are due to excess energy intake in relation to energy expenditure for a lengthy time period. The factors related to and mechanisms involved in both of these basic processes and in their interactions are very complex and not completely understood. Data from several national surveys indicate that over the past few decades, there has been either a slight increase or very modest decline in total energy and fat intake. At the same time work-related physical activity and the energy expenditure required for daily living have substantially decreased. Participation in leisure-time physical activity is rather low in most populations, and it has showed only modest changes. Cross-sectional and population studies consistently show a negative relationship between level of physical activity and indices
Chapter .
Activity of daily living
Workrelated physical activity
Sedentary behaviour
Body fat mass Ein
High-fat, energy-dense foods
Eout
Large-portion sizes
Palatable low-cost, easily available foods
of obesity. The few published cohort studies show that high levels of physical activity are protective against obesity. Thus, although there are no definitive prospective studies to show that a low level of physical activity is a risk for obesity development and that a high level of physical activity is protective against obesity, an overwhelming amount of indirect evidence suggests that this is the case. The major factor explaining the current obesity epidemic is most likely the continued decline in daily energy expenditure that has not been matched by equivalent reduction in energy intake. For most people it is difficult to restrict intake to meet energy requirements, and thus an increase in physical activity is necessary to curtail the increasing prevalence of obesity [,]. Although the biologic basis is sound and evidence from ecologic and observational studies strongly sup-
Fig. .. The effect of environmental factors on energy balance. When energy intake (Ein) equals energy expenditure (Eout), the system is in energy balance and body fat mass stable. In the current environment, factors (in circles) on the left are driving Ein up, whereas factors on the right are driving Eout down, creating a state of positive energy balance, leading to an increase in the body fat mass. (From [], with permission.)
port the value of physical activity in the prevention of overweight and obesity, data from prospective studies and clinical trials are less consistent. Systematic review of studies on physical activity and weight gain shows that results from the studies using baseline physical activity data were variable. When physical activity data at follow-up were used, four studies out of five found that a large volume of physical activity at follow-up was associated with less weight gain. If physical activity increased during the follow-up, less weight gain was observed in most studies []. Observational studies and clinical trials on the effect of physical activity on weight change after intentional weight reduction in previously obese subjects show that the effects of prescribed exercise training in preventing weight regain is on average only very modest, about g/year.
Exercise as Disease Prevention
Type 2 diabetes In early studies it was shown that the prevalence of
RR of all-cause mortality
3
(a)
84
2.5
40
2
96
1.5 1
75
42
91
0.5 0 7.5 6.5
RR of CVD mortality
The discrepancy between observational studies suggesting a substantial potential for physical activity in preventing weight gain and clinical trials indicating this effect to be very modest only can be explained by several factors. The two most important reasons are the great amount of physical activity needed to influence body weight significantly and the commonly poor adherence to prescribed exercise training. These same reasons largely explain also the good results in shortterm but poor results in long-term weight reduction programs based on exercise training [,]. In observational studies the comparison is made between those who have chosen to be highly active for a long time and those who have been sedentary, but in clinical trials even the prescribed activity is often modest and only part of that has actually been realized due to poor compliance. The amount of physical activity that is necessary to prevent weight gain is not yet definitively known, but a summary of the evidence suggests that approximately – kJ/week (– kcal/ week) in addition to energy consumed in daily living improves weight maintenance, but some studies suggest smaller and some studies larger amount of energy expenditure in physical activity for this purpose []. Overweight and obesity are health problems as such but largely also because of the great number of serious comorbidities. Even though the physiologic potential of physical activity for weight maintenance and particularly for weight reduction is hard to realize in practice, physical activity has significant independent beneficial effects on several comorbidities of obesity, and it appears to attenuate morbidity and mortality risk in overweight and obese individuals [] even to the extent that active obese individuals have lower morbidity and mortality than normal-weight individuals who are sedentary (Fig. ..) [,]. These effects of physical activity have been observed even when changes in weight have been modest or negligible. Thus, physical activity should be an important part of the effort to decrease the health consequences of obesity regardless of its effectiveness to influence body weight and fat mass.
38 (b)
5.5 39
4.5
12
3.5
23
2.5 1.5 0.5
6 Lean
26
Normal
Obese
Fig. .. Body fatness and relative risks (RRs) of (a) all-cause and (b) cardiovascular disease (CVD) mortality by cardiorespiratory fitness categories in men: , fit; , unfit. Fit, lean men comprised the reference category, represented by the heavy line at .. Unfit men were the lowest quartile of oxygen uptake (mL/kg/FFM/min) in each age group, and fit refers to all other men. RRs were adjusted for age (single year), examination year, smoking habit, alcohol intake and parental history of ischemic heart disease. Body fatness categories were, in percentage body fat, lean ( mm, which was used as an arbitrary cut-off value for upper limit of normal LV size. The major determinants of a large cavity dimension were greater body surface area and participation in endurance sports. The few athletes with > mm LV cavities had normal left ventricular systolic function and no regional wall motion abnormalities []. Female athletes have, as male athletes do, larger LV cavity dimensions than controls although somewhat smaller dimensions than males of the same age and body size training in the same sport. In a study of women athletes four women had left ventricular cavity diameter > mm []. The right ventricle is enlarged in athletes in endurance sports to the same degree as the left ventricle, i.e. larger than in controls, but usually within the upper normal limit. Left ventricular mass is larger in athletes in strength-trained sports and endurance sports, and a combination of these, compared to controls. Those with larger muscle mass usually have larger LV cavity diameter. Athletes training in strength sports, such as weight-lifting, have high values for wall thickness relative to cavity dimension, but their absolute wall thickness usually remains within normal limits. The upper limit to which the thickness of the left ventricular wall may be increased by athletic training appears to be mm. Athletes with a wall thickness of more than mm and a non-dilated left ventricular cavity are likely to have pathologic hypertrophy, such as hypertrophic cardiomyopathy []. It may be difficult to distinguish between physiologic hypertrophy and pathologic changes and in some cases cessation of
training may be necessary to see if the hypertrophy is reversible, meaning that there was physiologic hypertrophy. A study of six Olympic rowers after the Seoul Olympic Games who voluntarily rested for – weeks after the games showed that the ventricular septal thickness decreased from a mean of . mm in the trained state to a mean of . mm in the deconditioned state (change –%) []. Aging does not seem to influence the effect of detraining on left ventricular morphology. In a comparison of cyclists, detraining in a –-year age group induced fairly similar left ventricular morphologic changes to those in a -year age group. Athletes with a higher left ventricular mass do not show the slower diastolic filling of the LV seen in patients with pathologic left ventricular hypertrophy where left ventricular filling during diastole is abnormal and slow.
Conclusion Although there are clearly different cardiac adaptations to the different types of exercise, with few exceptions athletes’ LV dimensions are usually within the upper reference level of normal limits — the athlete’s heart is a normal heart. LV wall thickness above normal (> – mm) is found in only a few per cent of athletes (most likely cyclists or rowers) and is associated with an enlarged left ventricular cavity.
ECG findings in athletes Resting bradycardia is common in athletes and heart rate values below beats/min during the night are not uncommon [,]. Pauses (long R–R intervals) in sinus rhythm of –. s are often seen and pauses over s have been reported (Fig. ..). Pronounced sinus bradyarrhythmias during the night are due to a vagal influence on the heart and a normal finding. Sporadic atrial and ventricular premature beats are common and do not require investigation or treatment. The majority of athletes have normal ECGs or only minor alterations. Conduction abnormalities such as first- and second-degree (Mobitz type ) atrioventricular block are common, and complete heart block has also been described, usually at night and resolving during exercise. Grossly –% of athletes have aberrancies in their ECGs, usually increased voltage (high QRS am-
Cardiovascular and Peripheral Vessel Diseases
Fig. .. Sinus bradycardia at night in a -m runner, longest R–R interval in sinus rhythm . s. (Reproduced with permission from [].)
Fig. .. Resting ECG from a longdistance runner. Heart rate beats/min. Paper speed mm/s.
plitudes) which may reflect the increased cardiac volume and muscle mass (and the leaner body of the athlete). Other features include ST elevation, high T waves, prominent U waves and intraventricular conduction abnormalities, usually affecting the right branch bundle. Figure .. shows an ECG from a healthy long-distance runner. In an athlete without evidence of cardiac disease the above-mentioned ECG changes should be considered a normal variant. Among the total population of athletes there are a few, –%, with highly abnormal ECGs but without clinical symptoms and without evidence of pathologic structural or morphologic changes on echocardiography. However, in athletes presenting with symptoms such as syncope, near-syncope, sudden dizziness, etc., as for other patients a thorough investigation must be made as arrhythmias can also be symptoms of underlying structural heart disease, such as hypertrophic cardiomyopathy, arrhythmogenic right ventricular
dysplasia, acquired heart block, sinus node disease or myocarditis. If an ECG is taken for any other reason than the patient’s symptoms and is highly abnormal, or abnormal in an unexpected way, an echocardiography could be performed to rule out hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia (ARVD), or other structural cardiac disease. Figure .. shows an ECG from a patient with hypertrophic cardiomyopathy.
Veteran athletes Some studies have shown an increased prevalence of supraventricular and ventricular ectopic beats and complex ventricular premature beats in older athletes compared to controls [–]; there are however, also studies that do not show any difference in incidence of arrhythmias between athletes and controls. These arrhythmias found in elderly athletes seldom require treatment and evidence from epidemiologic studies
Chapter .
Fig. .. Resting ECG from a patient with hypertrophic cardiomyopathy. Heart rate beats/min. Paper speed mm/s.
shows that a physically active lifestyle reduces risk of cardiac death [].
Heart and vessel diseases and training From the patient’s point of view the main questions are: If I have a cardiovascular disease and want to participate in aerobic exercise, is it safe? Might the training have any positive effects? Does regular exercise increase the exercise ability and make it possible to increase the ability to handle daily life? Does regular exercise improve the prognosis? The term exercise below generally refers to aerobic exercise, such as walking, swimming, jogging and running. Exercise has been studied in terms of clinical outcomes (morbidity and mortality), exercise tolerance
(effect on V˙2) and effects on risk factors like blood lipids, body weight, and blood pressure and on quality of life. There are other aspects of exercise such as health economy which will not be dealt with. While total mortality among physically active people is less than among the inactive, there is an increased risk for sudden death or myocardial infarction during physical activity as compared to during rest. This is because the increased load on circulation and metabolism leads to long-term beneficial effects on the development of cardiovascular diseases, but in predisposed subjects the acute strain on the circulation might trigger myocardial infarction or a life-threatening arrhythmia. During exercise blood pressure and heart rate increase, resulting in increased myocardial oxygen demand. The autonomic tone is changed towards increased sympathetic activity. Depending on the exercise intensity and duration and climatic conditions
Cardiovascular and Peripheral Vessel Diseases metabolic changes such as lactic acidosis and/or electrolyte imbalances might occur. A vulnerable atherosclerotic plaque could then disrupt in response to the hemodynamic stress with subsequent platelet activation, aggregation and thrombus formation. Regional ischemia, blood pressure changes and increased sympathetic tone could trigger ventricular fibrillation in subjects with coronary abnormalities or stenosis, cardiomyopathies or myocarditis. It should, however, be emphasized that higher levels of physical fitness appear to delay all-cause mortality, with mortality rates found to be . and . times higher among the least fit men and women compared to the most fit men and women, respectively []. The different cardiovascular diseases have different pathophysiologic features which make the impact of the hemodynamics at rest and during exercise extremely variable in each of these conditions. The impact of training on the different cardiovascular diseases has been concluded from studies of groups of patients. The largest group of patients with cardiovascular disease are patients with atherosclerosis-related diseases like angina pectoris or myocardial infarction. Atherosclerosis is a disease of the intimal layer of large and medium-sized arteries developing silently for decades before onset of clinical manifestations such as an acute myocardial infarction or a stroke. Risk factors for atherosclerosis include smoking, high blood lipids, hypertension and a sedentary lifestyle, and are discussed in Chapter ..
Exercise after acute myocardial infarction In the th century William Heberden and Caleb H. Parry recommended physical activity for patients with angina pectoris [,]. Other views soon became dominant and for almost years rest was a major part in the treatment of angina pectoris and in myocardial infarction. In the s the bed rest period after a myocardial infarction was shortened and it was reported that the patients having shorter bed rest after a myocardial infarction returned to normal activities sooner. It was shown that patients who were mobilized early had a lower mortality rate and lower morbidity up to a year after acute myocardial infarction (AMI). Over the last few decades the length of hospital stay after an AMI has been reduced and exercise programs
have been safely and increasingly used since the s. The overall idea of postinfarction rehabilitation programs is to reduce the physiologic effects of the cardiac illness, to increase psychological well-being and to reduce morbidity and mortality. Training is often used in the context of a rehabilitation program with multiple risk factor modification but it seems that training in itself also reduces morbidity []. Aerobic exercise improves functional capacity and the higher the exercise intensity the higher the improvement in V˙2. Patients with the lowest V˙2 improve most with training programs but patients that at baseline have a preserved exercise capacity also improve with exercise. Patients with reduced LV function also improve their V˙2 max with exercise []. Rehabilitation programs including exercise have been shown to reduce ischemic symptoms, reduce the risk of new coronary events and reduce cardiac mortality [], and may prevent the progression or reduce the severity of coronary atherosclerosis []. After AMI, a predischarge symptom-limited exercise test [], or a test done – weeks after discharge can guide exercise prescription. Symptoms (chest pain or chest discomfort), ST depression, arrhythmias and a low blood pressure increase during exercise are predictors of adverse events following AMI and these patients should be further investigated and treated. A new exercise test should be done after treatment before patients are allowed to exercise. Previously patients with anterior MI (who usually have larger infarctions than patient with inferior infarctions) were restrained from early testing and training but newer studies have shown that patients recovering from anterior MI may exercise with moderate intensity. The long-term beneficial effects of supervised conventional exercise programs post-MI have been questioned: year after a completed post-MI training program there were only marginal improvements in physical performance []; other studies show that fitness level is maintained if the training is maintained. Exercise recommendations. The patient is recommended at discharge to take daily walks at comfortable speed and increase the time, length and speed of the walk gradually to moderate dynamic exercise (to toler-
Chapter .
Case study 4.1.1 A -year-old man with a lifelong history of strenuous training underwent cardiovascular testing in a study of veteran male athletes. He had no symptoms. ECG showed signs of an old myocardial infarction. Echocardiography showed a dilated left ventricle with regional hypokinesia of the LV wall and reduced LV function. Nuclear angiography showed decreased left ventricular function both at rest and during exercise. Myocardial scintigraphy revealed a large perfusion abnormality. Despite these findings he cycled on an ergometer cycle with gradual increase of workload of W/min to W. Running on a treadmill his pulmonary oxygen uptake was mL/kg/min which is higher than in healthy –-year-old controls. This suggests that the endurance training compensated for the deteriorating effect of the myocardial infarction via both central and peripheral mechanisms.
ance). Training in groups supervised by a physiotherapist is an alternative (See Case Study ..).
Stable angina pectoris This group of patients has been studied less extensively than post-MI patients. Studies show that training improves exercise tolerance and retards disease progression []. Measures of ischemia such as ST depression are reduced after a training program [] and exercise may improve symptomatology. The earlier used rehabilitation programs often excluded patients older than whereas later studies have shown that patients ≥ years of age with coronary artery disease show improvements in exercise capacity, lipid levels and quality of life parameters [].
studies. Patients in a rehabilitation group lower their blood lipids compared to controls which probably improves prognosis.
Exercise in patients with stable heart failure In congestive heart failure exercise tolerance is severely limited; the peak pulmonary oxygen uptake may be less than mL O/kg/min. This is due to central factors like attenuated myocardial function (the cardiac ejection fraction is often less than %), decreased inotropic response and increased diastolic pressures, and peripheral factors such as reduced vasodilator response, increased activity of sympathetic afferents and impaired muscle function. Exercise training programs, for example ergometer cycling three times a week at % of V˙2 max improves exercise capacity and reduces symptoms. In a prospective study of patients with class II and III chronic heart failure physical training was safe and resulted in improvements in exercise time, anaerobic threshold and quality of life []. Exercise improves blood flow to exercising muscles [] and work capacity of the trained peripheral muscle []. Exercise also results in an increase in peak heart rate and a partial reversal of chronotropic incompetence among patients with stable heart failure. Exercise with small muscle groups, one at a time, may be an alternative to whole-body exercise in patients severely limited by low cardiac output. Light strength training is also possible to carry out due to its low loading on the cardiovascular system. Exercise programs have been shown to increase heart rate variability (HRV) [] which is a measure of autonomic function, both vagal control on the heart and sympathetic control on the peripheral vessels []. There are no data at present on the impact of exercise training on mortality and morbidity in heart failure patients. Exercise recommendations: mild to moderate dynamic exercise (to tolerance) such as walking or easy bike riding.
After bypass surgery This group of patients have also been studied less than post-MI patients. It seems that exercise improves functional capacity but there is a lack of controlled
Hypertension In the middle-aged age groups –% of the population in Western countries have hypertension (resting
Cardiovascular and Peripheral Vessel Diseases blood pressure ≥ / mmHg). Regular aerobic exercise lowers blood pressure in patients with essential hypertension. Exercise in the form of walking and jogging is predominantly used in studies, often showing reductions in systolic and diastolic blood pressure of mmHg in around % of hypertensive patients. An exaggerated blood pressure response during physical exertion attenuates after regular training. The blood pressure response to mental stress has also been shown to be attenuated in borderline hypertensive persons after a training program. The greatest effect of exercise training on hypertension is observed after around weeks of regular training, whereas training more than three times per week or for more than min at a time does not lower the blood pressure further. In mildly hypertensive men, short-term physical activity decreases blood pressure for – h after exercise. Average blood pressure is lower on exercise than non-exercise days []. Mild to moderate intensity exercise (intensities of –% V˙2 max) appears to lower systolic blood pressure more and diastolic blood pressure to the same degree as higher intensity training and may be more effective in lowering blood pressure and attenuating an exaggerated blood pressure response to exercise than higher intensity exercises. Exercise also seems to be safe and to lower blood pressure in patients with severe hypertension and left ventricular hypertrophy. No gender differences in the antihypertensive effect of exercise is observed although most studies have been performed in men. Few studies have been performed in older patients; there does not, however, appear to be an age-dependent antihypertensive effect of exercise. A swimming training program reduces arterial blood pressure at rest in individuals with hypertension. Swimming is an alternative for patients that prefer swimming and for those that cannot walk or jog because of, for example, obesity or orthopedic problems [].
Exercise recommendations: exercise.
mild
to
moderate
Valvular disease Generally, mild valvular regurgitations, usually in the mitral and tricuspid valves, are a normal finding on echocardiography, and do not warrant further investigation or any restriction in activity. Mitral valve prolapse is a common disorder that affects a few per cent of the adult population and may cause mitral regurgitation. Some patients with mitral prolapse have supraventricular and/or ventricular arrhythmias. The prognosis regarding arrhythmias in these patients is, however, good. Patients with more than mild valvular regurgitations or patients with valvular stenoses should be followed for progress of valvular disease (for timing of valve repair or valve replacement) and should have an individualized exercise prescription from a cardiologist. In patients with significant aortic stenosis in particular, heavy exercise might be dangerous.
Cardiomyopathies Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy (HCM) is one of the most common causes of sudden death in young athletes. Athletes with symptoms such as syncope, nearsyncope or sudden dizziness, who have pathologic ECG findings with increased QRS amplitudes and ST–T changes or a family history of HCM should therefore be investigated. HCM is a cardiomyopathy with varying degrees of hypertrophy of the left ventricle, often with obstruction of the left ventricular outflow tract. The mechanism for sudden death is presumably malign ventricular arrhythmias although bradycardia also may occur. Subjects with suspected HCM should not exercise and should be investigated; an echocardiographic examination is generally diagnostic while chest X-ray may show an enlarged heart or be normal. A risk assessment should be made, including an exercise stress test and electrophysiologic evaluation. If an athlete wants to continue training at a high level treatment with an implantable defibrillator may be warranted. Figure .. shows an ECG from a patient with hypertrophic cardiomyopathy and Fig. .. shows LV cavity and wall dimensions measured at echocardiography in the same patient.
Chapter .
Fig. .. Echocardiography frame showing left ventricular cavity and wall dimensions in a patient with hypertrophic cardiomyopathy (ECG Fig. ..), septum thickness mm and posterior wall thickness mm compared to normal – mm.
be done to reveal any tendency for malign arrhythmias. An echocardiographic examination should also be made. If all investigations are normal, exercise can be resumed. Sometimes an athlete will have obtained the diagnosis of myocarditis on weak or faulty grounds and the athlete is unnecessarily restrained from training. However, a diagnosis of myocarditis may also indicate other diseases such as cardiomyopathies and an investigation can be warranted to reveal this. This is particularly important if any symptoms are present. In this context one should also keep in mind that congenital coronary artery abnormalities are not an uncommon cause of sudden death among young athletes as well as early coronary artery disease.
Arrhythmias Arrhythmogenic right ventricular dysplasia
Atrial fibrillation
Arrhythmogenic right ventricular dysplasia (ARVD) or arrhythmogenic right ventricular cardiomyopathy (ARVC) is a disease in the myocardium of the right ventricle. Muscle tissue in the right ventricle is replaced with fibrous and fatty tissue. A familial occurrence has been documented but the etiology is largely unknown. Symptoms are arrhythmias (ventricular) or syncope caused by arrhythmia. Typical ECG findings are inverted T waves in the right precordial leads (and this is not a normal finding among athletes), so-called epsilon waves and ventricular arrhythmias. Echocardiography findings include right ventricular dilatation, changes in the right ventricular wall with focal wall thinning and focal aneurysms. The right ventricle is difficult to assess with echocardiography and in patients with any suspicion of ARVD magnetic resonance imaging and/or right ventricle angiography should be performed. ARVD is a cause of sudden death in young athletes and it is of utmost importance to recognize and diagnose these patients early. These patients should be restricted from sports. Implantable defibrillator treatment may be warranted.
Exercise increases vagal tone and may decrease the need for rate regulation by drugs. When heart rate is well controlled during exercise, the subject may exercise to tolerance. Patients with atrial fibrillation are, however, often treated with anticoagulants and should therefore avoid contact sports. Patients with chronic atrial fibrillation can improve functional capacity through an exercise rehabilitation program []. Subjects with atrial fibrillation may compete at high level even in endurance sports as demonstrated by one orienteer who, despite a history of atrial fibrillation since youth, competed at national level and at years of age still had an exercise capacity of W or . W/kg on the bicycle and an oxygen uptake of mL O2/kg (Jensen-Urstad et al., unpublished data).
Atrial flutter The same considerations as for atrial fibrillation may be applied for atrial flutter. Atrial flutter may, however, constitute a larger problem for the subject as rate control may be more difficult. Atrial flutter can in many cases be cured by a radiofrequency ablation procedure []. Electrophysiologic evaluation and possibly curative radiofrequency ablation should therefore be considered.
Myocarditis A person with suspected acute myocarditis should not exercise. After the acute phase is over and the myocarditis is healed a maximal exercise stress test should
Supraventricular tachycardias Subjects with paroxysmal supraventricular tachycardias, with a sudden onset and abrupt ending, usually
Cardiovascular and Peripheral Vessel Diseases have an AV nodal re-entry tachycardia or an atrioventricular re-entry tachycardia utilizing an accessory pathway with or without pre-excitation in the resting ECG. More rarely ectopic atrial tachycardias are found. The tachycardia often starts during exercise when catecholamine levels increase. Patients may feel shortness of breath, palpitations, dizziness and in some cases also syncope. These arrhythmias are generally considered relatively benign but depending on the situation the abrupt onset can make them dangerous, e.g. during diving, cycling, driving etc. In older subjects they may also give more serious symptoms. Individuals with a history of tachycardias with sudden onset especially with symptoms such as dizziness or syncope should be investigated for a diagnosis. Today the arrhythmia can in most cases be cured by radiofrequency ablation. Of note is that resting ECG in most cases is totally normal. Subjects with overt preexcitation in their ECG can sometimes have an accessory pathway capable of conducting at very high frequencies making a paroxysmal atrial flutter or fibrillation dangerous. The accessory pathway may also facilitate development of atrial fibrillation. These individuals may not have a history of tachycardias, but can present with syncope or aborted sudden death as their first symptom (See Case Study ..). Electrophysiologic evaluation should be recommended until a
curative radiofrequency ablation is done. After successful radiofrequency ablation the patient is not restricted from any sport.
Ventricular arrhythmias Except for ventricular ectopic beats without symptoms, all ventricular arrhythmias should be thoroughly investigated. Subjects with a history of tachycardia and symptoms such as sudden dizziness, near-syncope or syncope should be restricted from physical activity until malignant arrhythmias are ruled out.
Cardiac transplantation Preoperatively these patients are severely physically limited. The transplanted heart is denervated and reliant on circulating cathecholamines for increasing heart rate during exercise, although reinnervation may occur. There is a delayed heart rate response at the onset of exercise and with change of exercise level. Exercise intensity cannot therefore be guided by heart rate monitoring and perceived exertion can be used instead. Exercise in these patients increases maximal oxygen uptake, reduces perceived exertion, heart rate and blood pressure during submaximal exercise, and results in a lower resting heart rate and blood pressure. No influence on rejection has been shown.
Peripheral vessel diseases
Case study 4.1.2 A -year-old boy with no previous history of arrhythmias or syncope suddenly loses consciousness during an ice hockey game. He is unconscious for about a minute. When he arrived in the emergency department he had a fast irregular pulse. Systolic blood pressure was mmHg. ECG showed pre-excited atrial fibrillation with a ventricular rate of – beats/min (Fig. ..a). ECG in sinus rhythm showed pre-excitation (Fig. ..b). He was successfully treated with radiofrequency ablation and could resume full activity with no restrictions.
In patients with intermittent claudication, arterial insufficiency in the legs, the major goal is to improve the ability to walk. Exercise training programs have great impact on functional capacity. Pain-free walking time may increase almost % and maximal walking time may be more than doubled in patients participating in an exercise program, and walking speed may increase substantially with an exercise program. A treadmill training program improves functional status during daily activities, weeks of training being more effective than weeks. Treadmill training (walking) alone is more effective in improving functional status in patients with intermittent claudication than strength training or combinations of the training modalities []. In one study comparing angioplasty to exercise training in the treatment of stable claudication the exercise training group had the greatest improvement in terms of improved walking performance
Chapter .
(a)
Fig. .. (a) Atrial fibrillation with rapid conduction over an accessory pathway, heart rate around beats/ min. (b) Pre-excitation in sinus rhythm.
(b)
and less pain []. The effects of exercise on atherosclerosis per se in peripheral arteries have been less studied than in coronary arteries but good cardiorespiratory fitness is associated with slower progression of early atherosclerosis, at least in the carotid arteries []. Exercise recommendations: walking to tolerance. For further recommendations regarding eligibility
for competition in athletes with cardiovascular abnormalities, the th Bethesda Conference [] provides panel consensus recommendations.
Summary Over years ago Henschen described the physiologic adaptation of the heart to physical training and distinguished this from cardiac enlargement due to heart disease. The term ‘athlete’s heart’ is commonly
Cardiovascular and Peripheral Vessel Diseases Table .. Which patients should not exercise? Patients with: uncontrolled hypertension untreated congestive heart failure severe stenotic or regurgitant valvular disease hypertrophic cardiomyopathy acute myocarditis arrhythmogenic right ventricular dysplasia unclear dysrhythmias
used for the increased left ventricular dimensions seen in trained athletes. The adaptation to intense physical training, especially endurance training, also comprises enlargement of other heart chambers and resting bradycardia. Physical exercise has well-documented positive effects on the cardiovascular system in both healthy and diseased subjects. In healthy subjects regular exercise has large long-term benefits with very few direct risks. For the vast majority of individuals with known cardiovascular disease physical exercise has positive effects regarding quality of life, and may decrease morbidity and mortality. In patients with known cardiovascular disease exercise programs should, however, be individualized with respect to the underlying disease. There is a small number of subjects where exercise might be contraindicated at least until they have received proper treatment (Table ..). Athletes with symptoms such as syncope, nearsyncope and sudden dizziness or with highly abnormal ECGs should be investigated to rule out an underlying possibly life-threatening disease.
Multiple choice questions A -year-old middle-distance runner experiences a syncope during interval training; during a -m run at maximal speed he falls and is unconscious for a couple of minutes before he wakes up and feels quite OK apart from a hurting arm. Which (one or more) of the following statements is/are correct? a Syncope during exercise is normal and no further investigation is warranted. b Syncope during exercise only needs investigation if it happens more than once.
c Syncope during exercise may be a sign of lifethreatening disease and the patient should be promptly investigated. Which (one or more) of the following statements about ECG and echocardiography findings in endurancetrained athletes is/are normal findings: a first-degree atrioventricular block b low resting heart rate, below beats/min c large QRS amplitudes and high T waves d slightly enlarged left ventricle on echocardiography. A strength-training athlete is investigated because of fatigue over the last few months. Echocardiography shows a left ventricle diameter of mm and a thickness of the posterior and septal wall of – mm. There is normal left ventricular function. Which (one or more) of the following statements is/are correct? a This is a normal finding. b The left ventricular walls are thick but this is normal finding in a strength-trained athlete. c The LV hypertrophy in this athlete is probably a pathologic finding and further investigation is warranted. An otherwise healthy patient with treated essential hypertension wants to start jogging. Which (one or more) of the following statements is/are correct? a Exercise in contraindicated as it may be harmful. b Moderate aerobic training is recommended. c Moderate aerobic training is recommended but only once a week. d Exercise a few times a week may reduce resting systolic blood pressure by mmHg. Which (one or more) of the following statements is/are correct about moderate aerobic exercise weeks after uncomplicated acute myocardial infarction? a Not allowed because of risk of arrhythmias. b Leads to increased exercise ability and V˙2. c Improves the prognosis. d Improves blood lipid status.
References Henschen SE. Om Skidlöpning och Skidtäfling ur Medicinsk Synpunkt. Upsala Universitets Årstidskrift. Medicin II. : –. Pelliccia A, Culasso F, Di Paolo FM, Maron BJ. Physiologic left ventricular cavity dilatation in elite athletes. Ann Intern Med ; : –. Pelliccia A, Maron BJ, Culasso F, Spataro A, Caselli G.
Chapter .
Athlete’s heart in women. Echocardiographic characterization of highly trained elite female athletes. J Am Med Assoc ; : –. Pelliccia A, Maron BJ, Spataro A, Proschan MA, Spirito P. The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes. N Engl J Med ; : –. Maron BJ, Pelliccia A, Spataro A, Granata M. Reduction in left ventricular wall thickness after deconditioning in highly trained Olympic athletes. Br Heart J ; : –. Jensen-Urstad K, Saltin B, Ericsson M, Storck N, JensenUrstad M. Pronounced resting bradycardia in male elite runners is associated with high heart rate variability. Scand J Med Sci Sports ; : –. Rost R, Hollmann W. Athlete’s heart — a review of its historical assessment and new aspects. Int J Sports Med ; : –. Grimby G, Saltin B. Physiological analysis of physically well-trained middle-aged and old athletes. Nord Med , –. Jensen-Urstad K, Saltin B, Jensen-Urstad M. High prevalence of arrhythmias in elderly male athletes with a lifelong history of regular strenuous exercise. Heart ; : –. Northcote RJ, Canning GP, Ballantyne D. Electrocardiographic findings in male veteran endurance athletes. Br Heart J ; : –. Leon AS, Connett J, Jacobs DR Jr, Rauramaa R. Leisuretime physical activity levels and risk of coronary heart disease and death. The Multiple Risk Factor Intervention Trial. J Am Med Assoc ; : –. Blair SN, Kohl HW III, Paffenberger RS Jr, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality. A prospective study of healthy men and women. J Am Med Assoc ; : –. Heberden W. Some account of a disorder of the breast. Med Trans Coll Physiol ; II: –. Parry CH. An Inquiry Into the Symptoms and Causes of Syncope Anginosa, Commonly Called Angina Pectoris; Illustrated by Dissections. London: R Cutwell for Caldell and Davies, . Hambrecht R, Niebauer J, Marburger C et al. Various intensities of leisure time physical activity in patients with coronary heart disease: effects of cardiorespiratory fitness and progression of coronary atherosclerosis. J Am Coll Cardiol ; : –. Balady GJ, Fletcher BJ, Froelicher EF et al. Statement on cardiac rehabilitation programmes. Circulation ; : –. Hedback B, Perk J, Wodlin P. Long-term reduction of cardiac mortality after myocardial infarction: -year results of a comprehensive rehabilitation programme. Eur Heart J ; : –. Haskell WL, Alderman EL, Fair JM et al. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervent Project (SCRIP). Circulation ; : –.
Jensen-Urstad K, Samad B, Bouvier F et al. Improved prognostic value of symptom-limited vs low-level exercise stress test after thrombolytically treated myocardial infarction. Heart ; : –. Holmback AM, Sawe U, fa*gher B. Training after myocardial infarction: lack of long-term effects on physical capacity and psychological variables. Arch Phys Med Rehabil ; : –. Niebauer J, Hambrecht R, Velich T et al. Attenuated progression of coronary artery disease after years of multifactorial risk intervention: role of physical exercise. Circulation ; : –. Todd IC, Ballantyne D. Effects of exercise training on the total ischaemic burden: an assessment by hour ambulatory electrcardiographic monitoring. Br Heart J ; : –. Stahle A, Mattsson E, Ryden L, Unden A, Nordlander R. Improved physical fitness and quality of life following training of elderly patients after acute coronary events. A year follow-up randomized controlled study. Eur Heart J ; : –. Wielenga RP, Huisveld IA, Bol E et al. Safety and effects of physical training in chronic heart failure. Results of the Chronic Heart Failure and Graded Exercise study. Eur Heart J ; : –. Tanaka H, Bassett DRJ, Howley ET, Thompson DL, Ashraf M, Rawson FL. Swimming training lowers the resting blood pressure in individuals with hypertension. J Hypertension ; : –. Magnusson G, Gordon A, Kaijser L et al. High intensity knee extensor training in patients with chronic heart failure. Major skeletal muscle improvement. Eur Heart J ; : –. Coats AJS, Adamopoulos S, Radaelli A et al. Controlled trial of physical training in chronic heart failure: exercise performance, hemodynamics, ventilation, and autonomic function. Circulation ; : –. Radaelli A, Coats AJ, Leuzzi S et al. Physical training enhances sympathetic and parasympathetic control of heart rate and peripheral vessels in chronic heart failure. Clin Sci ; : –. Pescatello LS, Fargo AE, Leach CN, Scherzer HH. Short term effect of dynamic exercise on arterial blood pressure. Circulation ; : –. Mertens DJ, Kavanagh T. Exercise training for patients with chronic atrial fibrillation. J Cardiopulm Rehabil ; : –. Waldo AL. Treatment of atrial flutter. Heart ; : –. Regensteiner JG, Steiner JF, Hiatt WR. Exercise training improves functional status in patients with peripheral arterial disease. J Vasc Surg ; : –. Perkins JM, Collin J, Creasy TS, Fletcher EW, Morris PJ. Exercise training versus angioplasty for stable claudication. Long and medium term results of a prospective, randomised trial. Eur J Endovasc Surg ; : –.
Cardiovascular and Peripheral Vessel Diseases Lakka TA, Laukkanen JA, Rauramaa R et al. Cardiorespiratory fitness and the progression of carotid atherosclerosis in middle-aged men. Ann Intern Med ; : –. Maron BJ, Isner JM, Mckenna WJ. th Bethesda Confer-
ence: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. Task force : hypertrophic cardiomyopathy myocarditis and other myopericardial diseases and mitral valve prolapse. J Am Coll Cardid ; : –.
Chapter 4.2 Exercise and Infectious Diseases BENTE KL ARLUND PE DE RSE N, GÖRAN FRI MA N & LA RS WE SSL É N
Classical reference
Introduction Compared with a sedentary lifestyle, the practice of moderate, regular physical training is generally considered to be associated with improved health including, for example, lower blood pressure and body weight, as well as improved glucose tolerance. The issues raised in this chapter are: (i) to what extent exercise and training influence susceptibility to infections; (ii) the potential risks of strenuous exercise during infections; (iii) to what extent infections influence performance; and (iv) suggestions as to practical guidelines for exercise with symptoms of infectious diseases.
40
Symptomatic Asymptomatic
r = 0,995 p < 0,01
35 Number of runners
Peters EM, Bateman ED. Ultramarathon running and upper respiratory tract infections and epidemiological survey. S Afr Med J ; : –. This was one of the first studies to demonstrate a relationship between acute stress and susceptibility to upper respiratory tract infections. A prospective study of the incidence of symptoms of upper respiratory tract infections in randomly selected runners, who took part in a -km run, was performed. Incidences were compared with individually matched controls who did not run. Symptoms of upper respiratory tract infections occurred in % of the runners compared with % of controls and were most common in those who achieved the faster race times. The incidence in slow runners was no greater than in controls. It is suggested that intense physical stress increases the susceptibility to upper respiratory tract infections (Fig. ..).
30 25 20 15
42%
10 5
32%
27%
47% 19%
0 % of V˙2 max) of long duration (> h) the immune system is impaired for several hours or even days (Fig. ..). Thus, in the recovery period after exercise, the lymphocyte concentration declines and the ability of the lymphocytes to proliferate and mediate cytotoxicity against virus-infected or malignant cells is impaired []. The use of in vivo immunologic methods supports these findings. Furthermore, salivary IgA levels decline with intense exercise []. Also, animal experi-
Exercise and Infectious Diseases ments tend to show that a given microorganism becomes more invasive and pathogenic if the animal performs intense physical activity during the incubation period or during the acute disease. This has been demonstrated for polio- and coxsackie virus B infection, as well as for influenza and others. After intense long-term exercise, not only is the immune system characterized by impairment of the cellular immune system but, concomitantly, markedly enhanced levels of pro- and anti-inflammatory cytokines can be demonstrated. A fully developed cytokine cascade develops within the first few hours of strenuous exercise, having some similarities to the acute phase response to trauma and sepsis (Fig. ..) []. One indicator of chronic exercise as a lifestyle factor is to compare resting levels of any immune parameter in untrained controls and in conditioned athletes. Most studies show that trained subjects compared to untrained subjects have enhanced natural immunity []. Animal experiments support these findings; thus, trained animals have enhanced survival when they are infected at rest with Salmonella typhimurium [] or influenza virus [].
Moderate physical activity
Thus, there is no doubt that exercise and training influence the concentration of immunocompetent cells in the circulating pool, as well as the function of these cells. An important question is, however, to what degree these cellular changes are of clinical significance
Relative increase in plasma concentration
IL-6
IL-lra IL-10 IL-8 MIP-I TNF IL-1 Time Marathon run Fig. .. Schematic changes in a number of cytokines in relation to strenuous exercise.
Reduced risk of infection
Strength of immune defence
Normal value
Intense physical activity
Increased risk of infection Open window
Physical activity Time Fig. .. During moderate to intense exercise the immune system is enhanced (as shown by mobilization of lymphocytes to the circulation), but intense exercise is followed by a period of immune impairment (decreased natural killer cell activity, lymphocyte proliferation and levels of salivary IgA) during which there is an ‘open window’ of opportunity for pathogens.
Chapter .
Exercise and infections Myocarditis One reason why clinicians advise against performing vigorous exercise during acute infections is the potential for supervening myocarditis [,]. Acute exercise during ongoing viral myocarditis causes increased viral replication, inflammation and necrosis in the myocardium. Thus, swimming during the initial phase of coxsackie virus B infection in immunologically immature (-week-old suckling) mice increased mortality []. Many of the affected mice died of congestive heart failure while swimming, with massive cardiac dilatation and necrosis upon autopsy. In another study of coxsackie virus B infection in –-week-old mice, exercise on a motor-driven treadmill to exhaustion at h after the inoculation of virus did not influence lethality but the myocarditic lesions were aggravated by the exercise []. As compared to the situation in infected control mice who were allowed to rest, the exercise-associated increased myocardial inflammation and necrosis were related to a decreased number of cells expressing major histocompatibility complex class II, such as macrophages. Thus, the extent of tissue damage in these exercised mice may be related to decreased macrophage mobilization followed by increased destruction of the myocardium, possibly mediated by cytotoxic T cells. Myocarditis may be an acute, subacute or chronic disease and most studies show acute myocarditis to be the most common of these manifestations (Fig. ..). Myocarditis may be either asymptomatic (subclinical) or cause chest symptoms of variable severity, ranging from vague oppression to sharp pain, as well as dyspnea and irregular heart rhythm. The observation that myocarditis can exist without any cardiac symptoms [] is in line with the finding of active myocarditis in % of unselected autopsies performed during a -year period []. Commonly, symptoms from other organs precede the onset of cardiac symptoms, such as symptoms of upper respiratory tract infection []. Acute infectious myocarditis is usually a benign condition, which has a favorable long-term prognosis in the great majority of cases [–]. Sudden unexpected death (SUD) in the acute phase
Number of cases
in humans, especially with respect to resistance to infectious diseases. Acute
Subacute
Chronic
Months
Years
Subclinical
Symptomatic Weeks
Time Fig. .. Spectrum of infectious myocarditis/ cardiomyopathy. Reproduced with permission from [].
of symptomatic or asymptomatic myocarditis is a well-known but rare phenomenon. SUD from cardiac causes in the young (below years of age) may be caused by several underlying conditions and is often precipitated by exercise [,]. Several studies have shown that an average of % of cases of SUD in young athletes have been caused by myocarditis [] and in only a few studies has myocarditis been a more frequent cause of SUD [,]. Clustering of SUD is rare []. During –, however, an increased rate of SUD was reported among young Swedish orienteers; there were men and one woman (Fig. ..) and myocarditis was the most frequent histopathologic feature [,]. The inflammatory process was subacute to chronic. All but two of the SUDs were associated with exercise. It has previously been found that loss of performance may be the only symptom of ongoing myocarditis [] but all of these deceased people had performed at, or close to, their individual maximum shortly before they died. Five of them, however, had experienced heart-related symptoms prior to death, such as fainting during exercise, tachycardia or chest pain, but the majority had not reported any prior warning symptoms. Since late there have been no new cases of SUD among young (< -year) Swedish orienteers. It seems plausible that the various measures taken at that time, including the introduction of a -month intermission in training and competition in early , may have had a favorable effect in changing behavorial patterns; previously, the training habits among young elite orienteers had been extreme
Exercise and Infectious Diseases Preventive measures introduced
2 1
[,]. Continued research has shown subacute Bartonella infection to be the suggested cause of the orienteers’ heart disease [,]. For details see http://publications.uu.se/theses/fulltext/--.pdf
Poliomyelitis In the s and s, it was demonstrated that polio took a more serious course if patients had exercised during the early stages of the disease. The idea that physical exercise might influence the clinical outcome of poliomyelitis was based on case reports of strenuous physical exertion prior to the onset of severe paralysis. In total, cases of poliomyelitis were reported and it was found that physical activity of any kind during the preparalytic stage increased the danger of severe paralysis. This observation was confirmed in epidemiologic studies and animal studies [,].
HIV infection The primary immunologic defect in individuals infected with human immunodeficiency virus (HIV) is a depletion of the CD+ T cell subset. However, conjoint effects have been reported on the function of other lymphocyte subpopulations, including the natural killer (NK) and lymphokine-activated killer (LAK) cells and cytokines. In healthy subjects exercise-induced alterations in the immune system include changes in blood mononuclear cells, proliferative responses as well as NK and LAK cell functions. A study [] on acute exercise was designed to determine to what extent HIVinfected individuals were able to mobilize immunocompetent cells to the blood in response to a physical exercise challenge. Interestingly, HIV-seropositive subjects were shown to possess an impaired ability
2000
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1996
1994
1992
1990
1988
1986
1984
1982
0 1979 1980
Fig. .. Sudden unexpected cardiac deaths (SUD) in young Swedish orienteers – (n = ); adapted from []. Since , no more cases of SUD have occurred among young (< years of age) Swedish orienteers (as of May ).
Cases
3
Year
to mobilize neutrophils, and cells mediating NK cell activity. Furthermore, only seronegative persons showed increased LAK cell activity in the blood in response to exercise, whereas HIV-seropositive subjects did not. There are only few controlled studies on the effect of chronic exercise on the immune system in HIVseropositive subjects. Despite significant increases in neuromuscular strength and cardiorespiratory fitness, there were no significant effects on the CD cell numbers or other lymphocyte subpopulations []. Similar observations have been found in a number of other studies (reviewed in []). However, recent findings in HIV-positive hom*osexual men suggest that exercising – times a week is associated with a temporary slowing down of the progression toward AIDS, compared with the situation in a non-exercising control group []. Taken together, however, the available data do not allow any firm conclusions to be drawn regarding possible beneficial or detrimental effects of exercise training on the immune system in HIV-positive individuals. Thus, although the case of ‘Magic’ Johnson highlights the fact that HIV infection is an issue also within elite sports and athletics, the current knowledge does not allow for any scientifically based guidelines regarding the advisability for an individual asymptomatic athlete to continue practising his sport at the elite level.
Upper respiratory tract infections In contrast to the limited experimental evidence, there are several epidemiologic studies on exercise and upper respiratory tract infection (URTI). These studies are based on self-reported symptoms rather than clinical verification. In general, an increased
Chapter . Metabolic responses to infections and effects on performance
number of URTI symptoms have been reported in the days following strenuous exercise (e.g. a marathon race) [–], whereas moderate training has been claimed to reduce the number of symptoms [,]. It has been suggested that a ‘J’-shaped curve best describes the relationship between the intensity of physical activity, ranging from a sedentary lifestyle to the activity of the high-performance endurance athlete (along the x-axis) and the sensitivity to upper respiratory tract infections (Fig. ..). The finding of an increased frequency of infections following intense exercise may be causally linked to the postexercise impairment of immune function.
Acute infections in general evoke a multitude of host responses, some of which are directed toward the causative microorganism, including specific cellular and humoral immunity, whereas others have the purpose of adapting the metabolism of the host in order to increase its potential for survival. This non-specific, systemic ‘acute phase reaction’ includes the mobilization of nutrients from body tissues, predominantly from muscle tissue (Fig. ..). This is to satisfy the increased nutritional needs of the activated immune system and to provide substrates for the accelerated energy production during fever, which is generally associated with anorexia and decreased food intake. The elevated insulin levels during infection and fever generally hamper the mobilization of fatty acids from fat depots. The generalized catabolism of muscle protein progresses throughout the acute phase of the infection and includes skeletal muscles, as well as the heart muscle, regardless of whether or not there is a coexisting myocarditis. Several mild infections, however, such as an uncomplicated common cold, may not give rise to any significant muscle protein degradation (for review, see [,,,]). When an acute infection is over, the decline in muscle strength and endurance from the individual’s baseline conditions when healthy is correlated to the muscle protein loss caused by the infection. In studies of otherwise healthy young male adults, a week-long uncomplicated febrile infection of a severity that re-
Risk of URTI
Above average
Average
Below average Sedentary
Moderate
High
Amount and intensity of exercise Fig. .. A J-shaped curve describes the concept that the relative risk of acquiring upper respiratory tract infections (URTI) is decreased in individuals who practice moderate exercise, but increased in those who ‘overtrain’, compared to the risk in sedentary subjects.
Fever Glucose Brain
Acute-phase reactants
Liver
Anorexia Macrophage Amino acids Stomach
Bone marrow
Heart Muscles
Immune cells
Fig. .. Schematic description of cytokine effects in acute infectious diseases. Cytokines stimulate muscle protein degradation by mediating release of amino acids from muscles and increased uptake of amino acids in the liver and other organs. Similarly, cytokines are involved in the fever response and in the development of anorexia during infection and fever. Reproduced with permission from [].
Exercise and Infectious Diseases quired ‘clinical bed rest’ resulted in a decrease in the isometric strength of –% [], and in the isometric endurance of –% [] in various major muscle groups tested shortly after the disappearance of clinical symptoms of disease, as compared to subsequent repeated individual baseline results when the patients were healthy. Furthermore, in both young male and young female adults, such infections caused a decrease in the aerobic exercise capacity, as determined from the heart rate response during submaximal exercise, by approximately % []. The aerobic exercise capacity is dependent on central factors, such as the plasma volume, the total hemoglobin and the myocardial function, as well as on peripheral factors, i.e. the state of the skeletal muscles []. Potentially, all these factors may be negatively influenced by either the infection or the clinical bed rest that is part of the treatment, or both. In a group of healthy young adult males who served as controls in the studies described above [,,], one week of bed rest, similar to the clinical bed rest of the patients in those studies, resulted in a decrease in the heart raterelated submaximal exercise capacity of –% [], whereas the maximal oxygen uptake decreased by only %, the plasma volume by % and the total hemoglobin by % []. (For obvious ethical reasons, maximal oxygen uptake studies could not be carried out in the patients, who were tested on day after abatement of fever.) Thus, in the patients, the infection and the associated bed rest both contributed to the deterioration in aerobic exercise capacity. Conversely, neither the isometric muscle strength nor the isometric muscle endurance was influenced by the clinical bed rest in the healthy control subjects [,]. The recorded decreases in the isometric strength and endurance of up to and %, respectively, in the patients on day after abatement of fever were thus solely linked to the infection as a result of the catabolic effects on muscle tissue (Fig. ..). During even the very early phase of ongoing infection and fever the muscle capacity, as well as the aerobic capacity, is already decreased, and these events are unrelated to the muscle catabolism, which is minimal at this early stage []. Furthermore, during ongoing infection and fever, muscle coordination and ‘motor precision’ required for carrying out ‘synthetic work’ are impaired []. This may potentially increase the risk of
ankle sprains, dislocations, etc. in many sports []. The underlying mechanisms explaining the deterioration in muscle function during early infection and fever are not fully understood; one study showing the safety margin of the neuromuscular transmission to be decreased during various ongoing febrile infections is suggestive of unspecific involvement of the nervous system, although that particular disturbance cannot account for any muscle weakness []. During infections that are severe enough to evoke a systemic acute phase reaction, the magnitude of the resulting muscle protein catabolism is the major determinant of the length of the convalescent period, provided there is no complicating myocarditis. For example, following a brief, flu-like illness with about h of fever, as in sandfly fever, as long as weeks is required for the accumulated muscle protein losses to be replenished. This period is longer after more longlasting or severe infections []. Available evidence suggests that the time to full replenishment of the muscle protein and resumed performance can be shortened by physical training once the infection is over [,].
Guidelines In general it may be said that physical activity in connection with infections is associated with certain medical risks, both for the infected individual and for fellow sportsmen, who may in turn become infected. The latter risk has relevance mainly in team sports, but is also possible in other sports where the participants are in close physical contact before, during or after the sporting event. Several previous publications include pertinent information on the handling of infections in athletes and on what to tell the patient [–]. Recently, the following considerations and suggestions for guidelines for management and counseling the athlete, primarily intended for the general practitioner, have been published [].
The risk to the individual The risks of deleterious effects of physical activity in an infected person vary considerably, depending both on the location, degree and cause of the infection and on the intensity and type of physical activity. Vigorous or prolonged physical activity as well as intensive mental stress can lower the defense against infection.
Chapter .
(a)
(b)
(c)
Furthermore, a subclinical complication of infection, e.g. myocarditis, can be aggravated by physical exertion. The risk level is generally higher in a competing sportsman than in the ordinary jogger, for example. The physician’s advice to different patients therefore needs to be individualized. The muscular and cardiac capacity is reduced in connection with most infections, especially if the infection is accompanied by fever. Continuing to train during the infection cannot generally prevent this temporary impairment of physical capacity. On the contrary, training during the course of an infection can lead to further reduction of the capacity, infection complications and other damage. The nervous system is affected in general by infection and fever, with impairment of the coordination
Fig. .. Transmission electron micrographs of quadriceps muscle biopsies from: (a) a healthy subject after week of ‘clinical bed rest’ showing normal ultrastructure (magnification ¥ ); (b) a patient who has suffered a weeklong influenza type A infection showing degeneration of myofilaments; biopsy taken days after abatement of fever (magnification ¥ ); and (c) a patient suffering from acute coxsackie virus type B infection with complicating myocarditis showing distended sarcoplasmic reticulum; biopsy taken after week of symptoms (magnification ¥ ). Changes occurred regardless of symptoms of myalgia [].
ability (the ‘motor precision’). This can influence physical performance, especially in sports that demand high precision. In addition, the risk of damage to joints, ligaments and tendons is increased. Physical exertion in the presence of fever means an increased hemodynamic load on the heart compared with such exertion in the healthy individual. This may lead to the manifestation, sometimes in the form of fatal dysrhythmia, of perhaps previously undiagnosed heart disease, e.g. coronary sclerosis or hypertrophic cardiomyopathy. Further, for example in respiratory tract infections, a heavy physical load may aggravate the infection, with more pronounced or prolonged symptoms, or development of complications, such as sinusitis and pneumonia. This applies even in the absence of fever. Myocarditis is the complication that has
Exercise and Infectious Diseases been discussed most in this connection. It should be pointed out, however, that in the majority of cases infectious myocarditis resolves, when properly attended to, without residual symptoms and that in myocarditis sudden death is rare. A large number of different viruses and bacteria can infect the heart and give rise to myocarditis. Some microorganisms are more prone than others to attack the heart, while others do this very rarely. The former group includes enteroviruses (mainly coxsackie virus), and the latter group includes common cold viruses (rhinovirus and coronavirus). There is no quick test for demonstrating these viruses in an infected person. Moreover, many other microorganisms associated with a varying degree of risk of myocarditis often give rise to similar symptoms. There are certain rules of thumb (see below), but their precision varies. In clinical practice, therefore, conclusions drawn from the symptomatology and clinical picture regarding the microbial cause and hence the risk of myocarditis can be uncertain. As a general rule, the physician should adopt a more cautious attitude towards physical activity in infected sportsmen who are under ‘pressure’ to achieve their maximal performance than in infected joggers, for example, as mental stress can also lower the defense against infection. Special attention must be paid to elite athletes, where the environmental demands and expectations regarding participation and success, as well as their own demands, are particularly high. In certain sports the impairment of performance associated with the infection can be compensated by the sportsman’s routine and skill, which may lead to increased risk-taking. Mononucleosis can often be diagnosed by a rapid test. This disease can be associated with myocarditis. Further, mononucleosis is not infrequently accompanied by splenic enlargement, which has an impact on counseling, especially of persons practicing contact sports and weight-lifting. Tonsillopharyngitis with b-streptococci can also be diagnosed by a quick test, and penicillin therapy should be given. There is some risk of myocarditis, despite treatment, during the first week. Gastroenteritis is associated with fluid losses, which reduce performance as a result of a decreased plasma volume. Fluid losses through sweating in connection with physical exercise accentuate this effect and in-
crease the risk of collapse and of manifestation of undiagnosed heart diseases. Myocarditis can sometimes occur as a complication of gastroenteritis. Skin infections of different kinds are common in sports, usually in the form of infected chafing sores, athlete’s foot, infected eczema and plantar warts. Dermal borreliosis (erythema migrans in Lyme disease) is common among sportsmen who are exposed to ticks. Myocarditis is a rare but well-known complication of borreliosis. Sometimes even minor skin infections, on account of their location, can form a hindrance to sports activities and in occasional cases can constitute a port of entry for bacteria that give rise to septicemia. Small superficial skin infections are seldom contraindications to training and competitions. One exception is herpes infection in the skin, particularly in wrestlers. During wrestling viruses can easily be transmitted to other wrestlers via skin lesions. Genital infections give rise to local and general symptoms of varying degrees of severity, or may be asymptomatic. It is uncommon for the microorganisms involved in such infections to lead to myocarditis. There is currently no evidence that the course of the disease in asymptomatic HIV infection is influenced unfavorably by physical activity and sports. On the contrary, it has been documented that training and competitive activities have an important effect in improving the quality of life in many HIV patients.
Suggestions for guidelines for management and counseling • In people with fever ( °C or more), rest should always be recommended. • People who know their normal temperature and pulse curves should rest if their resting temperature has increased by .– °C or more and at the same time their resting pulse has risen by b.p.m. or more, in combination with general symptoms (malaise, muscle pains, muscle tenderness, diffuse joint pains, headache). • General malaise of acute onset, especially in combination with muscle pains, muscle tenderness, diffuse joint pains and headache, should give reason to recommend rest, even when the body temperature is normal. • In all infections, caution should be observed during the first – days of symptoms, even with a normal
Chapter . body temperature, until the body defense against infection has had time to become mobilized and until the further development of the infection becomes clear. Serious infections often have prodromal symptoms, and in such cases it may take – days before the serious nature of the infection becomes evident. • In people with nasal catarrh without a sore throat, cough or general symptoms, caution is recommended during the first – days, after which training can gradually be resumed, if the symptoms do not become intensified. • If a cold is accompanied by further symptoms, e.g. sore throat, hoarseness or cough, the recommendation should be more restrictive, depending on the degree and development of the symptoms. • In people with a sore throat without any other manifestations, caution is advised until this has begun to improve. In cases of b-streptococcal tonsillopharyngitis, which should be treated with penicillin for days, rest is recommended until the symptoms have disappeared, and caution during the first week of treatment even in the absence of symptoms. • In cases of mononucleosis, the general recommendation is rest until the symptoms have disappeared. Sometimes, however, fatigue can persist for several months after this disease, and in such cases a suitable time for resuming training has to be judged individually. Further, mononucleosis is often accompanied by splenic enlargement, and an enlarged spleen in mononucleosis is fragile and can rupture if it is subjected to a blow or increased pressure. Thus people engaged in contact sports such as football, wrestling and so on, and weight-lifting, should wait month after they have become free from fever before taking up these sports again. • In gastroenteritis, heavy physical exercise should be avoided. • In skin infections, the recommendations need to be individualized. All athletes should observe caution in episodes of herpes accompanied by regional lymphadenitis or general symptoms. Individuals practicing contact sports should be screened for dermal herpes lesions and infected individuals should wait until the vesicles have dried before resuming these activities. Erythema migrans should be treated with penicillin or doxycycline for days and caution should be recommended during the first week.
• In cystitis, which mainly affects women, strenuous physical exertion should be avoided until the symptoms have subsided. • People with ongoing genital infections should avoid strenuous physical exertion. In asymptomatic genital chlamydial infection it seems reasonable to restrict the physical activity during the period of antibiotic therapy. • Asymptomatic HIV infection constitutes no hindrance to exercise and sports (as far as the infected person is concerned — see below). • In most cases of febrile infectious diseases, training can be resumed as soon as the fever has abated. It is important, however, that the training should be resumed gradually, and with attention paid to the ‘body signals’. If unexpected symptoms referable to the heart should appear, for example pain, a sense of pressure or discomfort in the chest, irregular heart beats, abnormal breathlessness or fatigue or exertional syncope, the training should be discontinued and a physician consulted, because myocarditis can occur in connection with a number of different infections. It is important to point out that myocarditis can develop even without prior symptoms of infection. In persons who have reached middle age, the possibility of coronary disease or myocardial infarction should also be considered with symptoms of this type. • In general, it may be said that in infections, as in other situations, it is important to ‘listen to the body signals’.
Risks to the environment — epidemiologic aspects Plantar warts are readily spread via shower floors and changing-rooms. These warts should therefore be treated quickly in athletes. Respiratory tract infections can be readily transmitted both by droplet infection (sneezing/cough) and by contact (direct skin contact such as hand-shaking, or indirect contact via objects) among sportsmen who are in close proximity before, during or after a training or competitive event. Examples of this are countless. In addition, the fact that strenuous or prolonged physical exertion can reduce the defense against infection increases the susceptibility to respiratory tract infection. Because prevention of exposure is the only prophy-
Exercise and Infectious Diseases lactic measure available in the vast majority of respiratory tract infections, the above aspects should be carefully considered by the individual athlete, as well as by trainers and sports leaders, before an infected individual allows himself or is allowed to meet his fellow participants prior to important training and competitive events. Annual immunization against influenza should be recommended for elite athletes. Generally, athletes with HIV infection should be allowed to participate in sports just like any others. Physicians of HIV patients who are engaged in sports associated with a risk of exposure of blood, such as wrestling, boxing, football and so on, should inform the patients concerned of the theoretical risk that the infection can be transmitted further and strongly advise against their continuing to take part in sports of that kind. It is important to consider the anonymity aspects and to ensure that the infection status of the person concerned does not come to the knowledge of leaders or team-mates unless the individual has given his/her consent.
Summary Exercise induces dramatic changes in the immune system. In essence, moderate exercise stimulates the immune system, whereas long-lasting intense exercise is followed by immune impairment, which may last from several hours to days. During this postexercise immune impairment, called ‘the open window in the immune system’, microorganisms may invade the host and establish an infection. Thus, it has been shown that several microorganisms become more invasive after strenuous exercise. A J-shaped curve describes the concept that the relative risk of acquiring upper respiratory tract infections is lower in individuals who practise moderate exercise, but higher in those who ‘overtrain’, compared to the risk in sedentary subjects. During infections the muscle capacity, as well as the aerobic capacity, is decreased and, in addition, muscle coordination and ‘motor precision’ are impaired, which may increase the risk of ankle sprains and dislocations in many sports. After abatement of fever, performance is impaired until the muscle protein loss, resulting from the infection, has been replenished. Although the physician’s advice to different patients needs to be individualized, the general advice is to rest when ill. This advice can be modified when the symp-
toms have lasted for a couple of days and are strictly ‘above the neck’ (stuffy or running nose, sneezing, watery eyes, scratchy throat and no fever). However, when ‘below the neck’ symptoms exist (aching muscles, malaise, hacking cough, nausea, vomiting, diarrhea, fever), exercise training should always be avoided.
Multiple choice questions Exercise influences the following immune parameters: a lymphocytes b neutrophils c natural killer cells d salivary IgA e cytokines. When trained animals and humans are examined at rest, you will find: a enhanced natural immunity b decreased natural immunity c enhanced survival of infections d decreased survival of infections e no changes from untrained controls. Metabolic responses to infections and effects on performance. a Nutrients are mobilized, especially from muscle, during infection. b The declines in muscle strength and endurance do not correlate with muscle protein loss caused by infection. c Bed rest induces a decrease in exercise capacity. Guidelines for athletes are: a In persons with fever ( °C or more), rest should always be recommended. b In persons with nasal catarrh without a sore throat, cough or general symptoms, caution is recommended during the first – days, after which training can gradually be resumed, if the symptoms do not become intensified. c In gastroenteritis heavy physical exercise should be avoided. d Asymptomatic HIV infection constitutes no hindrance to exercise and sports.
References Pedersen BK, Hoffman-Goetz L. Exercise and the immune system: regulation, integration and adaptation. Physiol Rev ; : –.
Chapter . Hoffman-Goetz L, Pedersen BK. Exercise and the immune system. A model of the stress response? Immunol Today ; : –. Gleeson M, McDonald WA, Pyne DB et al. Salivary IgA levels and infection risk in elite swimmers. Med Sci Sports Exerc ; : –. Pedersen BK. Exercise and cytokines. Immunol Cell Biol ; : –. Cannon JG, Kluger MJ. Exercise enhances survival rate in mice infected with Salmonella typhimurium (). Proc Soc Exp Biol Med ; : –. Ilbäck NG, Friman G, Beisel WR, Johnson AJ, Berendt RF. Modifying effects of exercise on clinical course and biochemical response of the myocardium in influenza and tularemia in mice. Infect Immun ; : –. Friman G, Ilbäck NG. Acute infection: metabolic responses, effects on performance, interaction with exercise, and myocarditis. Int J Sports Med ; : S–. Friman G, Ilbäck NG. Exercise and infection — interaction, risks and benefits. Scand J Med Sci Sports ; : –. Gatmaitan BG, Hanson JL, Lerner AM. Agumentation of the virulence of murine coxackievirus B myocardiopathy by exercise. J Exp Med ; : –. Ilbäck NG, Fohlman J, Friman G. Exercise in coxsackie B myocarditis: effects on heart lymphocyte subpopulations and the inflammatory reaction. Am Heart J ; : –. Karjalainen J, Heikkilä J, Nieminen M et al. Etiology of mild acute infectious myocarditis. Relation to clinical features. Acta Med Scand ; : –. Gravanis MG, Sternby NH. Incidence of myocarditis. Arch Pathol Lab Med ; : –. Karjalainen J, Heikkilä J. Incidence of three presentations of acute myocarditis in young men in military service. Eur Heart J ; : –. Bergström K, Erikson U, Nordbring F et al. Acute nonrheumatic myopericarditis: a follow-up study. Scand J Infect Dis ; : –. Giesecke J. The long-term prognosis in acute myocarditis. Eur Heart J Suppl ; J: –. Remes J, Helin M, Vaino P et al. Clinical outcome and left ventricular function years after acute coxsackievirus myopericarditis. Eur Heart J ; : –. Maron B, Shirani J, Poliac L, Mathenge R, Roberts W, Mueller F. Sudden death in young competitive athletes. J Am Med Assoc ; : –. McCaffrey FM, Braconier DS, Strong WB. Sudden cardiac death in young athletes. Am J Dis Child ; : –. Phillips M, Robinowitz M, Higgins JR, Boran KJ, Reed T, Virmani R. Sudden cardiac death in air force recruits. J Am Med Assoc ; : –. Wesslén L, Påhlson C, Lindquist O et al. An increase in sudden unexpected cardiac deaths among young Swedish orienteers during –. Eur Heart J ; : – .
Friman G, Wesslén L. Infections and exercise in highperformance athletes. Immunol Cell Biol ; : –. Larsson E, Wesslén L, Lindquist O et al. Sudden unexpected cardiac deaths among young Swedish orienteers — morphological changes in hearts and other organs. APMIS ; : –. Roberts JA. Viral illnesses and sports performance. Sports Med ; : –. Hargreaves ER. Poliomyelitis. Effect of exertion during the pre-paralytic stage. Br Med J ; : –. Horstmann DM. Acute poliomyelitis. Relation of physical activity at the time of onset to the course of the disease. J Am Med Assoc ; : –. Ullum H, Palmo J, Halkjaer Kristensen J et al. The effect of acute exercise on lymphocyte subsets, natural killer cells, proliferative responses, and cytokines in HIV-seropositive persons. J Acquir Immune Defic Syndr ; : –. Rigsby LW, Dishman RK, Jackson AW, Maclean GS, Raven PB. Effects of exercise training on men seropositive for the human immunodeficiency virus-. Med Sports Exerc ; : –. Mustafa T, Sy FS, Macera CA et al. Association between exercise and HIV disease progression in a cohort of hom*osexual men. Ann Epidemiol ; : –. Kendall A, Hoffman-Goetz L, Houston M, Macneil B, Arumugam Y. Exercise and blood lymphocyte subset responses: intensity, duration, and subject fitness effects. J Appl Physiol ; : –. Nieman DC, Johanssen LM, Lee JW. Infectious episodes in runners before and after a roadrace. J Sports Med Phys Fitness ; : –. Nieman DC, Johanssen LM, Lee JW, Arabatzis K. Infectious episodes in runners before and after the Los Angeles Marathon. J Sports Med Phys Fitness ; : –. Peters EM, Bateman ED. Ultramarathon running and upper respiratory tract infections. An epidemiological survey. S Afr Med J ; (): –. Nieman DC, Henson DA, Gusewitch G et al. Physical activity and immune function in elderly women. Med Sports Exerc ; : –. Nieman DC, Nehlsen Cannarella SL, Markoff PA et al. The effects of moderate exercise training on natural killer cells and acute upper respiratory tract infections. Int J Sports Med ; : –. Friman G. Effect of acute infectious disease on isometric muscle strength. Scand J Clin Lab Invest ; : – . Friman G. Effect of acute infectious disease on human isometric muscle endurance. Upsala J Med Sci ; : –. Friman G. Effects of acute infectious disease on circulatory function. Acta Med Scand Suppl ; : –. Åstrand P-O, Rodahl K. Textbook of Work Physiology: Physiological Bases of Exercise, rd edn. McGraw-Hill Co, : –.
Exercise and Infectious Diseases Friman G. Effect of clinical bed rest for seven days on physical performance. Acta Med Scand ; : –. Åström E, Friman G, Pilström L. Effects of viral and mycoplasma infections on ultrastructure and enzyme activities in human skeletal muscle. Acta Pathol Microbiol Scand Sect ; : –. Friman G, Wright JE, Ilbäck N-G, Beisel WR, White JD, Sharp DS, Stephen EL, Daniels WL, Vogel JA. Does fever or myalgia indicate reduced physical performance capacity in viral infections? Acta Med Scand ; : –. Alluisi EA, Beisel WR, Bartelloni PJ, Coates GD. Behavioral effects of tularemia and sand fly fever in man. J Infect Dis ; : –. Friman G, Schiller HH, Schwartz MS. Disturbed neuromuscular transmission in viral infections. Scand J Infect Dis ; : –. 44 Beisel WR, Sawyer WD, Ryll ED, Crozier D. Metabolic effects of intracellular infections in man. Ann Intern Med ; : –.
Eichner ER. Infection, immunity, and exercise. Phys Sports Med ; : –. Nieman DC. Exercise immunology: practical applications. Int J Sports Med ; (Suppl. ): –. Pedersen BK. Exercise and infection. In: Pedersen BK, ed. Exercise Immunology. New York: Springer, : –. Shephard RJ. Exercise, immune function and HIV infection. J Sports Med Phys Fitness ; : –. Simon HB. Exercise and infection. Phys Sports Med ; : –. Brenner IKM, Shek PN, Shephard RJ. Infection in athletes. Sports Med ; : –. Wesslén L, Ehrenbory C, Holmberg M. Subacute Bartonella infection in Swedish orienteers succumbing to sudden unexpected cardiac dealth or having malignant arrhythmias. Scand Infect Dis ; : –. McGill S, Wesslén L, Hjelm E, Holmb M, Rolf C, Friman G. Serological and epidemiological analysis of the prevalence of Bartonella Spp: antibodies in Swedish elite orienteers –. Scand Infect Dis ; : –.
Chapter 4.3 Osteoarthritis L. STEFAN LOHMANDE R & HARALD P. ROOS
Classical reference Fairbanks TJ. Knee joint changes after meniscectomy. J Bone Joint Surg ; B: –. This paper records an investigation of changes found in the knee joint at intervals ranging from months to years after meniscectomy. Radiologic study. After excluding all cases with definite osteoarthritis, a comparison was made between the preoperative and postoperative X-ray films in cases of meniscectomy. Owing to difficulty in securing identical views on separate occasions, the changes described were accepted as convincing only because they were seen repeatedly; occasionally a film of the normal knee provided better comparison. The changes noted, alone or in combination, were of three types: formation of an anteroposterior ridge projecting downwards from the margin of the femoral condyle over the old meniscus site; generalized flattening of the marginal half of the femoral articular surface — a reaction similar to but more diffuse than the ridge; and narrowing of the joint space on the side of the operation. The changes were within months of operation on many occasions, but they tend to become more obvious with time. No correlation was found between clinical and radiologic findings, many knee joints with the most marked radiographic changes being functionally perfect. The frequency of such changes after medial meniscectomy in cases was: no change %, ridge %, narrowing %, flattening %. Investigations. It is submitted that these changes result chiefly from loss of the weight-bearing functions of the meniscus — a function which has not been accepted universally.
Discussion. Meniscectomy must therefore result in the relative overloading of the articular surfaces on that side of the joint, with increasing compression of the cartilage. But narrowing of the joint space after operation was seen in X-ray films of the recumbent patient, and if such changes are permanent, and radiographically demonstrable, it must be due either to structural changes in the articular cartilages which impair the power of recoil, or to actual loss of tissue. Summary and conclusion. Changes in the knee joint after meniscectomy include ridge formation, narrowing of the joint space and flattening of the femoral condyle. Investigations suggest that these changes are due to loss of the weight-bearing function of the meniscus. Meniscectomy is not wholly innocuous; it interferes, at least temporarily, with the mechanics of the joint. It seems likely that narrowing of the joint space will predispose to early degenerative changes, but a connection between these appearances and later osteoarthritis is not yet established and is too indefinite to justify clinical deductions.
Background The benefits of physical activity are well documented and positive effects on diabetes, asthma and body weight have been postulated (see Chapters ., . and .). Physical activity also seems to decrease the risk of cardiovascular disease and its associated mortality. The positive effects of physical activity on the musculoskeletal system are also well documented, even extending to being a recommended treatment of osteoarthritis. However, vigorous physical activity and associated injuries are associated with short- and longterm side-effects. Osteoarthritis (OA) in the lower extremity as a con-
Osteoarthritis sequence of sports activities is the focus of this chapter. OA is characterized by a general loss of articular cartilage accompanied by an attempted repair of the articular cartilage, with remodeling and sclerosis of the subchondral bone. In many instances there is formation of bone cysts and osteophytes [,]. These changes in articular cartilage could be induced either by the physical activity itself or by associated joint injuries. It is important to point out that OA as discussed here is based on radiographic criteria and that there is an inconsistent relationship between symptoms and radiographic findings in OA. However, the presence of radiographic signs of OA increases the risk of current or future OA symptoms. The course of OA induced by exercise or trauma is not fully understood. There is no clear evidence that the progression of OA is faster in sports-related OA compared to primary (idiopathic) OA, but since the initiating events tend to occur at a young age, especially when trauma is concerned, both radiographic signs and symptoms of OA occur at a much younger age than in primary OA. Since the probable onset of the disease process, defined as the time of trauma, can be identified in most cases, post-traumatic OA is an attractive model for studying the course of OA and hom*ogenous cohorts can be defined for this purpose. There are many risk factors for the development of OA, age being the most important [–]. Sex, race, obesity, biomechanical factors and inherited susceptibility together with use and abuse of joints and joint trauma influence the development of OA [,]. The hand, knee and hip are most frequently affected by OA and the risk factors associated with OA differ according to the joint involved [,]. Hand and knee OA have a stronger female preponderance and knee OA also has a more solid association with obesity than hip OA [,,]. However, a recent report suggested an association between OA and overweight also for the hip []. Risk factors are probably additive and Doherty et al. [] noted an increased risk for developing knee OA after meniscectomy in patients with interphalangeal OA in the hand, suggesting that systemic factors can influence the course of postmeniscectomy OA []. This is in agreement with progressive joint space narrowing being more common in patients with multiple joint involvement [,].
Joint injury is a known risk factor for OA (secondary or post-trauma OA). Joint subluxation, dysplasia or incongruity as a consequence of a fracture with joint involvement will cause an abnormal contact stress on the articular surface []. However, joint trauma without overt skeletal injury, such as soft tissue trauma and contusion injuries to the joint cartilage, also probably increase the risk for OA. However, an experimental model on the effects of contusion injuries to the knee in dogs did not show consistent OA development []. Many studies have shown early cartilage changes secondary to meniscus and ACL injuries in the knee [,–].
Sports-induced osteoarthritis Physical activity and osteoarthritis The amount of loading appears to be an important factor for OA development. Moderate running ( km/day) increased the indentation stiffness of the cartilage and the cartilage matrix content of proteoglycan in beagle dogs [–], while running exercise of km/day for weeks in the same type of dogs decreased the proteoglycan content [,,]. Longterm ( year) strenuous running exercise ( km/day) resulted in a depletion of proteoglycans and a softening of the cartilage []. It is however, unknown whether these changes will cause OA, since the depletion of proteoglycans and softening of the cartilage might also represent a normal physiologic adaptation to enhanced mechanical stress induced by vigorous running [] (see Chapter .). A relationship between OA of the hip and knee, and heavy work or sports activities has been postulated. Sports activities with intense high impact and torsional loading are associated with an increased prevalence of OA []. Examples of such sports are soccer, American football, rugby, team handball, basketball, competitive running and water skiing []. Physical activities associated with knee bending have been suggested to increase the risk of knee OA []. There is also a correlation between heavy physical work that involves squatting and kneeling, and knee OA [,–]. A relation between occupational loading and hip OA has been demonstrated [,], exemplified by the increased prevalence of hip OA in farmers [] and ballet dancers [,], and an in-
Chapter . creased prevalence of knee and hip OA in coal miners [], shipyard laborers [], fire-fighters, foodprocessing workers, physical education teachers (Sandmark) and construction workers []. Long-distance running is an example of a sports activity that mainly consists of repetitive loading without traumatic injuries, and could thus serve as a model in the attempts to study the relationship between exercise and OA. Most studies on runners have failed to find a correlation between running and OA [,]. In a -year follow-up of runners, with a mean age of at follow-up, both runners and controls had a significant progression of radiographic features of OA, but running did not appear to accelerate the development of OA []. However, one study showed more radiographic hip joint changes in a group of former national team long-distance runners compared to bobsled competitors and a reference group []. In a study by Konradsen et al. [], out of former longdistance runners had hip OA, compared to none of the controls []. Thus, high-mileage running on a competitive level may increase the risk of hip OA, but the evidence is weak.
Soccer and osteoarthritis Soccer is the most popular sport in the world and is believed to have some million amateur participants []. During the last decade female soccer has become popular and now attracts a fair number of women, not least in North America. It has been estimated that at least half of the sports injuries in Europe are soccer related []. In a review on sports practice and OA the authors concluded that some sports, especially practiced on a high level, comprise an increased risk for OA in hip and/or knee joints []. Soccer is such an activity with a calculated relative risk of hip and knee OA compared to controls of .–. and .–., respectively. However, these risk estimates are only valid as far as elite players are concerned [–]. Soccer as a cause of hip OA was described by Klünder et al. [] and an increased prevalence of knee OA in former elite soccer players was reported by Chantraine []. The latter study was handicapped by a lack of a control group and considerable drop-out. Subsequent studies of former Finnish elite athletes
found a prevalence of tibiofemoral knee OA of % in soccer players, and patellofemoral OA in % of weight-lifters. No premature knee OA in runners or shooters was found in that study []. Swedish studies on hip and knee OA in former soccer players [,] found a prevalence of hip and knee OA of –% in former top-level players with a mean age of years, compared to –% in an agematched control group. However, there was no increased prevalence of either hip or knee OA among former non-elite players compared to age-matched controls. The increased prevalence of knee OA in former soccer players might be expected in the light of the high incidence of knee injuries in soccer. However, even after excluding patients with known injuries, % of the former players had knee OA, compared to % among controls, suggesting that soccer even in the absence of known injuries constitutes a risk factor for knee OA []. Female soccer is a more recent sport and long-term follow-up studies are thus lacking. In a Swedish study retired female soccer players with a mean age of years were radiographically examined []. The exposure to soccer was on average years. The prevalence of hip OA was comparable to age- and gender-matched controls. In contrast, knee OA was present in % of the female players, compared to % of the agematched male soccer ex-players and % of the agematched female controls. The females were recruited from all levels of competitive soccer and no differences according to level of soccer playing could be detected, which contrasts with the findings among male explayers. Spector et al. [] studied the risk of knee OA defined as the presence of osteophytes in female ex-athletes and similarly demonstrated an increased prevalence of knee OA, especially among tennis players and runners. Tennis players were more prone to have tibiofemoral knee OA while former runners showed patellofemoral involvement, especially on the lateral facet of the patella.
Knee injuries and osteoarthritis Experimental models of joint degeneration show that mechanical instability created by transection of the anterior cruciate ligament (ACL) and meniscectomy
Osteoarthritis often leads to progressive joint degeneration. Joint instability combined with loss of sensory innervation greatly increases the susceptibility of the articular cartilage to damage []. The association between primary knee OA and female gender is well known [,], but in OA induced by an injury no such association has yet been shown [,,,]. A prospective study of students examined the relation between trauma and hip and knee OA and found a relative risk of . for subsequent knee OA after a trauma at that site, and . for hip OA []. The reported rate of OA after knee injuries varies considerably between different studies (Fig. ..) []. Possible explanations for these considerable differences are: (a) the majority of the studies are crosssectional and show a considerable drop-out rate; (b) the age at onset of symptoms, trauma and surgery differs within and between the studies and is sometimes not defined; (c) associated injuries are not often described or taken into account; (d) different radiographic classifications are used; and (e) appropriate controls are lacking.
Meniscus total Meniscus partial Meniscus repair ACL total ACL repair
100
Frequency (%)
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40
20
0 0
5
10
15
20
25
30
35
Anterior cruciate ligament injuries ACL injuries may result in a faster development of joint cartilage changes than isolated meniscus tears, and radiographic evidence of OA will be seen in about % of the subjects – years after an ACL injury []. The possibly faster progression of OA after an ACL injury could be explained by the high forces involved in the initial trauma, with considerable injuries of associated structures in the joint, such as menisci, joint capsule and collateral ligaments. The bone bruises that can be visualized on MR images, often located in the lateral compartment of the joint, represent the effect of a contusion injury and may contribute to the initiation of the OA development [,]. Changes in gait pattern [] and loss of proprioception are other factors that have been proposed as causative for the development of OA after an ACL injury [,]. The risk of post-traumatic OA increases with time so that an injury in the teenage period will cause visible radiographic changes of OA early in life. A recent nationwide study on female soccer players with ACL injury showed that one-third had radiographic OA years after the injury and another % had other visible radiographic changes, but without reaching the criteria for OA. In this study, radiographic OA was defined as slight joint space narrowing (grade ) combined with osteophytes or definite joint space narrowing (grade ) according to the OARSI criteria []. This definition of radiologic OA corresponds to Kellgren and Lawrence grade II []. The mean age at time of trauma was years and accordingly the age at follow-up years later was years of age. Postinjury treatment (ACL reconstruction or not) did not significantly alter the risk for developing OA. At the -year follow-up some % of these young females experienced problems such as pain and restricted ability to participate in physical activity. However, there was no association between the presence of radiographic OA and symptoms. This finding is in accordance with other studies [].
Follow-up (years) Fig. .. Published outcomes for radiologic signs of osteoarthritis following knee ligament injury and intervention. Modified from []. Each symbol represents published results in the scientific literature for a specific patient group and intervention.
Meniscus injuries It is questionable whether a meniscus tear early in life represents the same disease as a tear in a -year-old patient. Tears in younger patients are usually caused by a trauma, whereas a tear later in life may be a part of
Chapter . a degenerative joint disease including the menisci. Following a meniscus tear the radiographic changes appear after a shorter time interval in those who suffered from the injury over years of age as compared to younger people with a meniscus tear []. A followup of patients who underwent meniscectomy in adolescence showed three times more radiographic changes in the operated knee compared to the opposite knee after years []. Seventy per cent were still satisfied with their knee, but the progression of changes paralleled a reduction in activity. In a Swedish study, mild radiographic changes were present in % of the patients years after total meniscectomy. The mean age of the cohort at follow-up was years, thus representing the ‘average’ age group of meniscectomy patients. More advanced changes, corresponding to Kellgren and Lawrence grade II [], were present in % []. The corresponding figures for the occurrence of mild and more advanced radiographic changes in an age- and gender-matched control cohort were and %, respectively. The risk ratios for radiographic changes of mild and more advanced OA compared to the age- and gender-paired controls were . and . for mild or advanced changes, respectively. However, as in the ACL study described above, the correlation between radiographic findings and experienced symptoms was limited. On the other hand, considerably more knee-related symptoms were seen in the meniscectomy group compared to the controls, suggesting that the loss of a meniscus causes symptoms independently of the presence of joint cartilage changes [].
Treatment of knee injuries and development of osteoarthritis No controlled studies on OA after ACL disruption comparing surgical vs. non-surgical treatment are available. The fact that an ACL reconstruction decreases the risk for a later meniscus injury appears to be an advantageous effect of surgical stabilization []. In a prospective uncontrolled outcome study Daniel et al. [] concluded that patients who had undergone a reconstruction of the ACL had more radiographic OA than non-surgically treated patients, which is in accordance with the study on female soccer players cited above []. The suggested increased risk of OA in surgically treated patients could be caused by the fact that
they have a greater ability to return to knee-demanding activities after knee stabilization. On the other hand it could be that the patients with the most severe symptoms of their injury, and also the more severe associated injuries, are the ones recommended for surgery. The surgical procedure may also be harmful to the joint cartilage either by direct insult during the surgery or by the altered biomechanical situation in the knee after a ligament reconstruction []. Theoretically, a preservation of the meniscus by a repair or a very located resection should be advantageous. However, no data supporting this theory are available, although suggested by some authors [–]. The only randomized study comparing subtotal and partial meniscectomy could not verify a positive longterm effect of saving a part of the meniscus []. On the other hand, supporting the theory that the meniscus is of importance for the knee function, patients with a more extensive resection of the meniscus had more knee-related symptoms compared to those who had the meniscus partially resected []. However, a recent study on the outcome after meniscus resection comparing subtotal and partial resection, showed no differences between the groups. If the tears were divided into degenerative and traumatic tears, more complaints were found after a degenerative tear, confirming that these meniscus tears may represent different conditions []. Meniscus repair, a demanding intervention for the patient with an extensive rehabilitation program, has not yet with certainty been shown to prevent later OA. A reduced incidence of OA after meniscus repair compared to resection was shown by Sommerlath [], but different types of tears were compared in this study. A difficulty in conducting a randomized study comparing equivalent meniscal tears is that reparable tears in stable knees are rare, and when they do occur they may be associated with degenerative changes in the meniscus substance []. Accordingly, a recent follow-up of meniscus repairs showed a prevalence of OA comparable to that after meniscus resection []. No controlled studies on meniscus transplantation are available yet []. In conclusion, as described in many publications, knee injuries increase the risk for OA considerably. ACL injuries seem to be more deleterious than an isolated meniscus tear. However, it must be kept in mind that the majority of ACL injuries are combined with
Osteoarthritis meniscus tears. There is no scientific evidence that ACL reconstruction, meniscus repair or meniscus transplantation reduces the risk of OA developing as a consequence of the initial injury.
Treatment of osteoarthritis For the ‘common or garden’ variety of patient with OA the disease is recognized as a slowly progressive condition that sometimes results in serious pain and functional impairment leading to a requirement for joint replacement. This disease stage for the hip and knee is frequently reached around the age of , an age where expectations of activity level have decreased. For the joint-injured athlete the situation is often different, with onset of radiographic changes and symptoms of increasing severity at a considerably younger age [,,,,,,,]. These individuals at the time of onset of symptoms have a longer life expectancy and expectations of a higher level of physical activity, even after joint surgery. The remarkable success of arthroplasty as a treatment for older individuals with severe OA is replaced by a high rate of implant failure and revision surgery among those operated on at a younger age [–]. Osteoarthritis in the young, often resulting from joint injury during athletic activities, thus represents a continued and unresolved challenge for the sports medicine community. The most important symptoms of OA are joint pain, stiffness and decreased range of motion. Pain is what brings the patient to the doctor and is the focus of most treatments for OA. There is no treatment that can change the course of joint destruction, but a range of modalities are effective in decreasing pain and retaining or improving function. Several recent reviews provide further information on OA and its management [,–] but few are evidence based []. This chapter is based on these reviews, favoring those based on evidence.
Prevention In view of our lack of effective means for dealing with OA in the young and our lack of treatments that could slow disease progression, much effort needs to be directed towards the prevention of joint injuries in young athletes. A recent study of proprioceptional training indi-
cates that it may be possible to reduce the incidence rate of ACL injuries in soccer [], but the results of this single study has to be verified further. The prevention of ACL injuries in female players is particularly important, since females have a higher incidence of this injury, get injured earlier in life and, in addition, have a greater risk of knee OA even when injuries are excluded. The increased popularity of female soccer, not least at high-school level, shows a clear path towards a problematic situation some years ahead. Knee injuries occurring at years of age, with radiographic OA in the early thirties and onset of symptoms perhaps a few years later or even before, may result in patients requiring OA surgery in their early forties. A study of injury risk factors in female soccer revealed that neither physical capacity, functional performance, nor muscle strength correlated to injuries []. In that study increased joint laxity was the only significant risk factor. In those who are overweight, even a moderate decrease in body weight results in decreased symptoms and perhaps also a decreased risk for further development of knee and perhaps also hip OA []. Weight loss is thus an important advice for the overweight with OA. As discussed above, there is little or no evidence that surgical reconstruction of a torn cruciate ligament or meniscus prevents the development of knee OA at a later time. The rationale for these interventions thus need to be sought elsewhere.
Non-surgical treatment of OA Treatment of OA varies with patient, disease stage, local resources and traditions. As with any chronic condition, the informed and empowered patient is a most important factor. Decisions on treatment should be based on three dimensions: patient, joint and environment. Information and education about the disease, and what will likely happen in the future is an important aspect of OA treatment. The message to give to the patient with early-stage OA is that the condition develops very slowly and that for many individuals exercise, training, simple aids and sometimes analgesics provide excellent relief. For a few, the disease will progress and require additional treatment.
Chapter . Pain is what the patient initially seeks help for. Information and (perhaps also printed) advice about weight loss, shoes with shock-absorbing soles, maintenance of physical activity and training programs and ‘over-thecounter’ (OTC) analgesics are often effective. The interested and educated physical therapist has an important role in guiding the patient to the right kind of exercises and encouraging compliance. Some reports suggest that quadriceps weakness is a primary risk factor for knee pain, disability and progression of joint damage in persons with osteoarthritis of the knee []. Several other studies support the beneficial effects of exercise on OA symptoms [–]. Aids and adjustment of home or work environment can be very helpful. A knee brace can be used in unilateral knee OA. One randomized clinical trial showed significant benefits from valgus-producing knee braces, unloaders, in patients with medial compartment OA, compared with a neoprene sleeve [].
Drugs Drugs have a very dominant position in the treatment of OA, despite the fact that many patients report that the effect of analgesics on OA pain is limited. Clinical trials have in fact shown that for many patients information, training programs, etc. are as effective as drugs against OA pain []. Any choice of analgesics should be made in the light of the fact that OA is a chronic disease and that medication may be long term. Paracetamol (acetaminophen) is recommended as a first choice for pain relief in OA, in doses of up to g/ h. The frequency of side-effects is low, compared to the alternatives, and those that occur are mainly associated with the combination of alcohol and paracetamol. Several randomized, controlled and blinded trials have shown a similar OA pain relief from paracetamol as from non-steroidal anti-inflammatory drugs (NSAIDs) []. NSAIDs. For those patients in whom paracetamol is insufficiently effective it is appropriate to try some form of NSAID. The effect on pain is similar to that of paracetamol, but some patients that do not respond to paracetamol respond to NSAIDs. There is no differ-
ence in effect on OA pain between the different members of this class of compounds or between those compounds that inhibit both cyclooxygenase- and -, or are selective for cyclooxygenase- (COX-) []. Several of the non-selective inhibitors have been in use for many years, such as diclofenac, ibuprofen and naproxen, and some are available OTC. The adverse effects of this class of compounds are significant and well known, affecting the gastrointestinal lining (dyspepsia, gastritis, gastrointestinal bleeding), kidney function, nervous system and thrombocyte function (clot inhibition). The risk of serious gastrointestinal bleeding, sometimes leading to death, varies significantly between different members of the class, and those mentioned above constitute a low-risk group within the class [,]. The risk of adverse effects increases with age. The patient should use the lowest effective dose for the shortest time needed. The coxibs constitute a recently introduced subgroup of NSAIDs, and selectively inhibit COX-. The pain relief is comparable to that for the non-selective COX inhibitors, but these compounds have the advantage of a lower risk of gastrointestinal bleeding and do not affect thrombocyte function. However, the adverse effects on e.g. the kidneys and cardiovascular system appear to be similar to those for the nonselective inhibitors. The absence of an effect on thrombocyte aggregation by the coxibs, which in some circ*mstances may be an advantage, means that an apparent protective effect of the traditional NSAIDs against thromboembolic disease is absent. This new class of compounds should be prescribed with the same care as non-selective COX inhibitors until our knowledge of their advantages and disadvantages has expanded []. Other analgesics, such as opioids (tramadol, codeine, etc.), may provide good relief for some patients with OA pain. However, side-effects and dependency limit their usefulness. For those ageless athletes with OA pain that does not respond well to analgesics, the addition of an antidepressant may be tried. Topical treatment of the knee or other joints with painful OA with gels containing NSAIDs has demonstrated effectiveness in some trials []. Gels contain-
Osteoarthritis ing capsaicin have also been effective in some trials and are available in some countries. Intra-articular injections are frequently used in the treatment of OA of the knee and some other joints. This treatment should not be considered a firstline treatment, but may be considered for those patients that experience insufficient effect of the treatments discussed above. The placebo effect of any intra-articular intervention, including injections, is considerable. Steroid injections are commonly used, but the treatment rests on a weak base of evidence. A few welldesigned and controlled trials show a moderate and short-lived effect of a few weeks on OA pain. Hyaluronan is an endogenous molecule that occurs naturally in connective tissues, cartilage and joint fluid. A review of the results of recent controlled clinical trials of intra-articular knee injections of hyaluronan in OA show a modest effect on pain over and above that of placebo injections []. Some individual patients may experience a more marked and extended pain relief. There is no support for a difference in efficacy or side-effects for the different preparations of hyaluronan now being marketed, irrespective of hyaluronan source or molecular size. Adverse effects of knee injections are rare, but potentially severe in the form of septic arthritis. Steroids may mask an intra-articular infection. Acupuncture, given as an adjunct to drugs and other treatments for OA, has been reported to provide significant pain relief in some patients. Other treatments for OA than those described above are commonly used. Unless asked, the patient may not, however, reveal these to the treating doctor. In the USA more than half of OA patients use treatments other than those prescribed by their treating doctor. Examples of such treatments are glucosamine, chondroitin sulfate, vitamins and other ‘nutraceuticals’. The scientific evidence for an effect of these treatments on OA symptoms (or disease progression) is still limited, and the mechanisms of action unknown. A recent review of glucosamine and/or chondroitin sulfate treatment suggested that the weight of evidence favored a modest symptomatic effect on OA pain, but
recommended additional trials to confirm this []. A common problem for many of the compounds of this group is uncertainty regarding quality control, purity and dosing.
Surgical treatment of OA For the patient in whom the treatment modalities discussed above do not provide sufficient pain relief, surgical treatment has to be considered. While the treatment methods used are the same as for any patient with OA, the often younger age of the patient with postinjury OA provides an important confounding factor in the decision. As mentioned, these patients often have expectations of a continued high level of physical activity and usually have a longer life expectancy than the average patient with OA. Joint replacement in these young patients is associated with a much higher risk of implant wear, loosening and revision than the average OA patient around the age of [–]. The risk for loosening and revision of a knee implant is more than three times higher in the patient operated on while younger than , than if older than at surgery []. For this reason, surgical interventions other than joint replacement should be considered first if at all possible. Cartilage or bone–cartilage transplantation in various forms are currently being developed to explore the benefits for the patient with symptomatic joint cartilage damage. However, although there are encouraging case reports [], no results of randomized controlled trials have yet been published. This treatment should therefore be regarded as experimental and recommended for use only within the envelope of carefully monitored clinical studies []. No results are as yet available to show if these forms of treatment of cartilage damage can prevent the later development of OA in the injured joint []. It also needs to be emphasized that no results have yet been presented to prove the utility of this treatment for the OA joint. Altered biomechanics and dynamic forces in the unstable and osteoarthritic joint provide a challenge for the repair and regeneration of joint cartilage. Joint lavage with physiologic salt solutions and/or arthroscopic debridement is frequently used. However, the evidence base for other than a temporary relief
Chapter . of pain is very weak and very few well-designed controlled studies exist that allow an analysis of the relative contributions to the effect of the debridement, the lavage or the placebo effect, which may be expected to be considerable []. Osteotomy, intended to correct unfavorable loading of the OA joint, is a treatment best suited for the patient younger than years and with high activity expectations. The rehabilitation is, compared to joint replacement, more demanding and extended. The surgery can in the knee be performed as a ‘closing wedge’ high tibial osteotomy for moderately advanced medial compartment knee OA, or as ‘callus distraction’ osteotomy []. Osteotomy has so far provided the best results for the valgus knee with medial compartment OA. Done on the right patient and with the same care in planning and precision as joint replacement the ‘survival’ of this intervention is as good as for unicompartmental knee replacement and may delay the need for replacement for at least years []. In young patients with knee OA after an ACL tear there is both pain and an instability problem. In such cases a combination of ACL reconstruction and an osteotomy may provide an acceptable solution [,]. It is usually recommended that the procedures are carried out separately, with an interval of – months between surgery. It is, however, possible to perform the procedures simultaneously, especially if the osteotomy is performed as a callus distraction. No clinical trial reports on the complication rate or outcome after such procedures are available yet. When required, a joint replacement can be done with good results in the postosteotomy knee [,]. Unicompartmental knee replacement is best suited for patients with stable knees and OA in one compartment only, usually the medial. Due to the previously discussed limitations of implant survival in younger patients [,], they should if possible be older than at the time of surgery, with no upper age limit. A considerable advantage of unicompartmental knee replacement is the limited need for hospital stay and the short rehabilitation. Minimally invasive surgery is increasingly used. These developments may warrant a future re-evaluation of the current limitations for this intervention, although ‘uni’ knees still have a higher
revision rate than ‘total’ knees [,]. Unicompartmental replacements can be successfully revised to total knee replacements if required []. Bi- or tricompartmental knee joint replacement is best suited for those patients with severe OA in more than one knee joint compartment. For those patients where the patellar joint contributes significantly to the symptoms, this may be the preferred treatment. Similar to unicompartmental knee arthroplasty, young age at surgery and high physical activity levels contribute significantly to the risk for subsequent wear and loosening. It is therefore often recommended that the patient should be over the age of at surgery. The surgical procedure is more extensive than for unicompartmental replacement. The results of both knee and hip joint replacements have continuously improved over the last few decades, with revision rates fairly similar for hip and knee OA, and more than % of the average patients having a well-functioning knee or hip at years after surgery [,,]. Deep infections are rare and below the % level, wear and loosening being responsible for the majority of problems. The adverse effects of arthroplasty, except for those related to the implant as such, are similar to those with other forms of surgery. An increased risk of deep vein thrombosis and lung embolism has been reported. Patients operated on with joint replacement need to recognize that they have been provided with a new joint, but not a normal joint. They should expect a stable and pain-free joint with a good range of motion that allows regular daily activities such as walking, cycling, swimming and other moderate physical activities or work. Patients wanting to engage in heavy physical activity or work should be informed that this will come at the price of a significantly higher risk of implant failure. As noted above, OA in the young and physically active is a largely unresolved problem. While nonsurgical treatments often provide relief from pain and support a maintained function, there is little to offer those young individuals with progressive and severe OA except joint surgery. The current limited survival of implants in the young and physically active would make us suggest that joint replacement should be de-
Osteoarthritis layed ‘until later and older’. However, the other view may well be that it is ‘now’ when young and active that the individual wants and needs the pain relief and improvement in function that can be provided by the replaced joint, even if the price is a higher risk of implant failure. It is in this context important to note that the relationship between the severity of radiologic change and symptoms in OA is only weak []. There is thus no reason to delay joint replacement, waiting for the severity of radiologic change to increase: young patients with symptomatic hip OA reach a higher score for patient-relevant outcome after joint replacement than do older patients (Nilsdotter, personal communication).
Summary Some sports activities, just like some occupations, are associated with an increased risk of knee and hip OA. Soccer is clearly such an activity, even in the absence of reported injuries. The risk of OA after knee injuries is well documented and some % of the subjects who suffer a knee injury will develop radiographic knee OA after years. Surgical treatment after a knee injury to repair or replace the injured structure has not yet been shown to influence the risk for postinjury OA. OA in the ageless athlete is treated like other OA with information, weight loss, exercise, aids, analgesics or surgery. However, the younger age at onset of symptoms compared to most other forms of OA influences the choice of surgical procedure for those with advanced disease.
Multiple choice questions An increased risk of development of osteoarthritis in the knee is seen among: a marathon runners b female competitive soccer players c patients who have undergone meniscectomy d patients who have chronic patella tendinosis (‘jumper’s knee’). Which of the following statements are correct? a Running will reverse manifest osteoarthritis in the knee and improve radiologic findings. b Surgical reconstruction of a cruciate ligament or a meniscus will fully prevent the development of osteoarthritis. c Osteoarthritis was observed in 50% of the middle-
aged patients who had meniscus operation performed around years earlier. d The suggested radiographic classification of osteoarthritis (Osteoarthritis Research Society) includes separate grading (from to ) of joint space narrowing, osteophytes and sclerosis.
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Chapter . Ostenberg A, Roos H. Injury risk factors in female soccer. A prospective study of players during one season. Scand J Med Sci Sports ; : –. Slemenda C, Brandt KD, Heilman DK et al. Quadriceps weakness and osteoarthritis of the knee. Ann Intern Med ; : –. Allegrante JP, Kovar PA, MacKenzie CR, Peterson MG, Gutin B. A walking education program for patients with osteoarthritis of the knee: theory and intervention strategies. Health Educ Q ; : –. Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. Ann Intern Med ; : –. Ettinger WH Jr, Burns R, Messier SP et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST) [see comments]. J Am Med Assoc ; : –. Minor MA. Exercise in the treatment of osteoarthritis. Rheum Dis Clin N Am ; : –. O’Reilly SC, Muir KR, Doherty M. Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheumatic Dis ; : –. Kirkely A, Webster-Bogaert S, Litchfield R, Amendola A, MacDonald S, McCalden R, Fowler P. The effect of bracing on varus gonarthrosis. J Bone J Surg ; A: –. Bradley JD, Brandt KD, Katz BP, Jalasinski LA, Ryan SI. Comparison of an anti-inflammatory dose of ibuprofen, an analgesic dose of ibuprofen and acetaminophen in the treatment of patients with osteoarthritis of the knee. N Engl J Med ; : –. Langman MJS, Well J, Wainwright P et al. Risks of bleeding peptic ulcer associated with individual nonsteroidal anti-inflammatory drugs. Lancet ; : –. Garcia Rodriguez LA, Jick H. Risk of upper gastrointestinal bleeding and perforation associated with individual non-steroidal anti-inflammatory drugs. Lancet ; : –. Goetsche PC. Non-steroidal anti-inflammatory drugs. Br Med J ; : –. Moore RA, Tramèr MR, Carroll D, Wiffen PJ, McQuay HJ. Quantitative systematic review of topically applied anti-inflammatory drugs. Br Med J ; : –. Brandt KD, Smith GN, Simon LS. Intraarticular injection of hyaluronan as treatment for knee osteoarthritis: what is the evidence? Arthritis Rheum ; : –. McAlindon TE, La Valley MP, Gulin JP, Felson DT. Glucosamine and chondroitin for treatment of os-
teoarthritis. A systematic quality assessment and metaanalysis. J Am Med Assoc ; : –. Brittberg M, Lindahl A, Nilsson A, Ohlsson C, Isaksson O, Petterson L. Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med ; : –. Lohmander LS. Cell-based cartilage repair — do we need it, can we do it, is it good, can we prove it? Curr Opin Orthop ; : –. Buckwalter JA, Lohmander LS. Surgical approaches to preserving and restoring cartilage. In: Brandt KD, Doherty M, Lohmander LS, eds. Osteoarthritis. Oxford: Oxford University Press, : –. Magyar G, Ahl TL, Vibe P, Toksvig-Larsen S, Lindstrand A. Open-wedge osteotomy by hemicallotasis or the closed wedge technique for osteoarthritis of the knee. J Bone Joint Surg (Brit) ; : –. Odenbring S, Egund N, Knutson K, Lindstrand A, Toksvig Larsen S. Revision after osteotomy for gonarthrosis. A –-year follow-up of cases. Acta Orthop Scand ; : –. Latterman C, Jacob RP. High tibial osteotomy alone or combined with ligament reconstruction in ligament deficient knees. Knee Surg Sports Traum Arthroscopy ; : –. Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament deficient knees. Am J Sports Med ; : –. Meding JB, Keating EM, Ritter MA, Faris PM. Total knee arthroplasty after high tibial osteotomy. A comparison study in patients who had bilateral total knee replacement. J Bone Joint Surg (Am) ; : –. Meding JB, Keating EM, Ritter MA, Faris PM. Total knee arthroplasty after high tibial osteotomy. Clin Orth ; : –. Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L. Patient satisfaction after knee arthroplasty. A report on knees operated on between and in Sweden. Acta Orthop Scand ; : –. Robertsson O, Borgquist L, Knutson K, Lewold S, Lidgren L. Use of unicompartmental instead of tricompartmental prostheses for unicompartmental arthrosis in the knee is a cost-effective alternative. Acta Orthop Scand ; : –. Lewold S, Robertsson O, Knutson K, Lidgren L. Revision of unicompartmental knee arthroplasty: outcome in cases from the Swedish Knee Arthroplasty Study. Acta Orthop Scand ; : –. Herberts P, Malchau H. Longterm registration has improved the quality of hip replacement: a review of the Swedish THR register comparing cases. Acta Orthop Scand ; : –.
Chapter 4.4 Exercise in the Treatment of Type 2 and 1 Diabetes HANNELE Y KI - JÄ RV I NE N & FL E MMI NG DE LA
Classical reference Lawrence RD. The effect of exercise on insulin action in diabetes. Br Med J ; : – . In , R. D. Lawrence, MD published in the British Medical Journal the first evidence on the additive effect of insulin and exercise on glucose uptake. Based upon observations from his insulin-treated patients of incidences of hypoglycemic symptoms when exercise was taken, he conducted two experiments with one patient. On both occasions insulin was omitted for h and uniform conditions of the diet were observed, which included breakfast and lunch taken as usual. An hour and a quarter after lunch the patient was given a dose of units of insulin. On one day the patient then started a strenuous exercise bout for / hours, only interrupted by blood sampling, and on another day no exercise was taken. With insulin alone blood glucose decreased as expected, but when exercise was added a clear hypoglycemic effect was observed and hypoglycemic symptoms were present during the last half-hour of exercise. R. D. Lawrence concluded: ‘. . . it seems clear that muscular activity greatly enhances the action of insulin.’ Carbohydrates were given at the end of exercise and normoglycemia was restored, but after an additional h the hypoglycemic symptoms recurred, and it was stated that: ‘Even after exercise, when the carbohydrate stores have been partially depleted, it is usually advisable to reduce the next dose of insulin.’ R. D. Lawrence recognized that people with diabetes should not be restricted to a sedentary life: ‘It should be the object of all treatment to enable a diabetic to lead a normal
and varied life . . .’ and continued, ‘Patients should and do easily learn to reduce their insulin before unaccustomed exercise or activity, or they must take vigorous exercise only at times when the effect of their injections has worn over.’
Physical inactivity and the epidemic of type 2 diabetes Physical inactivity predicts type 2 diabetes Data from several prospective epidemiologic studies have shown an inverse association between physical activity and the incidence of type diabetes [–]. Recently, Wei et al. extended these findings, which were based on self-reporting of physical activity and type diabetes, by examining the relationship of objectively measured cardiorespiratory fitness to the incidence of impaired fasting glucose and type diabetes []. This analysis included mostly white men with noninsulin-treated type diabetes, who were followed for years after baseline assessment of cardiorespiratory fitness by a maximal exercise test on a treadmill. Men in the low fitness group (the least fit % of the cohort) had a .-fold risk for impaired fasting glucose and a .-fold risk for diabetes compared to those in the high fitness group (the most fit % of the cohort) after adjusting for age, smoking, alcohol consumption and parental diabetes. After additional adjustment for body mass index, high-density lipoprotein (HDL) cholesterol and triglycerides and hypertension, the low fitness group still had a significantly increased risk of impaired fasting glucose (.-fold increase compared to the high fitness group) and diabetes (.-fold increase) (Fig. ..). These data support the hypothesis
Rate per 1000 person-years
Rate per 1000 person-years
Chapter . 8 7 6 5 4 3 2 1 0
(a)
9 8 7 6 5 4 3 2 1 0
(c)
P < 0.01 P < 0.001
Age ≥ 45 years
9 8 7 6 5 4 3 2 1 0
(b) P = 0.006
P < 0.001
Age < 45 years
BMI ≥ 27 kg/m2 25
BMI < 27 kg/m2
(d)
20 P = 0.004 15 P < 0.001
P < 0.001
10 5
P < 0.002
0 Parental diabetes
No parental diabetes
Impaired fasting glucose
Normal fasting glucose
Fig. .. Incidence of type diabetes per person-years by cardiorespiratory fitness levels according to age group (a), body mass index (BMI, b), history of parental diabetes (c), and impaired fasting glucose (d). White bars represent the low fitness group, light tinted bars represent the moderate fitness group, and dark tinted bars represent the high fitness group. Reproduced with permission from [].
that physical inactivity plays a significant role in the pathogenesis of type diabetes. Similar data have also recently been reported for women participating in the Nurses’ Health Study. This prospective study included self-reported data on physical activity in women surveyed in the United States in with updates in and []. During years of followup, cases of diabetes were documented. After adjusting for age, smoking, alcohol use, history of diabetes and hypertension, menopausal status and high cholesterol, the relative risks of developing diabetes across quintiles of increasing physical activity decreased from . to . []. After further adjustment for body mass index, the relative risk reduction was still significant and fell from . to . (lowest vs. highest quintile of physical activity). Importantly, equivalent energy expenditures from walking and vigorous activity resulted in comparable magnitudes of risk reduction []. These data suggested that in women also, greater physical activity level is associated with a sub-
stantial reduction in risk for type diabetes and also suggested that physical activity of moderate intensity and duration is beneficial.
Physical inactivity and the burden of cardiovascular disease in type 2 diabetes Patients with type diabetes have a two- to four-fold increased mortality from cardiovascular disease []. The ultimate goal of all therapies in type diabetes is to reduce this burden. In the Aerobic Center Longitudinal Study discussed above [], the association between low cardiorespiratory fitness and physical inactivity and total mortality in men with type diabetes was also studied. After adjustment for age, preexisting and family history of cardiovascular disease, fasting glucose and cholesterol concentrations, overweight and hypertension, type diabetic men in the low fitness group had a risk for all-cause mortality of .. The majority of deaths were attributable to cardiovascular disease [].
Exercise in the Treatment of Diabetes Physical training as a tool to prevent and treat type 2 diabetes Prevention of type 2 diabetes The convincing epidemiologic evidence linking physical inactivity to the development of type diabetes is supported by a few intervention studies. In the -year Malmö feasibility study, subjects with impaired glucose tolerance (IGT) and type diabetic patients participated in an intervention program which consisted of supervised training and dietary advice organized either as group sessions or individually for year []. The subjects were then encouraged to continue exercise without supervision from the investigators for years. At years, body weight was reduced .–.% amongst participants as compared to .–.% in non-intervened subjects. Maximal oxygen uptake was increased by –% vs. decreased by –% in participants vs. control subjects. Glucose tolerance was normalized in % of the subjects with IGT and in % in those with type diabetes in the intervention groups, as compared to % in an IGT control group []. These encouraging data may not, however, be generally applicable since the participants were not randomly assigned to intervention and control groups. This study also could not distinguish between physical activity vs. diet in the prevention of type diabetes. These limitations do not apply to the Da-Qing study, where subjects were randomized to either a control group or to one of three active treatment groups: diet only, exercise only or diet plus exercise []. The diet, exercise, and diet plus exercise interventions were associated with %, % and % reductions in developing diabetes over a -year period. All reductions were statistically significant. These data are novel in being the first to demonstrate in a randomized controlled trial that exercise alone can prevent type diabetes. Recently, a lifestyle modification program, with the goals of at least a % weight loss and at least min of physical activity per week, was shown in a large randomized trial in subjects with impaired glucose tolerance in the US to reduce the incidence of diabetes by % over a . year follow-up period []. Average weight loss was . kg in the lifestyle intervention and . kg in the placebo group. Similar data were reported in a Finnish study also in overweight subjects
with IGT []. The contribution of weight loss as compared to increased physical activity to the observed reduction in the incidence of diabetes was not determined in these studies.
Treatment of type 2 diabetes Effects of aerobic and resistive training on glycemic control Data on effects of aerobic and resistance training on glycemic control in established type diabetes are summarized in Tables .. and ... Many studies lacked an appropriate sedentary control group. This limitation is a concern as intensified patient–doctor interaction may itself improve glycemic control and other metabolic parameters. In many studies, the patients lost weight, which may or may not be a consequence of physical activity and confounds, as does small sample size, interpretation of effects of exercise as compared to weight loss per se on metabolic control. Overall effects of physical training on glycemic control have been modest and in roughly half of the studies non-significant. There are several potential explanations for the failure of exercise to be an effective antihyperglycemic therapy. First, physical training primarily improves insulin sensitivity in skeletal muscle (see below) rather than in the liver, which is the ultimate target of any antihyperglycemic drug []. Second, an increase in insulin sensitivity implies that the same amount of glucose can be utilized as before but less insulin is required. In the presence of endogenous insulin secretion, the expected effect of insulin sensitization is thus a decrease in the circulating insulin concentration and an unchanged or slightly lowered blood glucose concentration. However, even this effect has been poorly documented since insulin secretion remained unchanged in out of studies where it was measured (Table ..). Since muscle insulin sensitivity has improved when it has been quantified directly without reliance on endogenous insulin concentrations [], it is possible that physical training improves both insulin secretion and sensitivity and that the net effect of these two changes is an unchanged insulin concentration. In this respect resistive training seems more effective since the insulin concentration has consistently been found to decrease
Intervention/ Control (na)
Exercise programb times/ week, duration/session
Duration
Blood glucose
Serum insulin
HbA1C
Lipids
BP
BW
Improvement in fitness significantc
Trials with a sedentary control group 1985 [13] 33/13 3/week 1991 [98] 30/56 1.7 aerobics sessions/week 1992 [99] 38/40 3–4/week, 30–60 min
3 months 37 weeks 1–2 months
Ø Ø Øe
´ – –
– – Øe
´ – –
´ Ø Ø
Yes No No
1995 [100]
16/13
3–4/week, 30–90 min
3 months
´
–
´
Ø
´
Yes
1997 [101] 1997 [102] 1997 [103]
25/26 11/12 10/11
3/week, 60 min 3/week, 30–40 min 2/week, 45 min
26 weeks 8 weeks 8 weeks
´ ´ ´
´ – ≠
´ ´ Ø
´ – ≠ HDL-C Ø Tg Ø Chol ≠ HDL-C Ø Tg ´ Ø Tg –
– – –
´ Ø ´
Yes Yes Yes
Trials without a sedentary control group 1979 [104] 6 5/week, 30 min
6 weeks
´
´
–
–
´
Yes
1984 [105] 1984 [106] 1988 [107] 1990 [17] 1992 [108] 1993 [109] 1994 [110]
6 5 7 13 111 10–12 652
7/week, 60 min 3/week, 60 min 3/week, 30 min 4/week, 40–60 min 6/week, 30 min Daily exercised
6 weeks 6 weeks 10–15 weeks 12–14 weeks 3 months 1–2 months 3 weeks
Ø Ø ´ ´ Ø Ø Ø
´ ´ ´ ´ – – –
– Ø ´ ´ Ø Ø –
– – – ´ Ø – Ø
´ ´ ´ ´ Ø ´ Ø
– – –
1994 [111] 1996 [112] 2000 [113]
9 20 13
3/week, 30 min 3/week, 60 min 3/week, 40 min
2 years 6 months 3 months
Ø ´ ´
– ´ Øf
Ø ´ ´
Ø – Ø
Ø ´ ´
– Yes No
Year (ref)
Ø Tg Ø Chol – – ´ ´ Ø Tg ≠ HDL-C Ø Chol Ø LDL-C Ø Tg ´ ´ Ø Chol ´ Tg ≠ HDL-C
Yes Yes
a Number of subjects.
b In most studies, exercise intensity was between 60 and 80% of V· O 2 max and was performed using a bicycle or treadmill. c Implies no data;‘No’ implies V· O 2 max or some other measure of fitness was measured but no significant change was observed. d Primarily walking. e Effect observed in women but not in men. f Reduction in insulin dose. BP, blood pressure; BW, body weight; Chol, serum total cholesterol; HbA1C, glycosylated hemoglobin A1C; HDL-C, serum high-density lipoprotein cholesterol; LDL-C, serum low-density · lipoprotein cholesterol;Tg, serum triglycerides; V O2 max, maximum aerobic power; –, no data; ´, no change; Ø, decrease; ≠, increase.
Chapter .
Table .. Effects of aerobic exercise training on glycemic control and other parameters in patients with type diabetes.
Table .. Effects of resistive exercise training on glycemic control and other parameters in non-diabetic subjects and patients with type diabetes.
Year (ref)
Intervention/ Control (na)
´
´
· VO2 max measured (change)b
Duration
Blood glucose
Serum insulin
HbA1C
Lipids
BP
BW
Trials with a sedentary control group 1998 [26] 11/10 Type 2 DM CWTd 3/week 1998 [114] 9/8 Type 2 DM CWT 5/week
8 weeks 4–6 weeks
´ ´
´ Øe
´ ´
– –
´ Fat % ´
´ ´ BW ´
´
Trials without a sedentary control group 1988 [115] 11 NGTc CWT 3–4/week
16 weeks
´
Ø
–
Ø
15 NGT
CWT
12 weeks
´
Ø
–
–
1994 [117]
11 NGT
CWT
16 weeks
´
Ø
–
–
–
1997 [118]
18/20 Type 2 DM
Strength training 2/week
5 months
´
Ø
´
´
´
1998 [119]
8 Type 2 DM
CWT 2/week
3 months
´
Ø
´
Ø Chol Ø Tg Ø LDL-C ´
Fat % ´ BW ´ BW ´ Fat % Ø FFM ≠ BW ´ Fat % Ø FFM ≠ ´
´
1989 [116]
≠ HDL-C Ø LDL-C –
´
–
´
Exercise program
b Change in V· O 2 max is denoted by arrows: –, no data; ´, no change; ≠ significant increase. c NGT, normal glucose tolerance;Type 2 DM, type 2 diabetes. d CWT, circuit weight training. e Insulin sensitivity measured by the clamp technique improved 48%. Other abbreviations as in Table 4.4.1
.
´
Exercise in the Treatment of Diabetes
a Number of subjects participating in the intervention vs. control group.
´
Chapter . (Table ..). The mechanism underlying this change is, however, likely to be different from that of aerobic training.
Effects of aerobic and resistive training on insulin sensitivity and markers of cardiovascular risk Data are limited regarding non-glycemic effects of physical training in type diabetes. In many of the aerobic training studies, potentially beneficial effects in serum lipids ( out of studies, %) and blood pressure ( out of studies, %) were observed (Tables .. & ..). Data are too sparse (no study with a control group) to allow conclusions to be made regarding the effects of resistive training on lipids and lipoproteins in type diabetic patients. In non-diabetic power athletes, serum triglycerides, HDL and low-density lipoprotein (LDL) cholesterol are comparable to those of sedentary controls [], and thus lack the changes characterizing aerobically trained athletes. Hypertriglyceridemia, the hallmark of the dyslipidemia characterizing type diabetic patients [], is associated with abnormalities in fibrinolysis and coagulation such as increases in factor VII (FVII) and plasminogen-activator inhibitor (PAI-) concentrations []. In non-diabetic subjects, physical training has been consistently shown to enhance fibrinolysis by decreasing concentrations of PAI- but data on training effects on such parameters are very limited in type diabetes. Three months of aerobic training, which increased V˙2 max significantly by .%, was associated with no changes in coagulation parameters, including plasminogen or a2-antiplasmin, or in the measures of fibrinolysis but did cause a significant decrease in fibrinogen []. Oxidative stress is increased in patients with type diabetes, at least when measured from the total antioxidant trapping capacity of plasma, which is inversely related to the HbA1c concentration []. The concentration of superoxides and free radicals is also increased and can be reduced by antioxidants such as raloxifene [], allopurinol [] and tetrahydrobiopterin []. Numerous studies have demonstrated that free radical production (superoxides, hydrogen peroxide, hydroxyl radicals) is increased as oxygen production increases by stimuli such as aerobic exercise []. Free radical generation results in lipid peroxida-
tion, which is considered harmful. For example, intense, long-duration aerobic exercise has been shown, at least transiently, in two studies to increase LDL susceptibility to oxidation in non-diabetic subjects [,]. These data raise the possibility that type diabetic patients may be even more susceptible to exercise-induced oxidative damage. On the other hand, aerobic training is also able to increase the activity of free radical scavenging enzyme systems in red blood cells and skeletal muscle []. Thus, training might either deplete or restore antioxidant defense mechanisms in type diabetic patients but there are currently very limited data addressing this issue. Fisoprostanes consist of a series of chemically stable prostaglandin F (PGF2)-like compounds generated from the peroxidation of unsaturated fatty acids in membrane phospholipids independently of the cyclooxygenase enzyme. The urinary excretion rate of F-isoprostanes is increased in patients with type diabetes and is thought to reflect increased in vivo lipid peroxidation [,]. In the study of Mori et al. [], urinary excretion of F-isoprostanes was not altered by weeks of aerobic training consisting of -min bicycle ergometer exercise times a week. More data on this topic would, however, be of interest as the abovementioned antioxidants (allopurinol, raloxifene, tetrahydrobiopterin) not only reduce oxidative stress but also ameliorate endothelial dysfunction in patients with type diabetes [–], a change which might serve to protect against future development of atherosclerotic vascular disease [,]. In this respect it is of interest that high-intensity aerobic training in normal subjects depletes antioxidants and has been associated with a decrease in endothelial function [], although less intensive aerobic training regimens have improved endothelial function in healthy subjects [], in patients with essential hypertension with [] or without [] dyslipidemia, in hypercholesterolemia [], in chronic heart failure [] and in patients with coronary artery disease []. There are no data on effects of aerobic or resistive training on endothelial function in patients with type diabetes.
Mechanisms underlying improvements in insulin action by aerobic and resistive training Insulin has multiple actions in vivo in normal subjects, all of which could be considered potentially anti-
Exercise in the Treatment of Diabetes
Fig. .. Effect of a -week one-legged training program on glucose clearance (a), leg blood flow (b) and glucose extraction (c) in eight non-diabetic (squares) and seven type diabetic patients (circles). The measurements were made before and during three sequential intravenous insulin infusions. Euglycemia was maintained using a variable rate glucose infusion. The type diabetic patients had normal leg blood flows both basally and during the three insulin infusions compared to the non-diabetic subjects. Leg blood flow increased significantly and similarly in the trained leg in both groups. Glucose extraction was lower both before (open circles) and after (closed circles) training in the type diabetic patients compared to normal subjects. A significant improvement was observed in the type diabetic patients in response to physical training at all insulin infusion rates employed. Reproduced with permission from [].
300
(a)
Glucose clearance (mL/min)
250 200 150 100 50 0 700
100
1000
10000
100
1000
10000
100
1000
10000 Insulin (pM)
(b)
Blood flow (mL/min)
650 600 550 500 450 400 350 300 250 200 0 50
(c)
40 Glucose extraction (%)
atherogenic. These include the abilities of insulin to acutely: (i) decrease circulating glucose levels via inhibition of glucose production and stimulation of glucose uptake in skeletal muscle; (ii) decrease serum triglyceride concentrations via inhibition of hepatic VLDL production []; (iii) diminish large artery stiffness []; (iv) inhibit platelet aggregation []; and (v) regulate the autonomic nervous system []. All these actions are defective in insulin-resistant conditions [,–] and are likely to contribute to hypertriglyceridemia [], increased artery stiffness [], abnormalities in platelet function [] and inflexibility of the autonomic nervous system []. Data on effects of physical training in type diabetic patients are, however, largely confined to insulin stimulation of skeletal muscle glucose uptake. Insulin-stimulated glucose uptake across skeletal muscle can be calculated by multiplying glucose extraction and delivery []. During exercise, glucose uptake increases in the face of a marked increase in blood flow (glucose delivery) and a fall in glucose extraction [,]. This implies that blood flow is an important determinant of glucose uptake during exercise. In response to aerobic training, blood flow increases and this occurs similarly in normal subjects and patients with type diabetes [] (Fig. ..). The ability of high insulin concentrations to stimulate blood flow after training is better than before training in both normal subjects [] and patients with type diabetes []. Despite a normal blood flow response, the ability of skeletal muscle to extract glucose from the circulation in response to insulin remains lower than in non-
30
20
10
CONTROL, before and after training, respectively NIDDM, before and after training, respectively
Chapter . diabetic subjects in patients with type diabetes []. A normal response of flow to insulin but a defect in insulin stimulation of glucose extraction has also been found in most [–], although not all [] studies in patients with type diabetes in the untrained state. These data are similar to those recently documented using positron emission tomography-based techniques in insulin-sensitive and insulin-resistant normal subjects []. In both sensitive and resistant subjects, acute exercise increased blood flow markedly but similarly in both groups and glucose extraction decreased significantly. However, in the resistant subjects glucose extraction and glucose uptake remained lower than in the sensitive subjects. These data demonstrate that while exercise stimulates glucose uptake by enhancing glucose delivery, differences in this response appear intact in non-diabetic and diabetic insulin-resistant subjects. In insulin-resistant patients such as those with type diabetes, glucose uptake is determined under both resting and exercising conditions by the ability of skeletal muscle to extract glucose. Regarding the cellular mechanisms contributing to glucose extraction, it is now clear that insulin and exercise stimulate this process by independent mechanisms. In normal subjects, physiologic hyperinsulinemia stimulates glucose uptake in skeletal muscle via the classic insulin signaling pathway, i.e. by stimulating insulin receptor and insulin receptor substrate (IRS-) tyrosine phosphorylation, association of the p regulatory subunit of phosphatidylinositol (PI) -kinase with IRS- and glycogen synthase frac-
Microvesicles with glut-4
tional velocity []. In contrast, exercise has no effect on IRS- tyrosine phosphorylation and even decreases tyrosine phosphorylation of the insulin receptor []. After one-legged acute exercise in normal men, insulin-stimulated glucose uptake is higher in the exercised than the rested leg but this is accompanied by no change in insulin receptor or IRS- tyrosine phosphorylation [,], and by a decrease in IRS--associated PI -kinase activity []. In mice which lack insulin receptors selectively in skeletal muscle, insulin has no effect on muscle glucose uptake while the ability of exercise to stimulate glucose uptake is intact []. As in humans, acute exercise has no effect on insulin receptor tyrosine phosphorylation or PI-kinase activity. Regarding the mechanism of contraction-stimulated glucose uptake, ¢-AMP-activated protein kinase (AMPK) is one candidate [] (Fig. ..). AMPK, especially its a isoform, is activated by muscle contractions in human skeletal muscle. Activation of AMPK results in GLUT- translocation and an increase in glucose transport []. In animal studies, contractions but not insulin have been shown to increase AMPK activity []. The PI -kinase inhibitor wortmannin completely blocks insulin-stimulated glucose transport but has no effect on stimulation of glucose transport by contractions or an adenosine analog that stimulates AMPK []. On the other hand, in glycogen-loaded slow-twitch muscle, glucose transport increases sixfold by contractions despite an unchanged AMPK activity []. These data suggest that mechanisms other than AMPK may contribute to contraction-induced
Contraction
+ AMPK
? + Glut-4 translocation + ?
PI3 kinase + IRS-1 IR Insulin
Glut-4
Sarcoplasm Sarcolemma
Fig. .. Exercise and insulin stimulate glucose uptake in skeletal muscle by distinct mechanisms. The classic insulin signaling molecules such as the insulin receptor (IR), the insulin receptor substrate (IRS-) and phosphatidylinositol -kinase (PI-kinase) are necessary for insulin- but not contraction-stimulated glucose uptake. Contractions have been suggested to trigger glucose uptake by increasing the activity of an adenosine ¢-monophosphate-activated kinase (AMPK). Both insulin- and exercisestimulated pathways result in recruitment of glucose transporters (GLUT-) to the cell surface, which leads to glucose transport. Reproduced with permission from [].
Exercise in the Treatment of Diabetes
∗
∗
0.4 0.3 0.2 0.1 0 UT T Control
UT T Type 2 DM
independent exercise-stimulated glucose transport pathway in patients with type diabetes. A single bout of acute exercise, in contrast to insulin, seems to induce normal translocation of GLUT- from an intracellular pool to the sarcolemma in patients with type diabetes []. Taken together these data are encouraging as they suggest that signaling defects, which are important for insulin action, may be enhanced by aerobic training. The data also suggest that the signaling pathways via which exercise stimulates glucose uptake in patients with type diabetes may be intact. This has the practical implication that the glycemic response to exercise is unlikely to be blunted by insulin resistance. In contrast to aerobic training, resistive training does not increase capillary density [] or activity of oxidative enzymes [–]. Absence of these changes may explain why glucose uptake per muscle mass is similar in untrained subjects and weight lifters [,]. In studies comparing weight lifters or non-steroidusing body builders to sedentary subjects, a critical question is how the sedentary group is matched with the resistive-trained athletes. If muscular subjects are compared to equally heavy adipose subjects, insulin concentrations after an oral glucose load are lower in the muscular subjects [,]. This result could be explained by obesity-associated insulin resistance rather than enhanced sensitivity in muscular subjects. How-
50
200 ∗
180 160 140
∗
120 100 80 60 40 20 0
GS mRNA (arbitrary units/total RNA)
0.5
GLUT-4 mRNA (arbitrary units/10 µg total RNA)
GLUT-4 protein (arbitrary units/protein content)
glucose transport under conditions where AMPK has been deactivated by increasing muscle glycogen content. In insulin-resistant patients with type diabetes, the ability of insulin to stimulate tyrosine phosphorylation of the insulin receptor and of IRS-, and to stimulate IRS--associated PI-kinase activity is blunted. Furthermore, the ability of insulin to translocate GLUT- [], the insulin-sensitive glucose transporter, is subnormal []. Few data are available regarding the ability of acute exercise or physical training to reverse defects in insulin signaling. In the study of Cusi et al. [], type diabetic patients had higher basal levels of tyrosine phosphorylation of the insulin receptor and IRS- and blunted phosphorylation responses to insulin. After acute exercise, the increased basal levels decreased, the insulin-stimulated levels remained unchanged but the fold-response to insulin increased. These changes were not accompanied by any change in insulin-stimulated glucose uptake []. On the other hand, aerobic training in patients with type diabetes, as in normal subjects, has been shown to significantly increase the content of GLUT- in skeletal muscle [] (Fig. ..) and also to significantly increase the expression and activity of glycogen synthase [] and the ability of insulin to increase PI-kinase activity []. There are currently few data available regarding the integrity of the insulin-
∗ 40
∗
30 20 10 0
UT T Control
UT T Type 2 DM
UT T Control
UT T Type 2 DM
Fig. .. Effect of -weeks one-legged training program on skeletal muscle GLUT-4 protein (left), GLUT- mRNA (middle) and glycogen synthase (GS) mRNA (right) content in eight non-diabetic (control) and seven patients with type diabetes mellitus (Type DM). *Increased in trained (T) compared with untrained (UT) leg (P < .). Reproduced with permission from Dela et al. [].
Chapter . Training group 10
M-value (mg/kg • min)
8
6
4
2
–100
–80
–60
–40
–20
Sedentary group
M-value (mg/kg • min)
10
ever, even when muscular subjects are compared to normal-weight men with similar V˙2 max, both glucose and insulin concentrations are still significantly lower in muscular than the normal-weight subjects []. In both comparisons, the muscular subjects have relatively less fat, which could itself enhance insulin sensitivity, e.g. via free fatty acids, but this remains speculative. If insulin sensitivity is quantified in muscular and normal-weight sedentary subjects, who are matched with respect to V˙2 max, insulin-stimulated rates of glucose uptake expressed per unit muscle weight are identical [,] (Fig. .., Plates and facing p. ). These data could mean that the lower glucose insulin responses during an oral glucose tolerance test (OGTT) [] can be attributed to a larger muscle mass rather than to enhanced insulin sensitivity if defined as increased glucose uptake per unit muscle mass. Thus, both aerobic and resistive training enhance insulin sensitivity but via fundamentally different mechanisms.
8
Physical training in the treatment of type 1 diabetes
6
The role of physical activity has been emphasized in improving well-being and self-esteem in type diabetic patients also. Although data specifically addressing type diabetic patients are not available, exercise should have the same cardiovascular benefits in type diabetic as in type diabetic patients, provided the insulin treatment regimen and diet can be accurately adjusted to maintain normal glucose homeostasis during exercise.
4 Key Normal subjects Type 1 DM after training Type 1 DM before training
2
–100
–80
–60
–40
–20
Time (min) Fig. .. Insulin sensitivity of glucose uptake in patients with type diabetes before and after weeks of bicycle exercise training ( times/week ¥ min at an intensity corresponding · to % V 2 max with a -min rest period between exercise periods). Two control groups were studied: a group of sedentary type diabetic patients who had similar and good glycemic control during treatment with continuous subcutaneous insulin infusion therapy as did the exercise group; and a group of normal subjects. The sedentary control group with type diabetes was studied at and weeks. Body weight and HbA1c remained unchanged in both type diabetic groups. In the · training group, V 2 max increased significantly by %. This was sufficient to normalize insulin sensitivity. Reproduced with permission from [].
Effect of physical training on glucose control and insulin requirements Most studies have found no difference in glycemic control between type diabetic patients who are physically active compared to those who are inactive [,,], and no improvement in glycemic control by physical training [–]. On the other hand, physical training does improve and even normalize insulin sensitivity in type diabetic patients [] (Fig. ..), and this is associated with slight (%) decreases in insulin requirements [,].
Exercise in the Treatment of Diabetes Effect of physical training on vascular function and cardiovascular risk markers in type 1 diabetic patients Endothelial dysfunction, defined as an inability of the endothelium to release normal amounts of nitric oxide, characterizes some [–] but perhaps not all [–] patients with type diabetes. The impact of physical activity on endothelial dysfunction has been sparsely studied. In one cross-sectional analysis, endothelial function, measured from perfusion changes in the skin microcirculation during iontophoresis with acetylcholine, was similar between physically active and inactive patients with type diabetes []. Exercise does seem to have favorable effects on serum lipids and lipoproteins also in type diabetic patients. In controlled studies, physical training has also been shown to lower total [] and LDL [] cholesterol and triglyceride [] concentrations and to increase HDL cholesterol [], HDL cholesterol/ total cholesterol [,,] and apoA-I [] concentrations. In all of the controlled studies, these changes occurred independent of glycemic control and body weight and composition [,,]. In uncontrolled or cross-sectional analyses, physical activity is associated with increases in HDL2 cholesterol and decreases in serum triglycerides and LDL cholesterol [,]. Poorly controlled patients with type diabetes are characterized by changes in markers indicative of increased oxidative stress such as increased levels of plasma thiobarbituric acid reactive substance (TBARS), reduced total radical trapping capacity [], increased levels of oxidized LDL [] and antibodies against oxidative LDL []. During acute exercise ( min at % V˙2 max), markers of oxidative stress such as TBARS and blood oxidized glutathione concentrations increase by % []. The significance of this with regards to long-term effects of training on cardiovascular function is unknown. Little information is available on effects of different types of training on markers of metabolic control or cardiovascular risk. Aerobic circuit exercise training has been suggested to induce similar changes in body composition and lipids in type diabetic patients as in normal subjects and type diabetic patients but this study was uncontrolled [] (Table ..).
Diet and insulin treatment during exercise In normal subjects, the serum insulin concentration decreases during prolonged exercise in response to a slight decrease in glucose concentrations and protects against hypoglycemia []. In patients with type diabetes, the serum free insulin concentration is determined by the amount of insulin injected, its rate of absorption, insulin antibodies and insulin clearance. During exercise, the serum free insulin concentration is frequently higher than in normal subjects. This can be due to overinsulinization or injection of insulin before exercise, inability of glucose to regulate insulin concentrations or acceleration of insulin absorption by exercise, if insulin has been injected in a region which is actively exercising []. Overinsulinization increases the risk of hypoglycemia. On the other hand, if the insulin concentration is subnormal, this will allow the exercise-induced increase in counterregulatory hormones to stimulate hepatic glucose production excessively, which leads to hyperglycemia. Excessive counterregulatory responses in poorly controlled patients may further exaggerate hyperglycemia []. In a well-controlled type diabetic patient, it is usually recommended to increase carbohydrate intake by – g/h before or during exercise to prevent hypoglycemia. If hypoglycemia occurs despite this, the insulin dose should be reduced. To avoid changes in insulin absorption by exercise, insulin should be injected in a region which is inactive, and it is not recommended to exercise immediately after injection of regular insulin or a rapid-acting insulin analog []. Use of short-acting analogs has been shown to increase the risk of hypoglycemia if exercise is performed shortly ( min) after a meal but reduce it by approximately % if exercise is performed h after a meal []. In addition to the precautions necessary to minimize the occurrence of exercise-induced hypo- or hyperglycemia, the presence of complications should also be considered. This applies to type [] as well as type [] diabetic patients. Patients with proliferative retinopathy, poorly controlled hypertension or evidence of cardiovascular disease should avoid strenuous activities such as heavy weight-lifting and sprints. Individuals with autonomic neuropathy may experience
Chapter . postural hypotension after exercise. Heart rate responses may also be abnormal, which is why ratings of perceived exhaustion rather than heart rate should guide intensity of exercise. Non-weight-bearing activities should be preferred by patients with foot problems and peripheral neuropathy to avoid injuries and additional damage to feet [,].
Summary The observational and trial evidence supporting the hypothesis that both type diabetes and its cardiovascular complications can be prevented by being physically moderately active is rapidly emerging. The question of how beneficial exercise is in the treatment of type diabetes is more difficult to answer. If one neglects the potentially important effects of physical activity on subjective well-being and self-esteem, and considers the metabolic effects of physical activity, glycemic control has been slightly improved in approximately half of the studies and in some independent of changes in body weight and composition. Data are sparse on cardiovascular risk markers or factors but physical activ-ity appears to have beneficial effects on blood pressure, lipids and insulin sensitivity. In type patients physical activity has consistently not been found to improve glycemic control but has been shown to improve insulin sensitivity and induce potentially antiatherogenic changes in lipids and lipoproteins. According to the American College of Sports Medicine position stand, exercise is a major therapeutic modality in type diabetes and regular physical activity is imperative to sustain any glucose-lowering effects. It was also recommended that patients with type diabetes should strive to expend at least kcal/week in physical activities. Both aerobic and resistance training were recommended []. In patients with type diabetes, special precautions are necessary to avoid exercise-induced hypo- and hyperglycemia. In both types of diabetes, metabolic and physical screening should be performed in all patients with micro- or macrovascular complications and in those who are poorly controlled with respect to cardiovascular risk factors or who have longstanding disease.
Questions For the following statements, please answer true (a) or false (b).
Physical activity can prevent type diabetes and reduce the burden of cardiovascular disease. Resistive training increases capillary density in skeletal muscle. An intact insulin signaling cascade is necessary for exercise to stimulate glucose uptake in type diabetes. Physical training improves glycemic control in type diabetes. Physical training improves insulin sensitivity and induces potentially antiatherogenic changes in lipids and lipoproteins in type diabetes.
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Exercise in the Treatment of Diabetes Kalkhoff R, Ferrou C. Metabolic differences between obese overweight and muscular overweight men. N Engl J Med ; : –. Ligtenberg PC, Blans M, Hoekstra JB, van der Tweel, Erkelens DW. No effect of long-term physical activity on the glycemic control in type diabetes patients: a crosssectional study. Neth J Med ; : –. Wasserman DH, Zinman B. Exercise in individuals with IDDM. Diabetes Care ; : –. Laaksonen DE, Atalay M, Niskanen LK et al. Aerobic exercise and the lipid profile in type diabetic men: a randomized controlled trial. Med Sci Sports Exerc ; : –. Wallberg-Henriksson H, Gunnarson R, Henriksson J, Östman J, Wahren J. Influence of physical training on formation of muscle capillaries in type diabetes. Diabetes ; : –. Wallberg-Henriksson H, Gunnarsson R, Rossner S, Wahren J. Long-term physical training in female type (insulin-dependent) diabetic patients: absence of significant effect on glycaemic control and lipoprotein levels. Diabetol ; : –. Yki-Järvinen H, DeFronzo RA, Koivisto VA. Normalization of insulin sensitivity in type diabetic subjects by physical training during insulin pump therapy. Diabetes Care ; : –. Johnstone MT, Craeger SJ, Scales KM, Cusco JA, Lee BK, Craeger MA. Impaired endothelium-dependent vasodilation in patient with insulin-dependent diabetes mellitus. Circulation ; : –. McNally PG, Watt PAC, Rimmer T, Burden AC, Hearnshow JR, Thurston H. Impaired contraction and endothelium-dependent relaxation in isolated resistance vessels from patients with insulin-dependent diabetes mellitus. Clin Sci ; : –. Mäkimattila S, Virkamäki A, Groop P-H et al. Chronic hyperglycemia impairs endothelial function and insulin sensitivity via different mechanisms in insulin-dependent diabetes mellitus. Circulation ; : –. Skyrme-Jones RA, O’Brien RC, Luo M, Meredith IT. Endothelial vasodilator function is related to low-density lipoprotein particle size and low-density lipoprotein vitamin E content in type diabetes. J Am Coll Cardiol ; : –. Calver A, Collier J, Vallance P. Inhibition and stimulation of nitric oxide synthesis in the human forearm arterial bed of patients with insulin-dependent diabetes. J Clin Invest ; : –. Elliott TG, co*ckcroft JR, Groop PH, Viberti GC, Ritter JM. Inhibition of nitric oxide synthesis in forearm vasculature of insulin-dependent diabetic patients: blunted vasoconstriction in patients with microalbuminuria. Clin Sci (Colch) ; : –. Mäkimattila S, Mäntysaari M, Groop P-H et al. Hyperreactivity to nitrovasodilators in forearm vasculature is related to autonomic dysfunction in IDDM. Circulation , : –.
Pinkney JH, Downs L, Hopton M, Mackness MI, Bolton CH. Endothelial dysfunction in Type diabetes mellitus. relationship with LDL oxidation and the effects of vitamin E. Diabet Med ; : –. Smits P, Kapma J-A, Jacobs M-C, Lutterman J, Tien T. Endothelium-dependent vascular relaxation in patients with type diabetes. Diabetes ; : –. Gunnarsson R, Wallberg-Henriksson H, Rossner S, Wahren J. Serum lipid and lipoprotein levels in female type I diabetics: relationships to aerobic capacity and glycaemic control. Diabetes Metab ; : –. Lehmann R, Kaplan V, Bingisser R, Bloch KE, Spinas GA. Impact of physical activity on cardiovascular risk factors in IDDM. Diabetes Care ; : –. Tsai EC, Hirsch IB, Brunzell JD, Chait A. Reduced plasma peroxyl radical trapping capacity and increased susceptibility of LDL to oxidation in poorly controlled IDDM. Diabetes ; : –. Makimattila S, Luoma JS, Yla-Herttuala S et al. Autoantibodies against oxidized LDL and endothelium-dependent vasodilation in insulin-dependent diabetes mellitus. Atherosclerosis ; : –. Laaksonen DE, Atalay M, Niskanen L, Uusitupa M, Hanninen O, Sen CK. Increased resting and exerciseinduced oxidative stress in young IDDM men. Diabetes Care ; : –. Mosher PE, Nash MS, Perry AC, LaPerriere AR, Goldberg RB. Aerobic circuit exercise training: effect on adolescents with well-controlled insulin-dependent diabetes mellitus. Arch Phys Med Rehab ; : –. Koivisto VA, Felig P. Effects of leg exercise on insulin absorption in diabetic patients. N Engl J Med ; : –. Tamborlane WV, Sherwin RS, Koivisto V, Hendler R, Genel M, Felig P. Normalization of the growth hormone and catecholamine response to exercise in juvenile-onset diabetic subjects treated with a portable insulin infusion pump. Diabetes ; : –. Tuominen JA, Karonen SL, Melamies L, Bolli G, Koivisto VA. Exercise-induced hypoglycaemia in IDDM patients treated with a short-acting insulin analogue. Diabetol ; : –. Albright A, Franz M, Hornsby G et al. American College of Sports Medicine position stand. Exercise and type diabetes. Med Sci Sports Exerc ; : –. Winder WW, Hardie DG. AMP-activated protein kinase, a metabolic master switch: possible roles in type diabetes. Am J Physiol ; : E–E. Heath GW, Wilson RH, Smith J, Leonard BE. Communitybased exercise and weight control: diabetes risk reduction and glycemic control in Zuni Indians. Am J Clin Nutr ; : S–S. Vanninen E, Uusitupa M, Siitonen O, Laitinen J, Lansimies E. Habitual physical activity, aerobic capacity and metabolic control in patients with newly-diagnosed type (noninsulin-dependent) diabetes mellitus: effect of -year diet and exercise intervention. Diabetol ; : –.
Chapter . Lehmann R, Vokac A, Niedermann K, Agosti K, Spinas GA. Loss of abdominal fat and improvement of the cardiovascular risk profile by regular moderate exercise training in patients with NIDDM. Diabetol ; : –. Ligtenberg PC, Hoekstra JB, Bol E, Zonderland ML, Erkelens DW. Effects of physical training on metabolic control in elderly type diabetes mellitus patients. Clin Sci (Colch) ; : –. Dunstan DW, Mori TA, Puddey IB et al. The independent and combined effects of aerobic exercise and dietary fish intake on serum lipids and glycemic control in NIDDM. Diabetes Care ; : –. Mourier A, Gautier JF, De Kerviler E et al. Mobilization of visceral adipose tissue related to the improvement in insulin sensitivity in response to physical training in NIDDM. Effects of branched-chain amino acid supplements. Diabetes Care ; : –. Ruderman NB, Ganda OP, Johansen K. The effect of physical training on glucose tolerance and plasma lipids in maturity-onset diabetes. Diabetes ; (Suppl. ): –. Reitman JS, Vasquez B, Klimes I, Nagulesparan M. Improvement of glucose homeostasis after exercise training in non-insulin-dependent diabetes. Diabetes Care ; : –. Trovati M, Carta Q , Cavalot F et al. Influence of physical training on blood glucose control, glucose tolerance, insulin secretion, and insulin action in non-insulin-dependent diabetic patients. Diabetes Care ; : –. Allenberg K, Johansen K, Saltin B. Skeletal muscle adaptations to physical training in type II (non-insulindependent) diabetes mellitus. Acta Med Scand ; : –. Schneider SH, Khachadurian AK, Amorosa LF, Clemow L, Ruderman NB. Ten-year experience with an exercisebased outpatient life-style modification program in the treatment of diabetes mellitus. Diabetes Care ; : –. Di GX, Teng WP, Zhang J, Fu PY. Exercise therapy of non-
insulin dependent diabetes mellitus: a report of year studies. The efficacy of exercise therapy. Chin Med J ; : –. Barnard RJ, Jung T, Inkeles SB. Diet and exercise in the treatment of NIDDM. The need for early emphasis. Diabetes Care ; : –. Bourn DM, Mann JI, McSkimming BJ, Waldron MA, Wishart JD. Impaired glucose tolerance and NIDDM: does a lifestyle intervention program have an effect? Diabetes Care ; : –. Tarnow L, Cambien F, Rossing P et al. Insertion/deletion polymorphism in the angiotensin-I-converting enzyme gene is associated with coronary heart disease in IDDM patients with diabetic nephropathy. Diabetol ; : –. Rigla M, Sanchez-Quesada JL, Ordonez-Llanos J et al. Effect of physical exercise on lipoprotein (a) and low-density lipoprotein modifications in type and type diabetic patients. Metabolism ; : –. Ishii T, Yamakita T, Sato T, Tanaka S, Fujii S. Resistance training improves insulin sensitivity in NIDDM subjects without altering maximal oxygen uptake. Diabetes Care ; : –. Hurley BF, Hagberg JM, Goldberg AP et al. Resistive training can reduce coronary risk factors without altering · V 2 max or percent body fat. Med Sci Sports Exerc ; : –. Craig BW, Everhart J, Brown R. The influence of highresistance training on glucose tolerance in young and elderly subjects. Mech Age Dev ; : –. Miller JP, Pratley RE, Goldberg AP et al. Strength training increases insulin action in healthy - to -yr-old men. J Appl Physiol ; : –. Honkola A, Forsen T, Eriksson J. Resistance training improves the metabolic profile in individuals with type diabetes. Acta Diabetol ; : –. Eriksson J, Tuominen J, Valle T et al. Aerobic endurance exercise or circuit-type resistance training for individuals with impaired glucose tolerance? Hormone Metabol Res ; : –.
Chapter 4.5 Asthma and Chronic Airway Disease MALCOLM SUE - CHU & L E I F B J E RME R
Classical reference Aretaeus of Cappadocia (81–131 AD) Greek physician from Cappadocia who practiced in Rome and Alexandria, led a revival of Hippocrates’ teachings and is thought to have ranked second only to the father of medicine himself in the application of keen observation and ethics to the art. In principle he adhered to the pneumatic school of medicine, which believed that health was maintained by ‘vital air’ or pneuma. Pneumatists felt that an imbalance of the four humours — blood, phlegm, choler (yellow bile) and melancholy (black bile) — disturbed the pneuma, a condition indicated by an abnormal pulse. In practice, however, Aretaeus was an eclectic physician, since he utilized the methods of several different schools. Aretaeus was the first to describe asthma as an airway disease. Asthma comes from the Greek word ‘panting’ and in he wrote: ‘If from running, gymnastic exercise or any other work, the breathing becomes difficult, it is asthma.’ After his death he was entirely forgotten until , when two of his manuscripts, On the Causes and Indications of Acute and Chronic Diseases ( volumes) and On the Treatment of Acute and Chronic Diseases ( volumes) both written in the Ionic Greek dialect, were discovered (Fig. ..). In the first manuscript Aretaeus attributed asthma to ‘thick and viscid phlegm caused by coldness and humidity suffered by the patient.’ He also in the two books gave model descriptions of pleurisy, diphtheria, tetanus, pneumonia and epilepsy and was the first to distinguish between spinal and cerebral paralyses. He gave diabetes its name (from the Greek word for ‘siphon’, indicative of the diabetic’s intense
Fig. .. Picture of the book: De Causis et Signis Acutorum et Diuturnorum Morborum, Liber Primus (Of the Causes and Signs of Acute and Morbid Disease) printed in Oxford .
thirst and excessive emission of fluids) and rendered the earliest clear account of that disease now known.
Bronchial asthma Definition Asthma, which is derived from the Greek asqma, meaning short-drawn breath or panting, has until recently been defined as a disease characterized by an increased responsiveness of the trachea and bronchi to various stimuli and manifested by a widespread narrowing of the airways that changes in severity either spontaneously or as a result of therapy []. Although first highlighted in clinicopathologic studies of fatal asthma at the turn of the th century, it is only as a
Chapter . result of studies of bronchoalveolar lavage fluid, endobronchial biopsies and induced sputum over the past four decades that our appreciation and understanding of the inflammatory nature of the disease has increased [,]. This has resulted in a shift of emphasis away from airway smooth muscle dysfunction to a T-lymphocyte-modulated chronic desquamative eosinophilic bronchitis as the primary abnormality in asthma [–]. In the international consensus statement, asthma is now defined as ‘a chronic inflammatory disorder of the airways in which many cells play a role, in particular mast cells, eosinophils, and T-lymphocytes. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough particularly at night and/or in the early morning. These symptoms are usually associated with widespread but variable airflow limitation that is at least partly reversible either spontaneously or with treatment. The inflammation also causes an associated increase in airway responsiveness to a variety of stimuli.’[]
Exercise-induced bronchospasm (EIB) It is well recognized that physical exercise has adverse effects in asthmatic subjects. In the nd century , Aretaeus of Cappadocia wrote: ‘If from running, gymnastic exercise, or any other work the breathing becomes difficult, it is called asthma’ [], and the observation was repeated in the th century by the asthmatic physician, Sir John Floyer: ‘All exercise makes the asthmatic to breathe short… and if the Exercise be continued it occasions a Fit’ []. This phenomenon is described by the synonymous terms exercise-induced asthma (EIA) and exercise-induced bronchoconstriction (EIB). The breathing difficulties are due to bronchospasm, which can be detected by changes in the forced expiratory volume in s (FEV1) on spirometry or in peak expiratory flow (PEF) using a peak flow meter. After a standardized bicycle ergometer or treadmill exercise protocol in the laboratory, the normal response in the postexercise period is a maximum fall in FEV1 of less than % []. When exercise testing is conducted outside the laboratory, the normal fall in PEF is less than % []. In asthmatic individuals with entirely normal lung function or with a subclinical degree of obstruction at
baseline, an increase in resistance to airflow can be detected as early as min after the start of prolonged strenuous exercise [,]. During or within the first min after exercise, they have falls in lung function that are in excess of these limits, and commonly complain of wheeze, chest tightness, difficult breathing or cough, and may have difficulty in continuing or resuming exercise. An unusual complaint in children and adolescents may be chest pain on exercise []. The maximum fall in lung function occurs within – min of exercise, and the increased resistance to airflow is due to airway narrowing, which develops predominantly in the large airways. In severe cases, the small airways are involved [], leading to pulmonary hyperinflation and arterial hypoxemia []. Asthmatic symptoms and airway obstruction resolve spontaneously within min in most persons and, in approximately –% of subjects, is accompanied by a refractory period of – h duration []. During this period, significantly less (less than %) bronchoconstriction is evoked on performance of an identical exercise task. The degree of this protection is independent of the severity of the preceding bronchoconstriction []. Moreover, Hahn et al. showed in adult asthmatics with documented refractoriness that the absence of bronchoconstriction after an exercise challenge did not protect against bronchoconstriction in a subsequent exercise challenge. In that study, a mean (SD) fall in FEV1 of . (.)% was observed after a -min treadmill exercise challenge while breathing saturated air at °C. However, a repeat challenge min later at an inspired air temperature of °C resulted in a mean (SD) fall in FEV1 of . (.)% []. In some patients, the initial episode may be followed – h later by a second episode of bronchoconstriction [], which is associated with increased neutrophil chemotactic activity [] and is localized to the peripheral airways []. However, the existence of this late response has been disputed []. The severity of EIB is mainly dependent on the environmental conditions under which exercise is performed and the level of ventilation during exercise [,]. Environmental factors include the temperature and humidity of the inspired air, with an additive effect of inhalation of subfreezing air [–], and high levels of allergens and environmental pollutants
Asthma and Chronic Airway Disease 60 Absolute humidity (mg/L)
[]. The level of ventilation is dependent on the nature, duration and intensity of the exercise. Swimming with high humidity of the inspired air is considered to be less asthmogenic than walking, running and cycling [–], while cross-country skiing, with inspiration of large volumes of cold, dry air, is considered to be the most asthmogenic. However, it has been suggested that, when controlled for temperature, humidity and accumulated ventilation, all forms of exercise are equally effective stimuli for EIB [,]. EIB is a sensitive indicator of asthma, being present in % of asthmatics not treated with inhaled corticosteroids [] and in % of asthmatics despite current treatment with inhaled steroids [], and absent in those asthmatics who become symptom free []. The stimulus for acute airway narrowing in sensitive subjects is the loss of water from the airways. Under resting conditions, full conditioning of the inspired air occurs in the nose and the upper airway. During exercise, ventilation, gas exchange, skeletal muscle activity and cardiac output increase in order to meet the increased aerobic demands. The increased minute ventilation is facilitated by an increase in the diameter of the lumen of the lower airways [] and by a shift in ventilation from the nasal to the oronasal route, which forces the task of conditioning of the inspired air on to the lower airways. As the relationship between temperature and humidity is non-linear (Fig. ..), the colder the air the greater the loss of water from the airways during the conditioning process. There are two main hypotheses regarding the mechanism of the bronchoconstriction: the hyperosmolarity and the vascular hypothesis. According to the hyperosmolarity hypothesis, airway narrowing is due to bronchial smooth muscle contraction in response to mediators released from mast cells, airway epithelial cells and nerve cells, secondary to the development of a hyperosmolar environment in the airways []. In contrast, the vascular hypothesis proposes that airway cooling and bronchoconstriction occur during exercise and that the increase in airway resistance after exercise is due to the reactive hyperemia in the bronchial vasculature and subsequent edema with subsequent airway narrowing []. In practical terms, the inhalation of cold air almost always means inhalation of dry air, especially as air at temperatures of - °C and lower is almost depleted of water [].
50 44 40
100% RH
30 20 17 10
39% RH
0 –20
–10
10
20
30
40
50
Temperature (∞C) Fig. .. Relationship between temperature and absolute humidity. For example, the relative humidity of a gas at °C containing mg/L water (its absolute humidity) is %; if the gas is then heated to °C without the addition of water, its absolute humidity is the same but its relative humidity is only %. A saturated vapour at this temperature would hold mg/L. Adapted from [].
Training type and effects Any kind of physical exercise can be safely performed by almost all asthmatics, as EIB can be prevented or attenuated by regular anti-inflammatory treatment and the prophylactic use of pre-exercise warm-ups and b2-agonist or chromones [–]. Training programs should be based on the interval principle, as the airway response is less severe with intermittent than with continuous exercise []. Examples of useful activities are swimming, ball games, relay races and dancing. In addition to an amelioration of EIB, interval and endurance training result in significant improvements in the aerobic and anaerobic working capacities of asthmatics [–]. Minute ventilation is maintained under endurance training in asthmatics through a small increase in frequency with no change in tidal volume, which compensates for the airflow obstruction [].
Protocol for exercise challenge test Purpose For diagnostic purposes, a free running test may be sufficient. It is important to instruct the subject to exercise to the extent of maximum effort for a period of at least min. For scientific purposes, and when it is de-
Chapter . sirable to monitor effect by intervention, an exercise test preferably on a treadmill and under more controlled conditions of temperature and humidity is preferable.
Discontinuation of medication Short-acting b2-agonist Long-acting b2-agonist Antihistamine Antileukotrienes Anticholinergics Theophylline Inhaled glucocorticosteroids (GCS) Chromones
h h h h h h Keep stable dose h
Exercise workload In the free running test, it is important to instruct the subject to exercise to the extent of maximum effort for a period of at least min. In a treadmill or cycle ergometer test, a minimum provocation requires a minute ventilation of –% of predicted maximum voluntary ventilation (FEV1 predicted ¥ ) and a heart rate of more than % of maximum heart rate ( – age [beats/min]) during the last min of the exercise protocol. For optimal sensitivity in highly trained athletes, a greater exercise stimulus resulting in a heart rate of at least % maximum heart rate combined with inhalation of subfreezing air may be employed.
letes at other competitive levels, and was further intensified in the s following the observation that % of cross-country skiers finishing in the top places in short-distance competitive events in the World Championship used antiasthmatic medication (Videman Tapio, American College of Sports Medicine meeting, May ). The relationship between asthma and sports appears to be dual in nature. It has long been recognized that asthmatics participating in sporting activities experience EIB. However, recent studies have highlighted high prevalences of chest tightness, cough, wheezing or prolonged shortness of breath and asthma in highly trained athletes, especially American football players, swimmers and cross-country skiers (Table ..), suggesting that exercise per se may cause normal individuals to develop asthma. In non-asthmatic subjects, inhalation of large volumes of cold air can cause a decrease in lung function []. Moreover, in a recent study, Langdeau et al. reported that % of elite athletes had bronchial hyperresponsiveness to methacholine, defined as PC20 < mg/mL (provocative concentration causing % fall in FEV), with a greater prevalence in those athletes exposed to cold air and humid air []. In a case control study, Heir and Oseid observed that cross-country skiers with a diagnosis of asthma developed respiratory symptoms later in adolescence and early adulthood, compared to controls [].
Possible risk factors Evaluation of response Spirometry or peak expiratory flow (PEF) is used to measure the effect of exercise on lung function. Measurements are taken at baseline and at , , , and min after the end of exercise. In some individuals, the fall in lung function may occur at min after exercise. Exercise-induced bronchospasm is present if the fall in PEF exceeds % or in FEV1 exceeds %.
Asthma in sports After the disqualification of an asthmatic gold medallist in the Olympic Games for the use of a banned drug [], there has been an increased focus on accurate diagnosis and treatment of asthma in Olympic team athletes, especially from the United States and Australia. This interest has since encompassed ath-
There are three possible risk factors for asthma in sport: • allergy; • air pollution/irritants; and • exercise-induced immunosuppression.
Allergy Inhalation of seasonal allergens should be considered as a substantial risk factor in summer sports. A recent survey of elite Australian athletes in Summer Olympic disciplines revealed a history of seasonal allergic rhinoconjunctivitis with a positive skinprick test in % []. In another study, Helenius et al. reported that atopic athletes had nearly a four-fold increased risk of developing bronchial hyperresponsiveness and more than a seven-fold risk of developing asthma,
Asthma and Chronic Airway Disease
Table .. Asthma prevalence in highly trained athletes.
Athletic group
1976
185
Physical examination
9.7
[68]
106
Physical examination
8.5
[68]
1984
Australian Summer Olympic team Australian Summer Olympic team US Summer Olympic team
597
4.3
[69]
1986
Football players
156
11.5
[70]
1986 1993
Swiss athletes Swedish cross-country skiers Norwegian cross-country skiers Swedish cross-country skiers Finnish runners US swimmers Norwegian cross-country skiers Swedish cross-country skiers US Summer Olympic team US Winter Olympic team
3.7 54.8
[71] [72]
153
Questionnaire, treadmill exercise challenge in selected athletes Questionnaire, methacholine challenge Questionnaire Questionnaire, methacholine challenge Questionnaire
14.4
[54]
299
Questionnaire
15
[73]
103 738 118
Questionnaire Questionnaire Questionnaire, methacholine challenge Questionnaire, methacholine challenge Questionnaire Questionnaire Exercise challenge test
15.5 13.4 11.8
[74] [75] [76]
41.5
[76]
1980
1994 1994 1994 1995 1996 1996 1996 1998
n
Method
Asthma prevalence (%)
Study year
2060 42
53 699 196 170
Ref
16.7 (50% in cyclists) [77] 22.4 [78] 23% with EIB [79] (50% in cross-country skiers, 43% in short-track speed skating)
EIB, exercise-induced bronchoconstriction.
compared to non-atopic athletes []. This increased risk may be due to an increased exposure of the lower airways to pollen as a result of an increase in nasal resistance and oral breathing, and of reduced nasal filtration of pollen.
Air pollution/irritants Exposure to low levels of pollutants like sulfur dioxide and ozone during exercise causes a marked bronchoconstriction and reduced ventilatory flow, compared to exposure at rest []. The airways are exposed to a much higher dose than at rest, because of a higher ventilatory rate and oronasal respiration. Cyclists are exposed to a wide spectrum of irritants, including road dust, diesel exhaust and ozone. Fifty per cent of cyclists in the US Olympic team reported that they had asthma or had taken an asthma medication in the
past []. Moreover, low-level exposure to ozone negatively affected exercise performance in elite cyclists []. Another group of athletes where exposure to irritants may be a significant factor is swimmers. Although the ambient chlorine concentration is well below the acceptable threshold levels, swimmers are exposed to high concentrations of chlorine in the course of a practice session because of the high minute ventilation achieved during training and competition, especially in indoor pools [].
Immunosuppression Physical training affects the function of the immune system. Although there is no apparent effect on the adaptive immune system, the level of exercise appears to have a differential effect on the innate immune
Chapter .
10
–10 –20
5
–30 FEV1s
–40
MMEF25/75
–50 –60
FV area
Flow (L/s)
∆FEV1 s (%)
F/V ex
4
2
Fig. .. Example of a positive exercise bronchoprovocation test. Following min hard exercise, there was a significant fall in lung function parameters shortly after stopping exercise. A spontaneous recovery started to occur min later. Complete reversibility was achieved after inhalation of salbutamol mg.
6
5
FVC
–70
10 Pre
0.5 2 4 8 16 salbutamol 400 µg Post ex (min)
F/V in
system. Moderate exercise appears to enhance immune function, while prolonged endurance exercise appears to suppress immune function. Changes in immune function are discussed in detail in Chapter ..
Dyspnea in relation to strenuous exercise is common and there is always a risk of interpreting this as asthma. A carefully taken history is mandatory and an exercise challenge test to confirm the presence of EIB should be performed (Fig. ..). Typically, subjects with EIB report symptoms such as dyspnea and wheeze within the first – min after the start of the first bout of exercise. Some subjects are able to run through their symptoms, and after – min seem to attain a ‘second wind’ and become refractory to further episodes of bronchoconstriction. In the postexercise period, they usually complain of a worsening of dyspnea and cough within the first – min. Although commonly used to measure bronchial hyperresponsiveness in asthmatics, a positive response to methacholine or histamine challenge does not always imply the presence of EIB. Other important differential diagnostic aspects include vocal cord dysfunction, laryngotracheomalacia and vascular anomalies, which may also give symptoms early during exercise. While the typical subject with EIB experiences symptoms early in the course of exercise, a large proportion of subjects experience increasing dyspnea, sometimes associated with increased mucus production, at – min after the start of strenuous exercise. Lung function measurements in these subjects show a continuous decrease in FEV1 without the typical dual pattern seen in EIB (Fig.
3.0 2.5 FEV1 (L)
Differential diagnosis
3.5
2.0 1.5 1.0 0.5 0 –10
10
20
30
40 90
140
Time (min) Fig. .. Example of late-occurring obstruction in a ski athlete subject complaining of dyspnea and mucus production related to exercise. Exercise provocation test ( ) was negative but the patient experienced a continuous decline in lung function during endurance activity, measured by a pocket spirometer.
..). The reasons for this decline are unclear, but factors such as thoracic muscular fatigue, an uncoordinated breathing pattern and increased mucus secretion may be contributory. Finally, it is also necessary to state that dyspnea in relation to exercise may be related to overtraining, as well as to a limited capacity for improvement of physical fitness.
Treatment of EIB Non-pharmacologic intervention Non-pharmacologic measures are probably the most important, both to avoid the development of asthma in
Asthma and Chronic Airway Disease
Pharmacologic intervention In some subjects, obstructive symptoms on exercise may be the only complaint, while in other subjects, they may be one of several expressions indicative of inadequately controlled asthma. In the latter case, treatment should be instituted in accordance with modern asthma treatment guidelines. The baseline therapy
4
3 FEV1s
the healthy athlete and to prevent the occurrence of EIB in the asthmatic athlete. Prolonged endurance exercise should be avoided in the summer during periods and in areas with high pollen counts, and in the winter at temperatures lower than - °C. The same applies to exercise in areas with air pollution or other airway irritants, irrespective of the time of year. Moreover, strenuous exercise should not be commenced for at least days after recovery from a recent upper respiratory tract infection. Athletes should be given a clear message that it is better to rest and stay in bed than to recommence training too early after such infections. Lastly, the use of heat–moisture exchange devices should be encouraged during training sessions to minimize heat and water loss from the airways. Inspiration of air at °C and % relative humidity results in a loss to the environment of mL water and kcal/L of minute ventilation. The loss of heat and water can be considerable, especially in endurance athletes such as long-distance runners, swimmers and crosscountry skiers, who can maintain minute ventilations up to L/min for prolonged periods. Studies in dogs have shown that short periods of hyperventilation with inadequately conditioned air induce airway inflammatory changes that last for at least h []. A carefully designed warm-up program is necessary in order to prevent the occurrence of EIB in the asthmatic athlete. The warm-up has two main purposes. Firstly, it accustoms the airways to changes in conditions in the ambient air. Rapid changes in temperature can cause changes in the tone of the bronchial vasculature and thus changes in airway calibre and resistance. Secondly, the warm-up program should be designed to provoke multiple episodes of a minor degree of bronchoconstriction in order to exploit refractoriness to the exercise stimulus later on in the competitive event. This can be achieved by multiple short bouts of exercise at submaximal intensity, preferably early in the warm-up period (Fig. ..).
2
1
0 0
15
30
45
Time (min) Fig. .. Schematic illustration of a warm-up program aimed to induce refractoriness to exercise bronchoprovocative stimuli later during the competitive event.
should be anti-inflammatory, preferably with inhaled corticosteroids. Bronchodilator therapy with b2agonists should be given prophylactically prior to exercise. When inhaled corticosteroid therapy combined with short-acting b2-agonists is inadequate, add-on therapy with other prophylactic agents, such as a longacting b2-agonist or a leukotriene receptor antagonist, is recommended. Leukotriene receptor antagonist treatment has a slight advantage over long-acting b2agonist therapy in that it does not appear to induce tolerance with regular treatment. However, large individual variations in response are present, and thus the best combination should be explored on an individual basis. Therapy with chromones, such as nedocromil and disodium chromoglycate, is an additional treatment option that may be used either regularly or prophylactically before exercise. In those subjects with obstructive symptoms only on exercise, it is not clear at present whether longterm anti-inflammatory treatment is necessary or effective. They should be treated with inhaled b2agonists, either prophylactically prior to exercise or symptomatically after exercise. Exercise challenge testing should be performed and, if positive, regular anti-inflammatory treatment with either inhaled corticosteroids, chromones or oral antileukotriene receptor antagonists should be instituted on an individual basis.
Chapter . Doping In non-obstructed subjects, ventilation is never the limiting factor for athletic performance. Thus it is clear that medication that improves ventilation cannot be regarded as ergogenic. Studies of non-asthmatic, high-performance athletes using short- or long-acting b2-agonists by inhalation have failed to show positive effects on aerobic capacity and performance [– ]. On the contrary, inhaled b2-agonists may even have a negative effect on performance, possibly due to an increase in ventilation–perfusion mismatch []. The short-acting b2-agonists terbutaline and salbutamol, as well as the long-acting b2-agonist salmeterol are approved for use by asthmatic athletes only when they are given by the inhaled route. There are several reasons for allowing the use of b2-agonists only by inhalation. One reason is that b2-agonists are far more effective when given by the inhaled route than by oral administration in preventing exercise-induced bronchoconstriction []. Another reason is that experiments carried out mainly in animals have suggested that orally administered b-agonists, such as salbutamol and clenbuterol, may have an anabolic effect on and improve the strength of skeletal muscle tissue. However, recent studies suggest contradictory effects on exercise performance with a beneficial effect on intense submaximal exercise in recreational athletes after weeks of oral salbutamol administration [] and a deleterious effect on endurance and sprint exercise in rats after oral clenbuterol administration []. The leukotriene receptor antagonist, montelukast, when tested under similar conditions, has not been shown to have ergogenic effects [], and at present, this class of drug is not included on the list of prohibited preparations. The use of inhaled corticosteroids and chromones by asthmatic athletes is allowed. In all circ*mstances, the use of antiasthmatic medication is reserved for athletes with clearly diagnosed asthma, and it is a prerequisite that the athlete can present medical documentation of the need for such treatment.
Summary Asthma symptoms are common in athletes, with the highest prevalence figures seen in endurance sports athletes. Repeated hyperpnea may be stressful to the lower airways, with increased exposure to both aller-
gens and irritants in the summer and to cold, dry air in the winter. Chronic endurance exercise activity suppresses both humoral and cellular immunity and is associated with an increased susceptibility to upper respiratory tract infections. With suitable attention to known risk factors, the development of asthma in the elite athlete may be prevented. Hard training should be avoided in an environment with high pollen counts and airway irritants during the summer months, and in a cold, dry environment with temperatures lower than - °C during the winter months. It is especially important not to recommence training soon after an upper respiratory tract infection. Medical treatment of asthma in athletes is very much the same as for asthma in non-athletes. Antiinflammatory treatment with inhaled corticosteroids is baseline therapy, complemented with prophylactic and symptomatic bronchodilator therapy. Additional treatment with a long-acting b2-agonist or leukotriene receptor antagonist may be considered as add-on options when baseline therapy is insufficient. When exercise symptoms are the only manifestation, regular anti-inflammatory therapy may not be needed. Nonpharmacologic treatment with a carefully designed warm-up program and use of a heat–moisture exchanger during winter training is equally important as medical treatment. Although there are no data indicating that antiasthmatic medication taken by inhalation or orally administered leukotriene receptor antagonists have any ergogenic effect, both athletes and trainers should be aware of the regulations concerning the use of antiasthmatic medication to avoid disqualification or exclusion from competition.
Multiple choice questions What is the minimum required fall in lung function post exercise defining it as a positive test? a A DFEV1 ≥ %. b A DFEV1 ≥ %. c A DPEF ≥ %. What is the expected prevalence of exercise-induced bronchoconstriction in previously untreated young asthmatics? a >%. b –%. c –%.
Asthma and Chronic Airway Disease What is the most important trigger for exerciseinduced bronchoconstriction in asthmatic subjects? a Hyperventilation. b Anaerobic work with increase in blood lactate levels. c Increased heart rate and adrenergic stimulation. What are the main risk factors for asthma development in skiers? a Hyperventilation of cold, dry air. b Increased exposure to allergens. c Both of the above. The target workload required to induce EIB in an exercise challenge test should be: a a pulse rate of – age for min b a pulse rate > % of maximum pulse rate for min c an increase in blood lactate of more than %. The preferred treatment of persistent asthma with EIB should be: a a short-acting b2-agonist before exercise b chromones such as nedochromile or disodium chromoglycate before exercise c regular inhaled glucocorticosteroid plus shortacting b2-agonist before exercise.
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Sterk PJ, Fabbri LM, Quanjer PH. Airway responsiveness: Standardised challenge testing with pharmacological, physical and sensitising stimuli in adults. Eur Respir J ; (Suppl.): : –. Kukafka DS, Lang DM, Porter S, Rogers J, Ciccolella D, Polansky M, D’Alonzo GE Jr. Exercise-induced bronchospasm in high school athletes via a free running test: incidence and epidemiology. Chest ; : –. Ghory JE. Exercise and asthma: overview and clinical impact. Pediatrics ; : –. Suzuki S, Chonan T, Sasaki H, Takishima T. Time-course of response in exercise-induced bronchoconstriction. Ann Allergy ; : –. Wiens L, Sabath R, Ewing L, Gowdamarajan R, Portnoy J, Scagliotti D. Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma. Pediatrics ; : –. Cropp GJ. Grading, time course, and incidence of exerciseinduced airway obstruction and hyperinflation in asthmatic children. Pediatrics ; : –. Marotel C, Natali F, Heyraud JD, Vaylet F, L’Her P, Bonnet D et al. Severe forms of effort-induced asthma. Allergy Immunol (Paris) ; : –. McNeill RS, Nairn JR, Millar JS, Ingram CG. Exerciseinduced asthma. Q J Med ; : –. Henriksen JM, Dahl R, Lundqvist GR. Influence of relative humidity and repeated exercise on exercise-induced bronchoconstriction. Allergy ; : –. Hahn AG, Nogrady SG, Burton GR, Morton AR. Absence of refractoriness in asthmatic subjects after exercise with warm, humid inspirate. Thorax ; : –. Belcher NG, O’Hickey S, Arm JP, Lee TH. Pathogenetic mechanisms of exercise-induced asthma and the refractory period. N Engl Regional Allergy Proc ; : –. Lee TH, Nagakura T, Papageorgiou N, Iikura Y, Kay AB. Exercise-induced late asthmatic reactions with neutrophil chemotactic activity. N Engl J Med ; : –. Bierman CW, Spiro SG, Petheram I. Characterization of the late response in exercise-induced asthma. J Allergy Clin Immunol ; : –. Zawadski DK, Lenner KA, McFadden ER Jr. Reexamination of the late asthmatic response to exercise. Am Rev Respir Dis ; : –. Bar-Or O, Neuman I, Dotan R. Effects of dry and humid climates on exercise-induced asthma in children and preadolescents. J Allergy Clin Immunol ; : –. Kilham H, Tooley M, Silverman M. Running, walking, and hyperventilation causing asthma in children. Thorax ; : –. Fanta CH, McFadden ER Jr, Ingram RH Jr. Effects of cromolyn sodium on the response to respiratory heat loss in normal subjects. Am Rev Respir Dis ; : –. McLaughlin FJ, Dozor AJ. Cold air inhalation challenge in the diagnosis of asthma in children. Pediatrics ; : –.
Chapter . Shelly MP. Humidification: Intensive Care Rounds. Abingdon, UK: The Medicine Group (Education) Ltd, . Pierson WE, Covert DS, Koenig JQ , Namekata T, Kim YS. Implications of air pollution effects on athletic performance. Med Sci Sports Exerc ; : –. Bar-Yishay E, Gur I, Inbar O, Neuman I, Dlin RA, Godfrey S. Differences between swimming and running as stimuli for exercise-induced asthma. Eur J Appl Physiol ; : –. Inbar O, Dotan R, Dlin RA, Neuman I, Bar-Or O. Breathing dry or humid air and exercise-induced asthma during swimming. Eur J Appl Physiol ; : –. Fitch KD. Comparative aspects of available exercise systems. Pediatrics ; : –. Bundgaard A, Schmidt A, Ingemann-Hansen T, HalkjaerKristensen J. Exercise-induced asthma after swimming and bicycle exercise. Eur J Respir Dis ; : –. Bundgaard A, Ingemann-Hansen T, Schmidt A, HalkjaerKristensen J. Exercise-induced asthma after walking, running and cycling. Scand J Clin Lab Invest ; : –. Anderson SD, Silverman M, Konig P, Godfrey S. Exerciseinduced asthma. Br J Dis Chest ; : –. Waalkens HJ, van Essen-Zandvliet EE, Gerritsen J, Duiverman EJ, Kerrebijn KF, Knol K. The effect of an inhaled corticosteroid (budesonide) on exercise-induced asthma in children. Dutch CNSLD Study Group. Eur Respir J ; : –. Balfour Lynn L, Tooley M, Godfrey S. Relationship of exercise-induced asthma to clinical asthma in childhood. Arch Dis Child ; : –. Jones PS, Buston MH, Wharton MJ. The effect of exercise in ventilatory function of children with asthma. Br J Dis Chest ; : –. Anderson SD. Is there a unifying hypothesis for exerciseinduced asthma? J Allergy Clin Immunol ; : –. McFadden ER Jr. Hypothesis: exercise-induced asthma as a vascular phenomenon. Lancet ; : –. McFadden ER Jr. Heat and water exchange in human airways. Am Rev Respir Dis ; : –. Bundgaard A. Exercise and the asthmatic. Sports Med ; : –. Reiff DB, Choudry NB, Pride NB, Ind PW. The effect of prolonged submaximal warm-up exercise on exerciseinduced asthma. Am Rev Respir Dis ; : –. Weiler JM. Exercise-induced asthma: a practical guide to definitions, diagnosis, prevalence, and treatment. Allergy Asthma Proc ; : –. Morton AR, Hahn AG, Fitch KD. Continuous and intermittent running in the provocation of asthma. Ann Allergy ; : –. Svenonius E, Kautto R, Arborelius M Jr. Improvement after training of children with exercise-induced asthma. Acta Paediatr Scand ; : –. Henriksen JM, Nielsen TT. Effect of physical training on exercise-induced bronchoconstriction. Acta Paediatr Scand ; : –.
Freeman W, Williams C, Nute MG. Endurance running performance in athletes with asthma. J Sports Sci ; : –. Matsumoto I, Araki H, Tsuda K, Odajima H, Nishima S, Higaki Y et al. Effects of swimming training on aerobic capacity and exercise induced bronchoconstriction in children with bronchial asthma. Thorax ; : –. Freeman W, Nute MG, Brooks S, Williams C. Responses of asthmatic and non-asthmatic athletes to prolonged treadmill running. Br J Sports Med ; : –. Olympic MDs: win some, lose some. Med World News ; : –. O’Cain CF, Dowling NB, slu*tsky AS, Hensley MJ, Strohl KP, McFadden ER, Ingram RH. Airway effects of respiratory heat loss in normal subjects. J Appl Physiol ; : –. Langdeau JB, Turcotte H, Bowie DM, Jobin J, Desgagne P, Boulet LP. Airway hyperresponsiveness in elite athletes. Am J Respiratory Crit Care Med ; : –. Heir T, Oseid S. Self-reported asthma and exercise-induced asthma symptoms in high-level competitive cross-country skiers. Scand J Med Sci Sports ; : –. Katelaris CH, Carrozzi FM, Burke TV, Byth K. A springtime olympics demands special consideration for allergic athletes. J Allergy Clin Immunol ; : –. Helenius IJ, Tikkanen HO, Sarna S, Haahtela T. Asthma and increased bronchial responsiveness in elite athletes: atopy and sport event as risk factors. J Allergy Clin Immunol ; : –. Gong H Jr , Bradley PW, Simmons MS, Tashkin DP. Impaired exercise performance and pulmonary function in elite cyclists during low-level ozone exposure in a hot environment. Am Rev Respir Dis ; : –. Drobnic F, Freixa A, Casan P, Sanchis J, Guardino X. Assessment of chlorine exposure in swimmers during training. Med Sci Sports Exerc ; : –. Omori C, Schofield BH, Mitzner W, Freed AN. Hyperpnea with dry air causes time-dependent alterations in mucosal morphology and bronchovascular permeability. J Appl Physiol ; : –. Morton AR, Joyce K, Papalia SM, Carroll NG, Fitch KD. Is salmeterol ergogenic? Clin J Sport Med ; : –. Sandsund M, Sue-Chu M, Helgerud J, Reinertsen RE, Bjermer L. Effect of cold exposure (- degrees C) and salbutamol treatment on physical performance in elite nonasthmatic cross-country skiers. Eur J Appl Physiol ; : –. Sue-Chu M, Sandsund M, Helgerud J, Reinertsen RE, Bjermer L. Salmeterol and physical performance at - degrees C in highly trained nonasthmatic cross-country skiers. Scand J Med Sci Sports ; : –. Carlsen KH, Ingjer F, Kirkegaard H, Thyness B. The effect of inhaled salbutamol and salmeterol on lung function and endurance performance in healthy well-trained athletes. Scand J Med Sci Sports ; : –.
Asthma and Chronic Airway Disease Anderson SD, Seale JP, Rozea P, Bandler L, Theobald G, Lindsay DA. Inhaled and oral salbutamol in exerciseinduced asthma. Am Rev Respiratory Dis ; : – . Collomp K, Candau R, Lasne F, Labsy Z, Prefaut C, De Ceaurriz J. Effects of short-term oral salbutamol administration on exercise endurance and metabolism. J Appl Physiol ; : –. Duncan ND, Williams DA, Lynch GS. Deleterious effects of chronic clenbuterol treatment on endurance and sprint exercise performance in rats. Clin Sci ; : –. Sue-Chu M, Sandsund M, Holand B, Bjermer L. Montelukast does not affect exercise performance at subfreezing temperature in highly-trained non-asthmatic endurance athletes. Int J Sports Med ; : –. Fitch KD. Management of allergic Olympic athletes. J Allergy Clin Immunol ; : –. Voy RO. The U.S. Olympic Committee experience with exercise-induced bronchospasm, . Med Sci Sports Exerc ; : –. Weiler JM, Metzger WJ, Donnelly AL, Crowley ET, Sharath MD. Prevalence of bronchial hyperresponsiveness in highly trained athletes. Chest ; : –. Helbling A, Muller U. Asthma bronchiale bei Spitzensportlern. Schweiz Z Sportmed ; : –. Larsson K, Ohlsen P, Larsson L, Malmberg P, Rydstrom PO,
Ulriksen H. High prevalence of asthma in cross country skiers [see comments]. Br Med J ; : –. Larsson L, Hemmingsson P, Boethius G. Self-reported obstructive airway symptoms are common in young crosscountry skiers. Scand J Med Sci Sports ; : –. Tikkanen H, Helenius I. Asthma in runners. Br Med J ; : . Potts JE. Adverse respiratory health effects of competitive swimming. The prevalence of symptoms, illnesses, and bronchial responsiveness to methacholine and exercise. Academic dissertation, The University of British Columbia, Vancouver, . Sue-Chu M, Larsson L, Bjermer L. Prevalence of asthma in young cross-country skiers in central Scandinavia: differences between Norway and Sweden. Respir Med ; : –. Weiler JM, Layton T, Hunt M. Asthma in United States Olympic athletes who participated in the Summer Games. J Allergy Clin Immunol ; : –. Weiler JM, Ryan EJ III. Asthma in United States Olympic athletes who participated in the Olympic Winter Games J Allergy Clin Immunol ; : –. Wilber RL, Rundell KW, Szmedra L, Jenkinson DM, Im J, Drake SD. Incidence of exercise-induced bronchospasm in Olympic winter sport athletes. Med Sci Sports Exerc ; : –.
Chapter 4.6 Amenorrhea, Osteoporosis and Eating Disorders in Athletes MICHELLE P. WA RRE N, J ORUN SUNDGOT- B ORGE N & J OA NNA L. FRI E D
Classical reference
Amenorrhea
Drinkwater BL, Nilson K, Chesnut CH, Bremner WJ, Shainholtz S, Southworth MB. Bone mineral content of amenorrheic and eumenorrheic athletes. N Engl J Med ; : –. The study was designed to determine whether the hypoestrogenic status of amenorrheic athletes was associated with a decrease in regional bone mass relative to that of eumenorrheic peers (Table ..). It was demonstrated that bone mass as measured by dualphoton and single-photon absorptiometry at the lumbar vertebrae (L to L) was significantly lower in the amenorrheic group than in the eumenorrheic group. No difference was found at the radial site (Table ..). This study was one of the first to demonstrate that amenorrhea observed in female athletes may be accompanied by a decrease in mineral density of the lumbar vertebrae.
Introduction
Introduction Women derive numerous short- and long-term benefits from regular physical activity. However, female athletes face a special health risk due to the sensitivity of the reproductive system to environmental stresses such as weight loss or exercise. The amenorrhea that may arise because of intensive exercise, insufficient energy intake, disordered eating or other stresses puts women at a greatly increased risk for stress fractures, osteopenia, osteoporosis and other bone complications. Many athletic women display what is known as the ‘female athletic triad’, which consists of amenorrhea, osteoporosis and eating disorders.
Amenorrhea is most prevalent in exercise training which requires low body weight, such as ballet dancing or long-distance running. Women who participate in sports which do not place such a premium on low body weight, such as swimming or basketball, tend to experience menstrual dysfunction in other forms, such as irregular cycles []. Girls and women involved in sports such as gymnastics, long-distance running, skiing, ballet or figure skating are often pressured to keep their body fat below % of their total body weight [].
Definitions Amenorrhea is the lack of regular menstrual periods and may be classified as primary or secondary. Primary amenorrhea is a delay in menarche beyond the age of . Secondary amenorrhea is the absence of menstruation for more than – months in women who were previously cyclical []. Amenorrhea may occur in premenopausal women for a number of reasons, among them intensive physical training, premature ovarian failure, contraceptive use and nutritional restriction. We will focus here on hypothalamic amenorrhea, as it is the most relevant to the athlete. There are three types of hypothalamic amenorrhea.
Types of hypothalamic amenorrhea Athletic amenorrhea Women with low body weight and low body fat due to excessive exercise or disordered eating frequently
Amenorrhea, Osteoporosis and Eating Disorders in Athletes
Table .. Physical characteristics and training regimens of amenorrheic and eumenorrheic athletes.*
Age (yr) Height (cm) Weight (kg) Body fat (%) Lean body mass Age at menarche (yr) Duration of amenorrhea (mo) Length of participation in sport (yr) Training Days/week Hours/day Time for 10-km race (min:sec)† Miles run/week‡ Minutes/mile‡§
Amenorrheic
Eumenorrheic
P value
24.9 ± 1.3 166.1 ± 2.5 54.4 ± 2.3 15.8 ± 1.4 45.6 ± 1.6 12.5 ± 0.5 41.7 ± 7.4 7.0 ± 1.6
25.5 ± 1.4 165.7 ± 2.2 57.9 ± 2.2 16.9 ± 0.8 48.0 ± 1.6 12.8 ± 0.4
NS NS NS NS NS NS
6.6 ± 1.1
NS
6.2 ± 0.2 1.6 ± 0.2 39:06 ± 1:15 41.8 ± 5.2 7:32 ± 0:20
5.6 ± 0.3 1.8 ± 0.3 45:59 ± 1:49 24.9 ± 3.0 7:47 ± 0:18
NS NS NS < 0.01 NS
* Plus–minus values are means ± S.E.M. NS denotes not significant. † N = eight eumenorrheic and seven amenorrheic athletes. ‡ N = 12 eumenorrheic and 10 amenorrheic athletes. § Pace of long, slow distance run.
Table .. Bone mineral content and density in amenorrheic and eumenorrheic athletes at two forearm sites and at the L through L lumbar vertebrae.* Site Radius S1 Mineral content (g/cm) Mineral density (g/cm2) S2 Mineral content (g/cm) Mineral density (g/cm2) Vertebrae (g/cm2)
Amenorrheic
Eumenorrheic
P value
0.89 ± 0.03 0.53 ± 0.02
0.85 ± 0.03 0.54 ± 0.01
NS NS
0.91 ± 0.02 0.67 ± 0.02 1.12 ± 0.04
0.88 ± 0.03 0.67 ± 0.02 1.30 ± 0.03
NS NS < 0.01
* Plus–minus values are means ± S.E.M. NS denotes not significant.
develop hypothalamic amenorrhea []. In athletes, this may be due in part to some combination of heavy exercise, mental stress and the desire or pressure to maintain a certain body weight. The use of performance-enhancing drugs may also alter cycles, but the mechanism by which it does so is probably different. Menstrual irregularity is more common in female athletes than in non-athletic women []: in the general adult population, menstrual irregularities have an esti-
mated prevalence of .–% [,] while studies of adult athletes report a prevalence as high as % [] (Table ..).
Eating disorder amenorrhea The menstrual dysfunction seen in athletes in sports requiring low body weight is similar to that seen in women with eating disorders, particularly anorexia nervosa.
Chapter . Table .. Surveys of the prevalence of amenorrhea and oligomenorrhea in different athletic disciplines. Percentage with irregularities
Activity
Study
n
General population
Petterson et al. [5] Singh [6]
1862 900
1.8 5.0
29 53
79.0 59.0
128 67 394
6–43 34.0 24.0
237
26.0
33
12.0
197
12.0
Weight-bearing sports Ballet Abraham et al. [7] Brooks-Gunn et al. [8] Feicht et al. [9] Glass et al. [10] Running Shangold and Levine [11] Sanborn et al. [12] Non-weight-bearing sports Cycling Sanborn et al. [12] Swimming Sanborn et al. [12] From [3].
Idiopathic/functional hypothalamic amenorrhea Functional hypothalamic amenorrhea (FHA) is a diagnosis of exclusion; hypothalamic amenorrhea of unknown etiology in normal-weight, non-athletic women has long been thought to be psychogenic, caused by stress. However, mounting evidence suggests the possibility that this so-called idiopathic amenorrhea is actually caused by nutritional restriction and the resulting endocrine and metabolic response [–]. In a study, women with FHA were compared with normally menstruating controls of similar body mass index (BMI). In the amenorrheic women, body composition was significantly different from that of BMI-matched controls. The amenorrheic subjects had greater lean body mass and less body fat than the normal controls, and were also found to consume less fat and carbohydrates than the BMImatched controls. Thus, FHA attributed to exercise or stress may actually be a response to nutritional disturbance []. Evidence of subclinical eating disorders have been found in weight-stable, non-athletic women with FHA as well as a significant restriction of dietary
fat intake []. While stress may contribute to the disordered eating which may cause amenorrhea, it is unlikely that the stress itself is directly responsible for menstrual dysfunction in women with FHA.
Etiology The mechanism of the normal menstrual cycle is the result of a number of different endocrine systems working together. Puberty is initiated when the area of the brain called the hypothalamus is activated to secrete gonadotropin-releasing hormone (GnRH). Normally occurring every – min, the GnRH pulse signals the pituitary to release bursts of the gonadotropins (luteinizing hormone (LH) and folliclestimulating hormone, FSH), which in turn stimulate the ovary to release the mature follicle. The rhythm of the pulse is controlled by a pulse generator located in the arcuate nucleus in the medial central area of the hypothalamus. GnRH pulses activate a sequence of events in the reproductive tract; the normal menstrual cycle is marked by a cyclic pattern of hormonal secretion. The ovaries primarily secrete estrogens (mostly estradiol), progestins (mostly progesterone) and androgens. These steroids regulate the hypothalamic–pituitary–ovarian axis through a feedback mechanism by acting directly on the pituitary or indirectly on the hypothalamic GnRH pulses []. The physiologic basis for hypothalamic amenorrhea is the disruption of the hypothalamus’ pulsatile secretion of GnRH. The pulse generator appears to be very sensitive to environmental stresses and metabolic factors. GnRH inhibition seems to be caused by the decreased energy available when expenditure of exercise is greater than dietary intake []. GnRH inhibition then lowers the anterior pituitary’s secretion of LH and FSH, which shuts down or limits ovarian stimulation and estradiol production. A prolonged follicular phase, or the absence of a critical LH or estradiol surge midcycle, results in the mild or intermittent suppression of menstrual cycles frequently observed in athletes. When levels of LH are very low, the result is delayed menarche, or primary or secondary amenorrhea [,]. Early research focused on body composition and the stress of exercise as possible causes of amenorrhea in athletes. However, more recent evidence suggests that the primary factor in exercise-induced reproductive dysfunction is the energy deficit athletic women incur
Amenorrhea, Osteoporosis and Eating Disorders in Athletes when their daily caloric intake is insufficient for the level of their activity [,–]. Moreover, a significant amount of recent research suggests that a decrease in resting metabolic rate (RMR) is associated with a negative energy balance and with menstrual dysfunction [–]. Even women who maintain a normal weight may suffer an energy deficit; their normal weight is probably maintained by a decrease in metabolic rate []. While GnRH inhibition clearly plays a major role in certain types of amenorrhea, the etiology of hypothalamic amenorrhea is not entirely understood. The role of the adipocyte hormone leptin, a protein product of the obesity gene, has been highlighted in recent research, some of which suggests that leptin may be an independent regulator of metabolic function []. The roles of dehydroepiandrosterone (DHEA), insulinlike growth factor (IGF) and cortisol are also being explored.
Leptin New research on amenorrhea and body composition was prompted after the discovery of leptin, a hormone made by the adipocyte []. Leptin receptors were discovered on hypothalamic neurons thought to be involved in control of the GnRH pulse generator []. Studies have shown that rodents with an inactive form of leptin tend to be amenorrheic and infertile [,]. Low leptin levels have been associated with amenorrhea [,] and with disordered eating []; it appears that if leptin drops below a critical level, menstruation will not occur []. Because leptin regulates the basal metabolic rate, it is thought to be a particularly important indicator of nutritional status [], and indeed, amenorrheic athletes typically have low metabolic rates. Leptin may be a significant mediator of reproductive function in that it responds to a negative energy balance found in women with exercise-induced amenorrhea []. Leptin also plays a role in thyroid function and the initiation of puberty. Research has shown that alterations in leptin levels are directly associated with thyroid hormone changes in the presence of nutritional deficiencies []. Thus, leptin may act not only as a regulator of metabolic rates but also as a mediator of menstrual status, responding to starvation by slowing metabolism, and may be involved in returning the woman to a prepubertal-like state.
Cortisol Amenorrheic athletes often have slightly elevated cortisol levels, as do women with FHA or anorexia nervosa. Cortisol is a glucoregulatory hormone activated by low blood glucose levels []. Cortisol levels have found to be elevated in both FHA and exerciseassociated amenorrhea.
Treatment Management includes restoring ovulatory cycles if possible, replacing estrogen when necessary, reassurance and re-evaluation. In women with nutritional imbalances or disordered eating, one of the most important aspects of treatment is addressing and reversing unhealthy eating behaviors. Gonadotropin deficiency may be reversible in women with FHA upon the improvement of nutritional intake and body composition []. The treatment of amenorrhea should also take into account the likelihood of bone loss. It is not clear whether hormone replacement therapy works (see Tables .. & .. below). Early studies on small numbers of treated subjects (n = ) suggest that oral contraceptives may be effective in athletic amenorrhea []. This subject will be addressed in greater depth below, in the section on osteoporosis.
Osteoporosis Introduction The effects of exercise on the skeleton are generally thought to be positive, and numerous studies have indicated that physical activity increases bone mass in humans. Particularly for women, physical activity is recommended for preventing the development of osteoporosis, and regular, vigorous, weight-bearing activity of h or more each week is associated with an increase in bone mineral density (BMD) within a normal population []. However, research also indicates that too much physical activity in combination with inadequate energy intake may cause hormonal changes that ultimately increase the risk of bone loss []. While osteoporosis, or loss of bone mass, is a well-known effect of menopause and aging in adults, it is also a significant problem among younger individuals. Hypothalamic amenorrhea in young women is associated with reduced bone accretion or premature
Chapter . bone loss during adolescence [–], which places women at high risk for fractures, significant osteopenia (diminished bone mass) and severe osteoporosis at menopause. Amenorrhea in athletic women affects trabecular and cortical bone. Weight-bearing physical activity does not completely compensate for the side-effects of reduced estrogen levels even in weightbearing bones in the lower extremities and the spine []. The most recent research suggests that poor nutrition or an energy deficit with an adaptation to large caloric needs is fundamentally linked not only with a prolonged amenorrheic state, but with osteopenia as well [–].
Definitions Osteoporosis is a condition in which the rate of bone resorption exceeds the rate of bone formation. This imbalance leads to a progressive loss of bone mass, which in turn leads to a decrease in bone strength. It is a major public health concern and it often proceeds unnoticed until a stress fracture occurs. The World Health Organization formed a committee in to define osteoporosis. That committee created four diagnostic categories: Normal, Osteopenia, Osteoporosis and Established Osteoporosis. These diagnostic categories depend on bone density, and the presence of fractures. The committee set cut-off values that were relative to young healthy individuals. Osteopenia is a bone density between one standard deviation and . standard deviations below average for young people. Osteoporosis is a bone density lower than . standard deviations below young people [].
Etiology Like GnRH inhibition, osteopenia may also be an adaptive response to chronic low energy intake. Metabolic factors in response to nutritional insults might mediate reproductive and bone growth adaptations. Two homeostatic mechanisms act on bone simultaneously: hormones and mechanical stress. In normal circ*mstances, these homeostatic mechanisms maintain both skeletal integrity and serum calcium levels. However, with aging or menstrual disturbance, factors such as diet, hormonal levels and mechanical strain cause bones to become more vulnerable to fracture and osteoporosis [].
Recent studies suggest that at least % of bone mass is formed during adolescence and young adulthood, making this period critical to women’s health [,–]. The amount of bone attained during adolescence is a major determinant for fractures and osteoporosis later in life. As the skeleton enlarges in children and adolescents, bones are constantly growing; bones model as bone mass is added to areas of high loading or stress, and remodel as fatigue-damaged bone is resorbed and replaced by new bone []. Women who fail to reach peak bone mass (the maximal amount of bone tissue accrued in individual bones and the whole skeleton) are at an increased risk for osteoporosis later in life, and the reduction of bone mass accretion during adolescence may be a major cause of low bone density and fracture in old age []. After the age of , bone mass begins to decline []. Bone density is responsive to mechanical loading, and exercise is beneficial in preserving and increasing bone mass. In the mature, postmenopausal woman, exercise will offset the loss of bone mass associated with hypoestrogenism, and may even increase BMD above baseline. However, studies of hypoestrogenic ballet dancers suggest that they may not accumulate bone in response to mechanical stress [] and amenorrheic athletes consistently exhibit spinal BMD – % lower than their eumenorrheic counterparts [,–]. When peak bone mass is not attained, the relative osteopenia in weight-bearing bones results in a higher risk for injury. A high incidence of stress fractures (%), as directly related to delayed menarche, has been reported in young ballet dancers [] and one study of ballet dancers found that the incidence of both scoliosis and stress fractures rose with each year of delayed menarche []. Studies have shown that spinal BMD is particularly affected in amenorrheic athletes [] because high-impact activity appears to have a beneficial effect on BMD primarily at the hip []. One pilot study found the amenorrheic athlete’s vertebral BMD to be up to % lower than normally cycling athletes []. It is unclear what changes in bone metabolism cause osteoporosis in women with hypothalamic amenorrhea. One study of women with anorexia nervosa suggested that bone formation is reduced while bone resorption remains normal [], while another suggested that bone formation is decreased and bone
Amenorrhea, Osteoporosis and Eating Disorders in Athletes Eating disorders Vitamin supplements Low-caloric substitutes High-fat foods
100 90 80
Percentage
70 60 50 40 30 20 10 0
Dancers with Dancers without fractures fractures
Controls
Fig. .. Nutritional habits of dancers with and without stress fractures. From []. 200 Saccharine Fat
180 160 140 Milligrams
resorption increased []. Further analyses of bone turnover indices in women with hypothalamic amenorrhea and anorexia nervosa have also produced inconsistent results, with some data suggesting normal bone turnover, while others suggesting low bone formation that is uncoupled from bone resorption [,]. Results of a study of amenorrheic longdistance runners demonstrated reductions in bone turnover and, in particular, bone formation []. The reduced bone formation was linked to a low BMI and an estrogen deficiency []. While the effects of prolonged estrogen deficiency on adolescents are not fully understood, recent research suggests that hypoestrogenism in young women decreases bone density and increases the risk of stress fractures and osteoporosis [], causing serious bone loss similar to that which occurs after artificial or spontaneous menopause [,]. Nutrition and diet may be strongly predictive of stress fractures. A study found that dancers with restrictive eating patterns and eating disorders showed a much higher incidence of stress fractures than dancers without []. The diet of the dancers who sustained stress fractures was also much lower in fat and higher in the use of low caloric substitutes, such as saccharine, and nutritional supplements, such as vitamins. (Figs .. & ..). A recent study followed subjects: dancers ( amenorrheic, normal) and controls ( amenorrheic, normal). Both exercising and non-exercising amenorrheics showed reduced BMD in the spine, wrist and foot. During the course of the study, seven of the amenorrheic women resumed menses, and while these seven showed an increase in spine and wrist BMD of %, they did not achieve normalization of BMD, suggesting that reduced bone accretion may result in a permanent failure to achieve peak bone mass. This underscores the importance of treatment, either preventative or therapeutic, for women with amenorrhea [] (Table ..). Early bone loss and osteoporosis are well documented and are common complications of anorexia nervosa [,,–]. Up to one-third of females who recovered from anorexia nervosa during adolescence were found to have persistent osteopenia []. Young women with anorexia nervosa may suffer irreversible developmental and growth retardation; older chronic
120 100 80 60 40 20 0 Dancers with fractures
Dancers without fractures
Controls
Fig. .. Consumption of fat and saccharine. From [].
anorectics are at a higher risk for pathologic fractures []. Multiple factors increase risk, including decreased body weight and fat content, elevated cortisol levels, inadequate vitamin D and calcium intake, and amenorrhea and hypoestrogenemia. Patients with bulimia nervosa or an eating disorder not otherwise specified may also be at risk for osteoporosis, particularly if they had an episode of anorexia nervosa at some point []. A study of ballet dancers with and without stress fractures found a strong correlation between certain dietary measures and the incidence of stress fractures []. When matched for age, weight and height, dancers who suffered fractures had much
Chapter . Table .. Bone density in amenorrhea in a -year longitudinal study. Bone density (g/cm2 ± SE)
Amenorrheic (n = 12)
Resumption of menses (n = 7)
Normal (n = 36)
Spine Baseline 24 months % change
1.16 ± 0.04 1.20 ± 0.04 4.05 ± 1.95
0.99 ± 0.05 1.16 ± 0.06 17.47 ± 4.93*
1.27 ± 0.03 1.31 ± 0.02 4.01 ± 1.19
Wrist Baseline 24 months % change
0.61 ± 0.02 0.62 ± 0.03 3.09 ± 2.37
0.59 ± 0.05 0.67 ± 0.03 17.54 ± 8.75*
0.66 ± 0.01 0.67 ± 0.01 2.85 ± 1.44
Foot Baseline 24 months % change
0.84 ± 0.03 0.83 ± 0.02 -1.85 ± 2.88
0.76 ± 0.03 0.81 ± 0.03 7.05 ± 4.79
0.87 ± 0.02 0.86 ± 0.01 -0.74 ± 1.69
* P < 0.001. From [77].
more saccharin and much less fat in their diets than healthy dancers and normal controls, were significantly more likely to supplement their diets with vitamin supplements, and were far more likely to have eating disorders than their stress fracture-free counterparts (Figs .. & ..). Thus, even in two athletes with similar weights and training regimens, it is possible that diet and nutrition are strongly predictive of osteopenia. Other recent data also suggest that nutritionally regulated processes may underlie the osteopenia. Hypercortisolemia [,,], hypoprogestinemia [], insulin-like growth factor I (IGF-I) deficiency [] or other metabolic adaptations seen in these athletes may contribute to the osteopenia. Undernutrition lowers bone formation markers, triiodothyronine (T) and IGF-I in amenorrheic runners, but not in controls []. A study of ballet dancers showed normal vitamin D and parathyroid levels, suggesting that these may not be the causal factors in the bone loss []. In past studies of women with anorexia nervosa, levels of IGF-I and T, two nutritionally dependent hormones, predicted the change in trabecular bone mass with estrogen–progestin therapy [].
Leptin Recently, leptin receptors were found on bone [,], suggesting that leptin may function as a physiologic regulator of bone mass. This presents the possibility of a mechanism other than hypoestrogenism that could
account for the low bone density and high stress fracture rates seen in women whose amenorrhea is associated with caloric deficiency, nutritional insults and exercise [,,].
IGF-I Levels of the bone trophic hormone insulin-like growth factor I (IGF-I) are closely correlated with certain indicators of nutritional status, such as BMI and leptin levels [] and are also significantly reduced in patients with anorexia nervosa [,,]. Results of a study of long-distance runners showed that IGF-I was one of the most powerful predictors of serum estrogen concentration []. It is hypothesized that IGF-I acts as a major contributor to the pathogenesis of osteopenia in hypothalamic amenorrhea. Deficiencies of the adrenal steroid dehydroepiandrosterone (DHEA) may inhibit secretions of IGF-I and other bone growth stimulators. Correcting DHEA deficiencies may prove to be a mechanism by which to increase secretions of IGF-I and other bone growth stimulators [].
Cortisol Subclinical hypercortisolism is prevalent in women with hypothalamic amenorrhea [–]. Hypercortisolism is associated with osteopenia, and may possibly contribute to bone loss via hypercortisolismassociated derangements in calcium and vitamin D metabolism including decreased osteoblastic activity,
Amenorrhea, Osteoporosis and Eating Disorders in Athletes decreased intestinal absorption of calcium and increased urinary calcium losses [].
Treatment Ideally, female athletes should not develop long-term amenorrhea. In athletes with complete amenorrhea, a physical and pelvic examination is indicated to rule out androgenization, galactorrhea and hyperprolactinemia, as well as pregnancy. A careful history of weight loss and eating disorders should also be taken; eating disorders can often be missed, and often a standardized scale or diagnostic interview will be helpful in making the diagnosis []. Frequently, a weight gain of – kg or a % decrease in the duration or intensity of exercise is enough to reverse reproductive dysfunction [,]. Patients often resist this route, fearing weight gain may lead to decreased performance. The most common treatment for young amenorrheic women has traditionally been estrogen therapy and oral contraceptives. Because of estrogen’s antiresorptive effects on bone modelling, exogenous estrogen is often prescribed to prevent bone loss and/or increase overall bone accretion in women with hypothalamic amenorrhea, although clinical studies have not yet consistently demonstrated its efficacy in this group [,]. Preliminary studies on small numbers of subjects suggest that oral contraceptives may be effective in athletic amenorrhea [], and another study showed that estrogen treatment produced increased spine and femoral BMD []. However, another investigation of estrogens and oral contraceptives indicated
that the contraceptives prompted no change in BMD []. Research has not yet consistently demonstrated the efficacy of hormone replacement therapy or oral contraceptives in increasing the bone mass of women with hypothalamic amenorrhea [] (Tables .. & ..). A lack of response to estrogen–progestin therapy in replacement doses has also been reported when given to anorectic women with hypothalamic amenorrhea [,]. Treatment of osteoporosis in anorexia nervosa includes weight normalization and supplemental calcium and vitamin D. Unlike postmenopausal osteoporosis, estrogen replacement does not prevent or correct the osteoporosis that occurs in anorexia nervosa []. Even after recovery, studies have found conflicting data about weight gain and changes in bone mineral density, and there is still uncertainty about the restoration of bone density with complete and sustained clinical recovery from anorexia nervosa [,,,,]. The effect of estrogen supplementation differs from patient to patient. Further studies of different hormone replacement therapy regimens are needed, and the possibilities of other therapies aimed at increasing bone formation such as fluoride treatment, recombinant human insulin-like growth factor and recombinant human transforming growth factor b (TGF-b) are now being studied [].
Eating disorders Introduction Some athletes and non-athletes do not consider train-
Table .. Hormone replacement therapy (HRT) and its effect on bone mineral density (BMD). BMD Model
Study
Treatment (n)
Hypothalamic amenorrhea (including eating disorders)
Hergenroeder[98]
Exercise-induced amenorrhea
Cumming et al. [99]
Exercise-induced amenorrhea Anorexia nervosa
Hip
Total
Oral contraceptive, randomized, 12 months ≠ 0.035 mg ethinyl E2 0.5–1.0 mg norethindrone (5)
NS
≠
HRT, observed 24–30 months (8)
≠
≠
–
Warren et al. [77]
HRT, randomized, 24 months (13)
NS
NS
–
Klibanski et al. [86]
HRT, randomized (22)
NS*
–
–
* Patients with the lowest BMD showed some increase. NS, not significant.
Spine
Chapter . Table .. Markers of bone turnover. Bone Model
Study (n)
Formation
Resorption
Turnover
Postmenopausal estrogen deficiency Exercise-induced amenorrhea (runners) Exercise-induced amenorrhea (runners)
Manolagas [100] (review) Okano [101] (8) Zanker [102] (9)
≠ Ø Ø (osteocalcin BAP*)
≠ NA Ø (Dpyr†)
≠ ? Ø
* Bone-specific alkaline phosphate. † Deoxypyridinoline.
ing or exercise sufficient to accomplish their idealized body weight or percentage body fat. Therefore, a significant number of them diet and use harmful, ineffective weight-loss practices such as restrictive eating, vomiting, laxatives and diuretics to meet their goals []. Eating disorders are the common denominator for such behaviors. Eating disorders can result in short- and long-term morbidity, poor recovery, impaired sports performance and mortality [–]. Signs and symptoms of eating disorders in athletes are often ignored. In some sports disordered eating seems to be regarded as a natural part of being an athlete []. It has been claimed that female athletes are at increased risk for developing eating disorders due to the focus on low body weight as a performance enhancer, comments from coaches or others and the pressure to perform [,,]. Symptoms of eating disorders are more prevalent among elite athletes than non-athletes [,–]. This section reviews the definitions, diagnostic criteria, prevalence and risk factors for the development of eating disorders in sport. Practical implications for the identification and treatment of eating disorders in athletes are also discussed.
Definitions Eating disorders are characterized by disturbances in eating behavior, body image, emotions and relationships. Athletes constitute a unique population, and special diagnostic considerations should be made when working with this group [,,]. Despite similar symptoms subclinical cases in athletes are easier to identify than in non-athletes []. Since
athletes, particularly at the elite level, are evaluated by their coach every day, changes in behavior and physical symptoms may be observed. However, symptoms of eating disorders in competitive athletes are too often ignored or not detected by coaches. Reasons for this include lack of knowledge of symptoms, feelings of guilt and the absence of strategies for approaching the eating-disordered athlete. Tables .. and .. summarize the standard diagnostic criteria for anorexia nervosa and bulimia nervosa as defined by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) []. These criteria formalize overlapping conventions for subtyping anorexia nervosa into restricting and binge-eating/purging types on the basis of the presence or absence of bingeing and/or purging (i.e. self-induced vomiting or the misuse of laxatives or diuretics). Eating-disordered athletes often move between these two subtypes. However, it is the author’s experience that chronicity leads to an accumulation of eating-disordered athletes in the binge-eating/ purging subgroup. The ‘eating disorder not otherwise specified’ category (EDNOS) [] refers to disorders of eating that do not meet the criteria for any specific eating disorder. Examples of EDNOS are listed in Table .., and the category acknowledges the existence and importance of a variety of eating disturbances. In the early phase of research on athletes and eating disorders the term ‘anorexia athletica’ was introduced []. Most of those athletes meeting the anorexia athletica criteria will also meet the criteria described in EDNOS.
Amenorrhea, Osteoporosis and Eating Disorders in Athletes Table .. Diagnostic criteria for anorexia nervosa. A Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g. weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected) B Intense fear of gaining weight or becoming fat, even though underweight C Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on selfevaluation, or denial of the seriousness of the current low body weight D In postmenarcheal females, amenorrhea, i.e. the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone (e.g. estrogen) administration.) Specify type: Restricting type: During the episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics or enemas) Binge-eating/purging type: During the current episode of anorexia nervosa, the person has regularly engaged in bingeeating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics or enemas)
Table .. Diagnostic criteria for bulimia nervosa. A Recurrent episodes of binge eating.An episode of binge eating is characterized by both of the following: (i) eating, in a discrete period of time (e.g. within any 2-h period), an amount of food that is definitely larger than most people would eat during a similar period of time in similar circ*mstances; and (ii) a sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating) B Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as: self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise C The binge-eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months D Self-evaluation is unduly influenced by body shape and weight E The disturbance does not occur exclusively during episodes of anorexia nervosa Specify type: Purging type: The person regularly engages in self-induced vomiting or the misuse of laxatives, diuretics or enemas Non-purging type: The person uses other inappropriate compensatory behaviors, such as fasting or excessive exercise, but does not regularly engage in self-induced vomiting or the misuse of laxatives, diuretics or enemas
From [117]. From [117].
Prevalence of eating disorders among athletes The epidemiology of eating disorders poses a particular challenge to investigators due to problems with case definition, and the tendency of eating-disordered subjects to conceal their illness and avoid professional help. Estimates of the prevalence of the symptoms of eating disorders and clinical eating disorders among female athletes range from less than % to as high as % [,,]. The prevalence of anorexia nervosa (.%), bulimia nervosa (.%) and subclinical eating disorders (%) are more prevalent among female elite athletes than non-athletes []. Furthermore, this study showed that eating disorders are more frequent among female elite athletes competing in aesthetic and weight-class sports than among other sport groups where leanness is considered less important (Fig. ..). Only two previous studies on male wrestlers [,] have based their results on the diagnostic criteria set forth by the Diagnostic and Statistical
Table .. The ‘eating disorder not otherwise specified’ category. 1 All of the criteria for anorexia nervosa are met except the individual has regular menses. 2 All of the criteria for anorexia nervosa are met except, despite significant weight loss, the individual’s current weight is in the normal range. 3 All of the criteria for bulimia nervosa are met except binges occur at a frequency of less than twice a week or for a duration of less than 3 months. 4 An individual of normal body weight regularly engages in inappropriate compensatory behavior after eating small amounts of food (e.g. self-induced vomiting after the consumption of two cookies). 5 An individual who repeatedly chews and spits out, but does not swallow, large amounts of food. 6 Binge-eating disorder: recurrent episodes of binge eating in the absence of inappropriate compensatory behaviors characteristic of bulimia nervosa. From [117].
Control
Gravity
Power
Ball
Weightdependent
Aesthetic
Endurance
50 45 40 35 30 25 20 15 10 5 0
Technical
Percentage
Chapter .
Fig. .. Prevalence of eating disorders in female (n = ) and male (n = ) elite athletes. (None of the female athletes in the power and gravitation sports and none of the male athletes in the aesthetic or power sports met the DSM-IV criteria.) From [].
Manual of Mental Disorders (DSM) []. They reported .% and .%, respectively, of male wrestlers with bulimia. A recent Norwegian study reported the prevalence of eating disorders to be as high as % among male elite athletes and .% in age-matched controls. As many as .%, .% and .% met the criteria for EDNOS, bulimia nervosa and anorexia nervosa, respectively [,]. The prevalence of clinical eating disorders in male elite athletes is highest among those competing in weight-class sports and gravitation sports [].
Risk factors for the development of eating disorders The etiology of eating disorders is multifactorial [,]. Because of additional stress associated with the athletic environment, however, female elite athletes appear to be more vulnerable to eating disorders than the general female population []. Furthermore, recent studies suggest that specific risk factors for the development of eating disorders occur in some sport settings; one retrospective study indicated that a sudden increase in training load may induce a caloric deprivation in endurance athletes, which in turn may elicit biologic and social reinforcements leading to the development of eating disorders []. However, longitudinal studies with close monitoring of a number of sports-specific factors (volume, type and intensity of training) are needed to answer questions about the role played by different sports in the development of eating
disorders in athletes. Female athletes with eating disorders frequently start sport-specific training at an earlier age than healthy athletes []. Another factor to consider is that if female athletes start sport-specific training at a prepubertal age, they might not choose the sport that will be most suitable for their adult body type. Many athletes report that they developed eating disorders as a result of traumatic events, such as the loss or change of a coach, injury, illness or overtraining [,,]. An injury can curtail the athlete’s exercise and training habits. As a result, the athlete may gain weight owing to less energy expenditure, which in some cases may develop into an irrational fear of further weight gain. Then the athlete may begin to diet to compensate for the lack of exercise []. Pressure to reduce weight has been a common explanation for the increased prevalence of eatingrelated problems among athletes. However, the important factor may not be dieting per se, but rather the situation in which the athlete is told to lose weight, the words used and whether the athlete receives guidance. In addition to the pressure to reduce weight, athletes are often pressed for time and must lose weight rapidly to make or stay on the team. As a result they often experience frequent periods of restrictive dieting or weight cycling []. Weight cycling has been suggested as an important risk or trigger factor for the development of eating disorders in athletes [,] and has been seen in men as well as women. Wrestlers have been characterized as high-risk athletes for developing eating disorders. A recent study on wrestlers concluded that although in-season wrestlers are more weightconscious than non-wrestlers, these feelings and attitudes are transient []. Whether male athletes competing in weight-class sports have a transient condition or true clinical eating disorder may depend on the competitive level and the number of years of practicing weight loss techniques with weight fluctuation. On the other hand, some authors argue that specific sports attract individuals who are anorectic before commencing their participation in sports, at least in attitude if not in behavior or weight [,]. It is possible that the attraction-to-sport hypothesis might be true for the general population, but athletes do not achieve the elite level if the only motivation is weight loss. Therefore, this hypothesis could probably rather
Amenorrhea, Osteoporosis and Eating Disorders in Athletes be true for lower-level athletes. In most cases, the role of coaches in the development of eating disorders in athletes should be seen as part of a complex interplay of factors. Most researchers agree that coaches do not cause eating disorders in athletes, although inappropriate coaching may trigger or exacerbate the problem in vulnerable individuals []. There is a clear need for longitudinal quantitative and qualitative studies.
Medical issues Eating disorders may cause serious medical problems and can even be fatal. Whereas most complications of anorexia nervosa occur as a direct or indirect result of starvation, complications of bulimia nervosa occur as a result of binge eating and purging []. Hsu [], Johnson et al. [], and Mitchell [] provide information on the medical problems encountered in eating-disordered patients. Anorexia nervosa has a standard mortality rate up to six times higher than that of the general population []. Death in anorexia nervosa is usually attributable to fluid and electrolyte abnormalities, or suicide []. Mortality in bulimia nervosa is less well studied, but deaths do occur, usually secondary to the complications of the binge– purging cycle, such as gastric ruptures, or suicide. Mortality rates of eating disorders among athletes are not known. However, a number of deaths of toplevel female athletes in gymnastics, running, alpine skiing and cycling have been reported in the media. Of the female elite athletes diagnosed in the Norwegian study .% reported suicide attempts [].
at high risk of sustaining fractures. Longitudinal data on fast and gradual body weight reduction and cycling in relation to health and performance parameters in different groups of athletes are clearly needed. The nature and the magnitude of the effect of eating disorders on health and athletic performance are influenced by the severity and chronicity of the eating disorder and the physical and psychological demands of the sport. In addition to the negative health consequences, repeated or severe weight-loss attempts will result in poor recovery and impaired sports performance [–]. Norwegian female elite athletes reported increased fatigue, anger or anxiety when attempting to rapidly lose body weight [].
Identifying athletes with eating disorders Many individuals with eating disorders do not realize that they have a problem and therefore do not seek treatment on their own. Athletes might consider seeking help only if they experience that their performance level is leveling off. In contrast to the athletes with anorectic symptoms most athletes suffering from bulimia nervosa are at or near normal weight, and therefore their disorder is difficult to detect. Hence the team staff must be able to recognize the physical symptoms and psychological characteristics listed in Table ... It should be noted that the presence of some of these characteristics does not necessarily indicate the presence of the disorder. However, the likelihood of the disorder being present increases as the number of presenting characteristics increases [].
Long-term health effects of eating disorders The long-term effects of body-weight cycling and eating disorders in athletes are unclear. Biologic maturation and growth have been studied in girl gymnasts before and during puberty, suggesting that young female gymnasts are smaller and mature later than females from sports that do not require extreme leanness, such as swimming [,]. However, it is difficult to separate the effects of physical strain, energy restriction and genetic predisposition to delayed puberty. Besides increasing the likelihood of amenorrhea and stress fractures, early bone loss may inhibit achievement of normal peak bone mass. Thus, athletes with frequent or longer periods of amenorrhea may be
Treatment of eating disorders Eating-disordered athletes are more likely to accept the idea of going for a single consultation than the idea of committing themselves to prolonged treatment. Themes and questions that should be included in the first consultation with athletes possibly suffering from eating disorders are listed in Table ... Included in Table .. is also what should be included in the review of system, evaluation, lab tests and treatment. At the Norwegian Olympic Training Center, athletes with eating problems have their first consultation without any medical examination, blood tests or nutrition evaluation. The first consultation focuses on the
Chapter . Table .. Physical symptoms, psychological and behavioral characteristics of athletes with eating disorders. Physical
Psychological and behavioral
Significant weight loss beyond that necessary for adequate sport performance* Frequent and often extreme weight fluctuations† Low weight despite eating large volumes† Amenorrhea or menstrual irregularity Reduced bone mineral density Stress fractures Dehydration Hyperactivity Electrolyte abnormalities Bradycardia Fatigue beyond that normally expected in training or competition Gastrointestinal problems (i.e. constipation, diarrhea, bloating, postprandial distress) Hypothermia* Lanugo* Muscle cramps, weakness or both Swollen parotid glands† Anxiety, both related and unrelated to sport performance Avoidance of eating and eating situations
Claims of ‘feeling fat’ despite being thin Resistance to weight gain or maintenance recommended Dieting that is unnecessary for appearance, health or sport performance Binge eating† Agitation when bingeing is interrupted† Unusual weighing behavior (i.e. excessive weighing, refusal to weigh, negative reaction to being weighed) Compulsiveness and rigidity, especially regarding eating and exercise* Excessive or obligatory exercise beyond that required for a particular sport Exercising while injured despite prohibitions by medical staff Restlessness Social withdrawal Depression and insomnia Excessive use of the restroom† Self-critical, especially concerning body, weight and performance Substance abuse Use of laxatives, diuretics (or both)
* Anorexia nervosa. † Bulimia nervosa.
athlete’s presentation of her ‘problem’. Then one of the members of the treatment team presents the treatment approach to athletes with one or more components of the triad. In the Norwegian model, athletes with eating disorders receive individual therapy, a modified cognitive group therapy program and nutritional counselling. The first consultation with athletes with suspected or manifested eating disorders is extremely important. The goal is to create an alliance for treatment. Furthermore we define the roles and clarify who will make decisions about the athlete’s training and health. For a number of athletes with eating disorders we also have to redefine their ambitions and clarify the therapist’s involvement in training and competition programs.
Treatment, training and competition The treatment of athletes with eating disorders should be undertaken by health care professionals. Coaches should never try to diagnose or treat eating disorders, but they should be specific about their suspicions. Furthermore, coaches should encourage medical evaluation and support the athlete during treatment.
Establishing a trusting relationship may be easier when the eating-disordered athlete feels that the therapist is familiar with the athlete’s sport in addition to being trained in treating eating-disordered patients. Therapists who have good knowledge about eating disorders and know about various sports will better understand the athlete’s training setting, daily demands and relationships that are specific to the sport, the types of events and the competitive level. Building such a relationship includes respecting the athlete’s desire to be lean for athletic performance and expressing a willingness to work together to help the eatingdisordered athlete to be lean and healthy. The treatment team needs to accept the athlete’s fears and irrational thoughts about food and weight, and then present a rational approach for achieving selfmanagement of healthy diet, weight and training program []. The various types of treatment strategies have been described in detail elsewhere []. A total suspension of training during treatment is not necessarily an appropriate solution. Unless there are severe medical complications, the athlete should be allowed to continue training at a lower volume and decreased intensity. For athletes with an eating disorder,
Amenorrhea, Osteoporosis and Eating Disorders in Athletes
Table .. History and medical examination of female elite athletes with disordered eating. HISTORY RELATED TO EATING DISORDERS Exercise Athlete’s sport participation (is it fun, does she want to continue competing?) ?Hours spent training per week and intensity: aerobic and anaerobic training Time spent exercising outside of normal training regimen Continuing training in spite of injury Nutrition Eating pattern 24-h food recall/3-day weighing Number of meals/snacks per day List of foods avoided (e.g. meat, sweets) How does she feel about her present weight/percentage body fat? What does she consider her ideal weight/percentage body fat? Has she ever tried to control her weight using vomiting, laxatives, diuretics, other drugs, fasting or excessive exercise? Menstrual history Age of menarche Frequency and duration of periods Date of last menstrual period Degree of regularity since menarche Use of hormonal therapy How does she feel about menstruating/not menstruating Family, medical and psychological history Family including: weight history eating disorders or any other psychiatric disorders Medical: chronic disease infections previous surgery medications injuries (including stress fractures) Psychological: present stress factors in her life general mood, self-esteem and body image
REVIEW OF SYSTEMS, EVALUATION, LAB TESTS AND TREATMENT Symptoms of starvation and purging Cold intolerance Amenorrhea, delayed menarche Light-headedness/lack of concentration Abdominal bloating Fatigue Constipation/diarrhea Sore throat and chest pain Face and extremity edema Physical examination Dry skin, brittle hair and nails Decreased subcutaneous fat Hypothermia Bradycardia Lanugo Cold and discolored hands and feet Orthostatic blood pressure changes Parotid gland enlargement Erosion of dental enamel Laboratory evaluation Urine analysis Complete blood count and sedimentation rate Chemistry panel including electrolytes, calcium, magnesium and renal, thyroid and liver function tests Indication for an electrocardiogram: pulse is less than 50 b.p.m.* (depending on sport participation) Electrolyte abnormality Frequent purging behavior Treatment Multidisciplinary team approach Physician Nutritionist Psychologist/mental health professional Coach (?)† Trainer (?)† Criteria for hospitalization: weight 30% below normal hypotension/dehydration electrolyte abnormalities
* Take into consideration that low pulse could be training induced. † Dependent on the coach or trainer and athlete relationship.A good relationship is assumed to have a positive effect on treatment.
it is important to acknowledge that some aspects of their disregulated eating patterns may be the result of self-discipline and long-term goals. Moreover, it may be necessary for the athletes to continue with a dietary regimen or intensive training program that would automatically be targeted for elimination in a non-athlete. In
general, to avoid reinforcing a message that sport performance is more important than health, it is recommended that athletes do not compete during treatment. Nevertheless, competitions during treatment might be considered for individuals with less severe eating disorders who are engaged in low-risk sports.
Chapter . Prognosis For most athletes, the reasons for the development of eating disorder seem to be related to extreme dieting, overtraining, injury or other more sports-specific factors. Data from a pilot study indicate that it may be easier to treat athletes, and that their prognoses should be better. However, this has not been fully investigated. When it comes to treatment, athletes may have some advantages compared to non-athletes; they are used to complying with rules and programs and few have personality disorders or clinical depression. However, there are a few possible negative factors that may delay the treatment progression in some athletes: lack of introspection, atypical psychological experiences and ‘brainwashed’ parents.
Prevention of eating disorders in athletes It is likely that talking to athletes and coaches about eating disorders and related issues such as reproduction, bone health, nutrition, body composition and performance may help to prevent eating disorders in that population []. Therefore, coaches, trainers, administrators and parents should receive information about eating disorders and related issues. In addition, coaches should realize that they can strongly influence their athletes. Coaches or others involved with young athletes should not comment on an individual’s body size, or require weight loss in young and still growing athletes. Without further guidance, dieting may result in unhealthy eating behavior or eating disorders in highly motivated and uninformed athletes []. Because of the importance that athletes ascribe to their coaches, the success of a prevention program tends to be related to the commitment and support of the coaches and others involved. Early intervention is also important, since eating disorders are more difficult to treat the longer they progress. Therefore professionals working with athletes should be informed about: the possible risk factors for the development of eating disorders; early signs and symptoms of eating disorders; the medical, psychological and social consequences of these disorders; how to approach the problem if it occurs; and what treatment options are available.
Summary Overall, exercise is extremely beneficial to women. It
reduces adiposity while improving cardiovascular fitness, physical endurance, work capacity, muscle mass, muscle strength, flexibility, neuromuscular coordination and cognitive function. However, overtraining, energy deficit and/or disordered eating can result in reproductive dysfunction for athletes. Untreated amenorrhea may result in an increase in the incidence of stress fractures, scoliosis and thin body mass, and greatly increases the risk of osteopenia and osteoporosis. It is important to address amenorrhea as soon as possible, using the appropriate combination of weight normalization, nutritional evaluation, training reduction, behavior modification and/or in some cases oral contraceptives or hormone replacement therapy. The treatment of amenorrhea can frequently double as treatment for the accompanying osteoporosis. Many studies have shown an increased prevalence of eating disorders among athletes when compared with the general population. Eating disorders in athletes can easily be missed unless they are specifically targeted. If untreated, eating disorders can have long-lasting physiologic and psychological effects and may even be fatal. Treating athletes with eating disorders should be undertaken only by qualified health care professionals, ideally those who are familiar with the athlete’s sport.
Multiple choice questions The inhibition of this hormone is speculated to cause athletic amenorrhea: a luteinizing hormone b gonadotropin-releasing hormone c follicle-stimulating hormone d estradiol. With undernutrition leptin levels are seen to: a fall b rise c remain the same. Which of the following is/are thought to be predictive of loss of bone mass? a Leptin. b Dehydroepiandrosterone. c Parathyroid. d Insulin-like growth factor I. e Triiodothyronine. Which of the following types of athletes are more likely to develop an eating disorder and/or amenorrhea:
Amenorrhea, Osteoporosis and Eating Disorders in Athletes a long-distance runner (female) b swimmer (female) c wrestler (male) d figure skater e gymnast. Which of the following are common symptoms of eating disorders? a Swollen parotid glands. b Abdominal bloating. c Increased bone density. d Warm hands and feet. e Bradycardia.
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Bachrach LK, Katzman DK, Litt IF, Guido D, Marcus R. Recovery from osteopenia in adolescent girls with anorexia nervosa. J Clin Endocrinol Metab ; : –. Hartman D, Crisp A, Rooney B, Rackow C, Atkinson R, Patel S. Bone density of women who have recovered from anorexia nervosa. Int J Eating Disord ; : –. Powers PS. Osteoporosis and eating disorders. J Pediatr Adolesc Gynecol ; : –. Ding JH, Sheckter CB, Drinkwater BL, Soules MR, Bremner WJ. High serum cortisol levels in exerciseassociated amenorrhea. Ann Intern Med ; : –. Prior JC, Vigna YM, Schechter MT, Burgess AE. Spinal bone loss and ovulatory disturbances. N Engl J Med ; : –. Klibanski A, Biller BMK, Schoenfeld DA, Herzog DB, Saxe VC. The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa. J Clin Endocrinol Metab ; : –. Steppan CM, Chidsey-Frink KL, Crawford DT et al. Leptin administration causes bone growth in ob/ob mice. Regul Pept ; : –. Thomas T, Gori F, Burguera B et al. Leptin acts on human marrow stromal cells to enhance differentiation to osteoblasts and to inhibit adipocyte differentiation: Endocrinology ; : –. Grinspoon S, Baum H, Lee K, Anderson E, Herzog D, Klibanski A. Effects of short-term recombinant human insulin-like growth factor I administration on bone turnover in osteopenic women with anorexia nervosa. J Clin Endocrinol Metab ; : –. Miller KK, Klibanski A. Amenorrheic bone loss. J Clin Endocrinol Metab ; : –. Berga SL, Mortola JF, Girton L et al. Neuroendocrine aberrations in women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab ; : –. Biller BMK, Federoff HJ, Koenig JI, Klibanski A. Abnormal cortisol secretion and responses to corticotropinreleasing hormone in women with hypothalamic amenorrhea. J Clin Endocrinol Metab ; : –. Suh B, Liu J, Berga S, Quigley M, Laughlin G, Yen S. Hypercortisolism in patients with functional hypothalamic amenorrhea. J Clin Endocrinol Metab ; : –. Drinkwater BL, Bruemner B, Chesnut CH III. Menstrual history as a determinant of current bone density in young athletes. J Am Med Assoc ; : –. Prior JC, Vigna YM. Gonadal steroids in athletic women: Contraception, complications and performance. Sports Med ; : –. Robinson E, Bachrach LK, Katzman DK. Use of hormone replacement therapy to reduce the risk of osteopenia in adolescent girls with anorexia nervosa. J Adolesc Health ; : –. Biller BMK, Schoenfeld D, Klibanski A. Premenopausal osteopenia: Effects of estrogen administration (#). Endocrin Soc Annu Meeting ; : . Hergenroeder AC, O’Brian Smith E, Shypailo R, et al. Bone mineral changes in young women with hypothalamic amen-
Chapter .
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Chapter 4.7 Physical Activity and Obesity PERTTI MUSTAJ OKI , PE R B J ÖRNTORP & ARNE AST RUP
Classical reference Prentice A, Jebb S. Obesity in Britain: gluttony or sloth. Br Med J ; : –. The paper describes the increased prevalence of clinical obesity in Britain and demonstrates that this has doubled over the decade from to . It is demonstrated that the cause for obesity cannot be described as an increased absolute energy intake over the years, but rather as a mismatch between food intake and energy expenditure. From Fig. .. it can be seen that the increased prevalence of obesity coincides with an increasing amount of cars and hours of television viewing. Although no cause and effect relationship could definitively be stated from this paper, it is one of the first papers to elegantly show that low levels of physical activity play an important and perhaps dominating role in the development of obesity by greatly reducing
Fig. .. Secular trends in diet (left) and activity (right) in relation to obesity in Britain. Data for diet from National Food Survey; data for body mass index from Office of Population Censuses and Surveys and historical surveys; data for television viewing and car ownership from Central Statistical Office.
% Of mean for all time points
200
energy needs. The authors of the paper suggest that public health strategies must be targeted both at a reduction in the fat content of the diet and at avoidance of physical inactivity if they are to have any chance of reversing the current trend in obesity and of avoiding the associated health consequences.
Introduction There is a worldwide epidemic of obesity and because it is followed by increased incidences of type diabetes, heart disease and many other serious health problems the WHO has given its prevention and treatment the highest priority. Evidence suggests that a major causal factor is increased physical inactivity. The formulation of strategies to counteract this is therefore highly topical. Physical activity and exercise have many beneficial effects on health; among these are increased energy expenditure, improved appetite
% Obese Energy intake (MJ/day) Fat intake (g/day)
% Obese Cars (per household) Television viewing (hours/week)
100
0 1950 1960 1970 1980 1990 Year
1950 1960 1970 1980 1990 Year
Chapter . regulation and a lower risk of weight gain and obesity. Increased physical activity may be difficult to achieve in obese subjects and the impact on weight loss is minor. However, in normal-weight and slightly overweight populations, and in previously obese individuals after a dietary-induced weight loss, increased daily physical activity is an important component in the prevention of weight gain or regain, and obesity.
The role of physical inactivity in weight gain and obesity The nature of physical activity Physical activity is the increase of contraction of the muscles, particularly the large muscles in the leg, e.g. in walking or running. This costs energy and prevents the storage of too much lipid energy in adipose tissue, an essential part of the prevention of obesity. In the same way, the energy expended in physical activity can contribute to the creation of a negative energy balance, thus diminishing energy stores, and contribute to the treatment of obesity. A negative energy balance can also be accomplished by a decreased energy intake. Physical activity is consequently a cornerstone in the prevention and treatment of obesity, but it must be acknowledged that a negative energy balance of theraTable .. Different mechanisms by which increased physical activity and exercise can contribute to body weight control, and improve other health parameters. 1 Increased energy expenditure 2 Better aerobic fitness 3 Improvement of body composition: • fat loss • preservation of lean body mass • reduction of visceral fat depot 4 Increased capacity for fat mobilization and oxidation 5 Control of food intake: • short-term reduction of appetite • reduction of fat intake 6 Stimulation of thermogenic response: • resting metabolic rate • diet-induced thermogenesis 7 Change in muscle morphology and biochemical capacity 8 Increased insulin sensitivity 9 Improved plasma lipid and lipoprotein profile 10 Reduced blood pressure 11 Positive psychological effects
peutic significance is more easily accomplished by dieting than by exercise. A decrease in daily food intake of kcal (. MJ) is easily managed, but this corresponds to about h of jogging, an activity which is impossible for most obese patients. Yet there is evidence that regular physical activity improves the possibility of maintaining energy balance, perhaps through an enhanced regulation of energy intake. It is frequently forgotten that physical exercise exerts profound beneficial effects on the comorbidities associated with obesity (Table ..). The major action is the sensitization of muscle to insulin, and physical activity is thus the best available means to counteract insulin resistance, diminishing the risk of the development of type diabetes mellitus, comorbidities such as dyslipidemia and hypertension, and other prevalent diseases. Physical exercise appears to improve insulin sensitivity without necessarily creating a negative energy balance. This is seen as an acute effect after a bout of exercise and lasts for a day or two []. But, apparently, physical training also has more long-lasting effects. In a study by Björntorp et al. a group of obese subjects was submitted to a conventional physical training program whilst continuing with their habitual diet, i.e. they were asked not to diet during the experiment. In this way loss of body fat was prevented, but there was still a remarkable effect on insulin resistance []. This study showed that exercise training is a very efficient way to improve insulin resistance, and that this effect of training is independent of a decrease in body fat. However, as a rule body fat mass decreases with physical training, and this amplifies the sensitization to insulin. Lean, middle-aged men who exercise regularly have been found to dispose of g oral glucose within h of ingestion with a minimal increase in circulating insulin. In other words, they were markedly insulin sensitive []. This poses the question whether the effects of exercise on insulin resistance are not equally as important as the effects of loss of body fat mass in obesity, because obesity without its comorbidities should be a comparatively benign condition.
Assessment of physical activity The amount of daily physical activity is very difficult to quantify, particularly over the prolonged period of time (years) involved in the development of obesity.
Physical Activity and Obesity Typically an increase in weight of kg occurs over a period of perhaps years. This indicates that the individual has a positive energy balance of some – kcal/day, or the equivalent of –% of total energy expenditure. This corresponds to an extra energy intake of less than half a sandwich per day or, on the output side, a walk of – min/day. In the short term these are such small changes in energy balance that they could perhaps correspond to differences in minor unconscious movements (‘fidgeting’) []. No method exists that can measure such differences over a sufficient period of time. The available methods, such as measurements of V˙2 max, step registration, Holter monitoring or activity history, are not very helpful at this low level of long-term change in energy balance. The problem is equally difficult for both energy intake and energy output, and such technical problems make obesity research very complicated. Free living energy expenditure can be measured with reasonable accuracy by the double-labeled water technique, and by subtracting resting metabolic rate from these readings a good estimate of the energetic cost of physical activity can be achieved. However, this method is very costly, which prohibits its use in population studies.
Epidemiologic evidence Following the results of a survey by an expert group [] of the global prevalence of obesity, the WHO has now declared obesity to be one of the major international health problems. The situation continues to worsen; for example, the prevalence of overweight and obesity in England has doubled over the past – years []. In this same period energy consumption, estimated on a national level, has been seen to be decreasing. This must mean that energy expenditure by physical exercise has diminished or, more accurately, that physical inactivity has been increasing. This is probably caused by a combination of the widespread availability of mechanized transportation, which requires no muscular activity, the increase in physically inactive jobs and production methods, and the increase in inactive leisure activities, such as watching television. The latter is a particular problem in children, where many age groups spend up to – h/day in front of the television []. The significance of these observations is, however, rather uncertain, as watching television is frequently
associated with snacking, an indisputable contributor to the generation of obesity. Because of the difficulties of assessment described above, most observations on physical inactivity are circ*mstantial. The available information does, however, suggest that physical inactivity is an important ingredient in the pathogenesis of the current obesity epidemic. If this interpretation is correct then the diminished physical inactivity is, of course, a highly important target priority in both prevention and therapy of obesity and its complications.
Prevention Studies on the prevention of obesity by means of increased physical activity exclusively have not been performed, probably due to the practical difficulties inherent in such trials. The results of a few studies are available, showing some hopeful preventive results following a general change in lifestyle, including both dieting improvement and increased physical activity. The effects found are small. Even so, from a broader perspective they may be useful [,].
Physiologic mechanisms linking physical activity and energy balance Increased physical activity and less physical inactivity raises total energy expenditure, allowing individuals to consume more calories without gaining weight. There are several lines of evidence to indicate that individuals with ‘a low energy output syndrome’ are at an increased risk of weight gain and obesity, irrespective of whether this is caused by a genetically determined low resting metabolic rate [], by low levels of fidgeting or by an environmentally determined low level of physical activity []. Athletes with very high levels of physical activity may have the opposite problem: difficulty in ingesting enough calories to replenish and maintain body energy and fat stores. Exercise bouts are followed by an acute suppression of hunger. This mechanism is short lived and it is more likely to occur after exercise of high intensity. Both physiologic and behavioral factors play a role in the maintenance of energy balance. Sedentary behavior allows more opportunity for food intake than a physically active lifestyle, e.g. children watching television are more likely to snack and drink than children engaged in sports activities.
Chapter . The effect of exercise on energy intake Does physical activity and exercise contribute to an improved appetite regulation? There is a public perception that exercise makes you eat more. This is most certainly true, but the important question is whether the resulting increase in energy intake fully, or only partially, compensates for the energetic cost of the physical activity. This may depend on the sizes of the fat stores and there is evidence to suggest that lean subjects fully compensate for the energy cost of exercise, while overweight and obese subjects are less likely to fully compensate. In a review, King et al. [] conclude that exercise tends to normalize appetite response. It has also been suggested that exercise may help to regulate energy balance because of an asymmetry in appetite control, in which the hunger drive operates more powerfully and precisely than the satiety drive []. Overall, the available literature provides little evidence to suggest that exercise causes an increase in energy intake beyond compensation for the energy expended because of the exercise. There is usually a net energy deficit, which is more apparent in obese people, who appear to be less appetite responsive to exercise than normal-weight individuals.
Increased fat oxidation The effect of exercise on substrate utilization may exert an impact on appetite regulation and energy intake, independent of the effect of exercise on energy expenditure. The contribution of fat oxidation to energy expenditure changes from nearly % at rest and during low-intensity exercise to very low levels during high-intensity exercise. However, the absolute oxidation of fat may be higher during high-intensity exercise than low-intensity exercise, because of the difference in total energy expenditure. It is known from studies in athletes that the body’s capacity to store carbohydrate is very limited compared to its capacity to store fat. This has implications for the fuel mix that is oxidized, as well as for the ability of the overall regulatory system to counteract depletion of glycogen stores []. Consequently, variations in carbohydrate stores have a larger impact on appetite and satiety, and it is generally recognized that exercise that mainly utilizes fat as substrate is less likely to stimulate appetite. However, with regular high-intensity exercise training
muscular fat oxidation capacity increases with increased fitness, and a larger proportion of the exerciseinduced energy expenditure is covered by fat than in untrained individuals. Although these considerations suggest that fitness is an important independent factor in the regulation of body weight there is a need for more controlled studies with emphasis on identifying the optimal type of activity, i.e. endurance or strength, and optimal duration and frequency.
Interactions between dietary fat and physical activity In a number of countries the prevalence of obesity has continued to rise despite a reduction in the proportion of calories from fat in the national diet. Having been observed in the USA, this phenomenon has been named ‘The American Paradox’ []. Among the explanations suggested for this apparent contradiction have been a concomitant overriding effect of decreasing physical activity, overconsumption of highly palatable, energy-dense, carbohydrate-rich, low-fat products, underreporting of fat consumed in dietary surveys, and obesity being an infectious disease caused by an adenovirus. It should be stressed, however, that a high dietary fat content is unlikely to be the only environmental factor responsible for obesity. A sedentary lifestyle with a low level of energy expended on physical activities is another causative factor, which interacts with dietary fat content. It has been demonstrated that dietary fat tolerance is greatly lowered by a sedentary lifestyle, even in non-obese individuals []. The result of this short-term study has been extended by a meta-analysis of intervention studies on the effect on weight loss of low-fat diets alone, and in combination with exercise []. Weight loss achieved by low-fat diet alone was . kg; with diet and exercise it was . kg. On a population basis the reduction of mean body weight by kg could result in quite a dramatic change in the prevalence of obesity. The decrease in physical activity observed in population studies may therefore be responsible for the continuing increase in the prevalence of obesity. And the very modest, if any, decrease in dietary fat intake is insufficient to compensate for this development.
Physical Activity and Obesity Physical activity in the treatment of obesity Exercise and weight loss The effect of exercise on body weight has been investigated in several studies. Wing systematically analysed investigations in which exercise without diet intervention had been studied in adults []. She found randomized, controlled investigations which fulfilled the criteria set. Most of them included aerobic exercise (mostly walking). In six investigations statistically significant weight loss was observed, in four no change was seen. Thus, exercise without diet intervention seems to cause only minor weight loss, usually no more than – kg. The number of studies in children is too limited to evaluate the effect of exercise alone on weight reduction []. Weight reduction programs use a multidisciplinary approach. These include dietary counselling to decrease energy intake, exercise, and cognitive and behavioral therapy to promote permanent lifestyle changes. What are the effects of exercise in these programs? In Wing’s review [], randomized, controlled trials addressing the treatment of adult obesity were evaluated. Interventions lasted from to months. Aerobic exercise was used in nine of the investigations, and strength exercise in four. In only two of the investigations did exercise cause statistically significant better weight loss than experiments with dietary intervention only. Thus, exercise seems to have only a weak, or even no, effect on weight loss, also in connection with dietary and behavioral interventions. Epstein and Goldfield [] evaluated controlled trials in children and concluded that exercise increases the amount of weight lost in the short term. There were not enough trials to evaluate the long-term effect. In weight reduction some three-quarters of the weight lost is comprised of adipose tissue and approximately one quarter is lean body mass. Does exercise during a weight reduction program preserve lean body mass better than dietary interventions without exercise? Garrow and Summerbell [] evaluated this in a meta-analysis of studies in which exercise and non-exercise groups were compared. They found studies from the years – that fulfilled the criteria used. A regression analysis showed that for
every kg lost . kg in men and . kg in women was lean body mass when dietary intervention alone was used. When dietary intervention was combined with exercise the loss of lean body mass was . kg in both sexes. Thus exercise, especially strength exercise, may spare some .– kg lean body mass for every kg lost. This is probably advantageous although its clinical importance has not been demonstrated by investigation.
Exercise and maintenance after weight loss Weight loss can generally be satisfactorily achieved through modern weight reduction programs but most people regain weight after concluding the weight loss programs. Weight maintenance after weight loss is a major challenge to obesity research. The effect of exercise on maintenance after weight loss has been evaluated in two recent reviews. Wing [] collected all randomized, controlled trials in which follow-up was year or more. Six studies fulfilled the criteria used. In two studies exercise plus diet therapy was associated with significantly better maintenance than diet therapy alone. In four studies no significant effects were seen. Fogelholm and Kukkonen-Harjula [] evaluated all studies in which exercise was compared with nonexercise regimens and follow-up was year or more. Seventeen non-randomized trials were included in the analysis. In of these weight maintenance was associated with exercise during the intervention. Eighteen randomized, controlled trials were included and an association between weight maintenance and exercise was seen in four of these. All in all, these results indicate some effect of exercise on weight maintenance, but the results vary. One reason for the variable results is that the investigation of long-term effects of exercise on weight maintenance is hampered by methodologic problems, such as how to measure the total amount of exercise, poor adherence to exercise programs, or a high dropout rate during long follow-up periods. Weight gain is a consequence of an imbalance between energy intake and expenditure. Increased energy expenditure would certainly be an effective measure for weight maintenance, if people were willing to adopt a more active lifestyle. Variable and modest
Chapter . results in weight maintenance studies suggest that many obese people are not willing to do this. A key question is how obese individuals can be helped to adopt more active lifestyles.
A practical strategy for increasing physical activity in susceptible subjects To increase physical activity it is necessary that individuals change their behavior. In planning a strategy for increasing physical activity in susceptible subjects general rules of behavior modification must be taken into consideration. These rules include the fact that most individuals are not motivated to change their habits when meeting a health care professional, admonition and advice is not usually effective, and changing an individual’s habitual behavior is a complex process which takes time [,]. In addition there are specific problems attached to exercise for obese people: they are generally in worse physical condition and less motivated to exercise than normal-weight people. If counselling is to be effective in increasing an individual’s physical activity great attention must be paid to his or her motivation. Table .. summarizes approaches that are likely to increase motivation for lifelong changes. Exercise ‘prescribed’ by a therapist is unlikely to be continued for the rest of a lifetime. Communication skills that include a client-centered approach are more likely to motivate sustained changes. In this approach the client determines the amount and quality of physical activity to be practised, and is responsible for planning the activity. A multidisciplinary approach for increasing physiTable .. Suggested practical strategies for counselling a client to increase physical activity for weight control. Communication with the client The counsellor does not give direct advice about how to exercise The counsellor gives information and alternatives, the client makes choices Minor changes are also reinforced, although they do not meet the expectations of the counsellor Type of physical activity Emphasis on low-intensity physical activity Lifestyle activity as an alternative to structured exercise The client selects a suitable type of physical activity in which he or she is interested
cal activity is recommended. This implies that preconceptions involving fixed pulse rate, specific types of exercise and whether the exercise is aerobic or not are not criteria of significance in the counselling of an obese individual about exercise. A client should be encouraged to select a type of exercise in which he or she is interested. Many obese people are not interested in formalized exercise programs and for them lifestyle activities are a useful alternative. Lifestyle activity includes taking the stairs instead of taking elevators or escalators, walking journeys of moderate distances instead of taking the car, using manual means to complete domestic tasks instead of using household machines, etc. In a randomized, controlled trial lifestyle activity has been shown to be as effective as aerobic exercise in weight maintenance after weight loss []. A recent clinical guideline for the treatment of obesity recommends that adults should set a long-term goal that they perform at least min of moderateintensity physical activity on most, and preferably all, days of the week []. This is a realistic goal for most obese people but in motivational communication minor changes, although they do not meet the expectations of the counsellor, should be reinforced.
Summary Decreased levels of daily physical activity and exercise are important contributors to the increasing prevalence of overweight and obesity. The workplace and leisure-time-related inactivity which accompanies our modern lifestyle seems to be an additional factor. Lack of physical activity also increases the risk of type diabetes, independent of the size of body fat mass. Increased daily physical activity level is therefore an important strategy for the prevention of weight gain and obesity. Compared to energy restriction physical activity programs have only modest effects on weight loss in obese subjects. However, once a weight loss has been achieved through dietary restriction increased daily physical activity is important for long-term weight stability (Fig. ..).
Multiple choice questions To lose kg body fat you have to jog for: a h
Physical Activity and Obesity 50 Sedentary women Moderately active women Active women
Weight gain (kg)
40 30 20 10 0
In response to similar amounts of physical activity, which may be correct? a Males appear to lose more weight. b Females appear to lose more fat weight. c Males lose more fat-free mass compared to females. d Males increase their fat mass. e None of the above.
References
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EEPA (kJ/kg body weight/day) Fig. .. Relationship between the free living energy expenditure produced by habitual physical activity and subsequent gain of body fat among a group of females with increased susceptibility to weight gain. The intercept with weight gain = indicates that weight stability requires a daily energy expenditure of at least kJ/kg body weight, which corresponds to an average of min/day of moderate activity or min/day of vigorous activity added to a sedentary lifestyle.
b h c h d h e h. What is the definition of insulin resistance? a Increased insulin secretion. b Increased secretion of hormones with effects antagonizing insulin effects. c A diminished effect of insulin. d Diabetes mellitus. e Physical inactivity. Which one of the following statements is not correct? Insulin resistance is followed by: a hyperinsulinemia b elevated very low density lipoproteins c increased risk of the development of diabetes d elevated cholesterol e increased risk of developing cardiovascular disease. Physical activity may be useful for weight management because: a it represents a volume of energy expenditure under voluntary control b it generates a large-scale energy deficit compared to energy restriction c it has universal effects on individuals d it only increases fat oxidation e none of the above.
Fahlén M, Stenberg J, Björntorp P. Insulin secretion in obesity after exercise. Diabetol ; : –. Björntorp P, deJounge K, Sjöström L, Sullivan L. The effects of physical training on insulin production in obesity. Metabolism ; : –. Björntorp P, Grimby G, Sanne H, Sjöström L, Tibblin G, Wilhelmsen L. Adipose tissue fat cell size in relation to metabolism in weight-stabile, physically active men. Hormone Metabol Res ; : –. Ainsworth BE. Compendium of physical activities: classification of energy costs of human physical activities. Med Sci Sports Exerc ; : –. Obesity. Preventing and Managing the Global Epidemic. Report of a WHO Consultation on Obesity. Geneva, – June . WHO/NUT/NCD/., . Dietz WH, Gortmaker SL. Do we fatten our children at the televison set? Obesity and television viewing in children and adolescents. Pediatrics ; : –. Jeffery RW, French SA. Preventing weight gain in adults. The Pound Prevention Study. Am J Public Health ; : –. Taylor CB, Fortmann SP, Flora J et al. Effect of long-term community health education on body mass index. Am J Epidemiol ; : –. Astrup A, Gøtzsche PC, van de Werken K et al. Metaanalysis of resting metabolic rate in formerly obese subjects. Am J Clin Nutr ; : –. Thorburn AW, Proietto J. Biological determinants of spontaneous physical activity. Obesity Rev ; : –. King AC, Tribble DL. Effects of exercise on appetite control: implications for energy balance. Med Sci Sports Exerc ; : –. Blundell JE, King NA. Effects of exercise on appetite control: loose coupling between energy expenditure and energy intake. Int J Obes Metabol Disord ; (Suppl. ): S–S. Saris WHM. Physical activity and body weight regulation. In: Bouchard C, Bray GA, eds. Regulation of Body Weight: Biological and Behavioral Mechanisms. Chichester, UK: John Wiley & Sons Ltd, : –. Astrup A. The American paradox: the role of energy-dense fat-reduced food in the increasing prevalence of obesity. Curr Opin Clin Nutr Metabol Care ; : –. Astrup A. Nutrition and diet for healthy lifestyles in Europe: obesity and diabetes. Pub Health Nutr ; : –.
Chapter . Yu-Poth S, Zhao G, Etherton T, Naglak M, Jonnalagadda S, Kris-Etherton PM. Effects of the National Cholesterol Education Program’s step I and step II dietary intervention programs on cardiovascular disease risk factors: a metaanalysis. Am J Clin Nutr ; : –. Wing R. Physical activity in the treatment of the adulthood overweight and obesity: current evidence and research issues. Med Sci Sports Exerc ; (Suppl.): S–S. Epstein L, Goldfield GS. Physical activity in the treatment of childhood overweight and obesity: current evidence and research issues. Med Sci Sports Exerc ; (Suppl.): S–S. Garrow JS, Summerbell CD. Meta-analysis: effects of exercise, with or without dieting, on body composition of overweight subjects. Eur J Clin Nutr ; : –.
Fogelholm M, Kukkonen-Harjula K. Does physical activity prevent weight gain — a systematic review. Obesity Rev ; : –. Rollnick S, Kinnersley P, Stott N. Methods of helping patient with behaviour change. Br Med J ; : –. Biddle SJH, Fox KR. Motivation for physical activity and weight management. Int J Obes Metabol Disord ; (Suppl. ): S–S. Andersen RE, Wadden TA, Barlett SJ, Zemel B, Verde TJ, Frankowiak SC. Effects of lifestyle activity vs. structured aerobic exercise in obese women. A randomized trial. J Am Med Assoc ; : –. Clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults — the evidence report. Obesity Res ; (Suppl. ): S–S.
Chapter 4.8 Gastrointestinal Considerations FRANK MOS E S
Classical reference Fordtran JS, Saltin B. Gastric emptying and intestinal absorption during prolonged severe exercise. J Appl Physiol ; : –. Endurance exercise causes a loss of water, electrolytes and glycogen. Replacement of these is essential to avoid fatigue and impaired performance. This requires a functioning gastrointestinal (GI) tract and many athletes find it difficult to ingest enough to adequately replenish that which is lost. There are many factors that govern the rate of gastric emptying (GE) in the resting state. However, limited data existed regarding the effects of exercise on GE and results had been conflicting. In a landmark study Fordtran and Saltin performed one of the earliest and most rigorous evaluations of the effects of exercise on upper gastrointestinal function. In their study GE was analysed by gastric aspiration of mL of water and a test solution containing .% glucose and .% sodium chloride. Five healthy subjects were trained to the techniques and
50
600 Volume gastric contents (mL)
% PEO remaining
Fig. .. Effect of exercise on the recovery of polyethylene glycol (PEG) and on calculated volume of gastric contents h after ingestion of -mL test solutions was started. Dotted lines refer to tests carried out with water, solid lines to those with a solution containing .% glucose and .% sodium chloride.
then tested at rest or with exercise on a treadmill for h at –% of V˙2 max. The subjects drank mL of the test solution at the start and at -min intervals for min. At min a French tube was placed and gastric contents were aspirated for analysis. Furthermore, four subjects then were tested to determine the effects of exercise on intestinal absorption by a standard non-absorbable marker, constant perfusion technique. A small triple-lumen tube was placed in the jejunum and subsequently in the ileum and position verified by fluoroscopy. The authors measured net water, electrolyte and glucose (active) absorption, and (passive) absorption of -xylose, urea-14C and tritiated water in both the jejunum and ileum. GE of water was more rapid than that of the saline–glucose test solution. However, exercise had minimal effect on GE (see Fig. ..), as measured by the remaining non-absorbable marker (polyethylene glycol) or residual gastric volume. Exercise did not alter absorption of the tested substances in either the jejunum or ileum. These results showed that rather intense exercise (% of maximum) for h had a very
40 20 0
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Exercise
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Chapter . slight inhibition of liquid gastric emptying and no effect on intestinal absorption of water, electrolytes or glucose or passive intestinal absorption of -xylose, urea-14C or tritiated water. The authors acknowledge prior studies demonstrating that exercise was associated with substantial reductions in splanchnic blood flow. However, they concluded that exercise to this degree did not alter intestinal blood flow sufficiently to significantly reduce GE or intestinal absorption. They felt that these data demonstrated that athletes should be capable of adequate rehydration and energy replacement during sustained heavy exercise, even during exercise in hot environments. The study was limited by the small number of young, asymptomatic, healthy subjects, but used rigorous methods of directly measuring GE and, in particular, intestinal absorption. The study demonstrated how successful these evaluations can be when performed by trained investigators. It opened up the field of GE with exercise that became of great interest to athletes, trainers, scientists and industry.
Introduction Exercise influences gastrointestinal (GI) physiology in a variety of different ways and can alter GI function in healthy individuals and those who suffer underlying GI disorders. Some of these changes are beneficial. Exercise has been associated with improved gastric emptying, reduced constipation and reduced rates of GI malignancies. More commonly, the medical literature has linked exercise to unfortunate outcomes, such as ischemic bowel disease or GI bleeding following a marathon race. Over the past years many investigators have contributed to the expanding literature of this topic. There has been extensive research to optimize oral rehydration during athletic events. Many case reports and series have demonstrated uncommon or untoward effects during exercise such as severe lower GI bleeding. However, much remains unknown or untested. This chapter will briefly review pertinent GI physiology associated with exercise and highlight the effect of exercise on healthy individuals and on those suffering from GI diseases.
GI physiology with exercise Gastrointestinal physiology has traditionally been studied at rest and the methodology is typically vali-
dated for resting conditions. Experimental stress on the GI tract is more typically generated by drugs or disease. Evaluation of GI physiology under the stress of exercise often requires extensive modifications in experimental techniques and most GI physiologists are untrained in these methods. Intestinal motility, for example, is extremely sensitive to motion artifact. This has limited the published literature. The most dramatic change associated with exercise is that cardiac output is diverted to exercising muscles and visceral blood flow falls by –% of baseline values [,]. During prolonged events there is increased demand for absorption of water, electrolytes and nutrients. This relative hypovolemia may be compounded by hyperthermia, dehydration and, potentially, the use of non-steroidal anti-inflammatory drugs (NSAIDs). The stomach and colon seem particularly sensitive to ischemia induced by exercise. The autonomic nervous system (ANS) is altered by acute and chronic exercise. During acute stress, the sympathetic nervous system predominates. However, with habitual exercise, the ANS adapts and parasympathetic effects predominate. These effects alter intestinal transit, blood flow and permeability. GI hormones are variably changed by exercise and these changes can also alter a variety of GI functions. The mechanical effects of exercise on the GI tract are uncertain but could alter GI function by changing intra-abdominal pressure or facilitating trauma to more mobile sections of the GI tract.
Effects of exercise on GI function and symptoms in healthy individuals and athletes GI symptoms: abdominal pain, cramps and diarrhea Initial reports found that up to half of all marathon runners have occasional loose stools or three or more bowel movements per day. Furthermore, the urge to defecate, abdominal cramping and increased flatulence are common lower GI symptoms of runners. A small percentage of marathoners report bloody bowel movements with running. Upper GI symptoms such as heartburn are not infrequent, particularly during running. Other upper tract symptoms include increased eructations, abdominal pain, nausea and vom-
Gastrointestinal Considerations iting. Women, untrained athletes, younger athletes and competitors who ‘give it all’ more frequently reported GI symptoms. Symptoms such as abdominal pain, ‘side stitch’ [], nausea and even vomiting are greater with hard runs or longer races such as the marathon and among athletes who suffer dehydration and hyperthermia []. While these may be infrequent causes of severe or lasting disability, they are common and may limit performance. GI symptoms with long-distance walking are less severe than during running but may limit performance and are also more severe in dehydrated or less experienced athletes []. A few of these surveys are based on large populations, which may limit the inherent reporting bias. However, many of these ‘exercise-associated’ symptoms are characteristic of the irritable bowel syndrome and the surveys are not generally controlled with a non-running group. Furthermore, these symptoms are non-specific and may be manifestations of dehydration, electrolyte disturbances or hyperthermia. Exercise may serve at times to be a ‘disease detector’, uncovering symptoms of underlying illness that are not symptomatic during non-strenuous normal daily activities []. This is most often seen in competitive athletes or others, such as soldiers, who are in a physically demanding occupation. Alternatively, the clinician can ask patients if they have recently chosen to avoid an active lifestyle for particular reasons. Clinical evaluation of these cases is difficult but is frequently most instructive if the athlete can be evaluated during or soon after a symptom-provoking event. Occasionally it may be necessary to recreate the athletic event in order to document the particular disorder. While abdominal pain is typically transient and of little clinical consequence, more severe outcomes may occur and should always be considered in appropriate circ*mstances []. (See Case Study ..)
GI bleeding Gastrointestinal bleeding in athletes is an uncommon but dramatic and potentially serious complication that may manifest as acute upper or lower GI bleeding, as chronic bleeding or iron deficiency, or as incidentally noted occult positive stool tests. The term runners’ (or sports) anemia was initially coined in . While mean hemoglobin values of elite athletes may be lower than in the general population, the incidence of anemia
Case study 4.8.1: GI bleeding A -year-old elite woman runner was admitted to hospital following completion of a marathon []. She had developed crampy lower quadrant abdominal pain followed by several episodes of bloody diarrhea at the -mile mark. Her symptoms improved transiently during the race but worsened near the end. Following the marathon she began passing frank blood per rectum and presented to an emergency room. While her past GI history was unremarkable, she had noted abdominal pain and diarrhea during peak training – weeks previously while she was running miles/week at a -foot elevation. She was on no pertinent medications and the remainder of her past history was unremarkable. A sigmoidoscopy showed external hemorrhoids and severe hemorrhagic colitis of the sigmoid colon. The patient was admitted and treated with bowel rest, intravenous fluids and antibiotics. Her symptoms resolved within h and she was discharged in days. Further evaluation for other etiologies was unremarkable. A subsequent endoscopy at weeks showed complete resolution and she resumed active running without recurrent symptoms over months.
in athletes is difficult to determine but probably not different from age-matched controls []. The etiology of sports anemia is frequently multifactorial and may most commonly be artifactual due to plasma volume expansion. Alternatively, the anemia may be due to blood loss from GI bleeding which has the greatest potential to cause significant anemia. However, other causes are intravascular hemolysis, hematuria, increased iron loss in the sweat, or decreased dietary iron intake or intestinal absorption. Sports hematuria is generally felt to be a benign self-limited condition due
Chapter . Table .. Evaluations of GI bleeding in endurance events. Distance
Subjects
Method
Results
Marathon Marathon Marathon Marathon
39 707 63 24
Postrace HemOccult Survey Pre/postrace HemOccult Pre/postrace HemQuant (Hb/g stool)
Marathon Marathon 100-mile ultramarathon
125 32 34
Pre/postrace HemOccult Pre/postrace HemOccult Pre/postrace HemOccult
8% positive conversion 1.2–2.4% report blood per rectum 13% positive conversion Pre: 0.99 mg Post: 2.25 mg 21% conversion 22% conversion 85% conversion
HemOccult is a guaiac-based qualitative test for fecal occult blood. HemQuant is a quantitative measurement of hemoglobin in stool.
to repeated traumatic impact of the posterior bladder wall against the bladder base. However, renal causes of hematuria may exist and coexisting urinary pathology should be carefully excluded []. The incidence of clinically significant GI bleeding is difficult to determine but probably rare. Examples of acute upper or lower GI bleeding associated with exercise have been published as isolated case reports or small series. However, anemia and/or iron deficiency is not rare, particularly in women athletes where it may occur in up to a third. Occult GI blood loss prevalence has been generally found to range from to % following marathons and to occur in the majority of ultramarathon competitors [] (Table ..). The frequency and quantity of occult GI blood loss peaks – h following an event and may be proportional to athletic intensity as it is more prominent following competition than practice. Hemorrhagic gastritis (HG) has been the most frequently reported endoscopic finding associated with exercise-associated GI bleeding. It is typically transient, spontaneously resolving within h with rest and also when gastric acid is inhibited by cimetidine, a histamine receptor antagonist (H2RA) []. Histologic changes of submucosal hemorrhage and edema in the gastric antrum immediately following running occur even in the absence of obvious endoscopic damage []. The prevalence of endoscopic changes with running has not been established but is likely common []. A recent endoscopic study found erosive gastritis in and gastric ulcer in of runners completing a -km race []. Ischemia, mediated perhaps by gastric acid, has been the most frequently proposed etiol-
ogy. Prospective trials using prophylactic cimetidine to prevent GI bleeding in a group of recreational marathon runners have not been conclusive []. The second most commonly recognized site of exercise-associated GI bleeding is the colon. Several cases have been published of presumed ischemic colitis following strenuous running or other athletic events []. The cases may be associated with heat and ischemic damage to other organs and have led to diagnostic laparotomy and even subtotal colectomy []. Ischemic lesions develop in the right colon [] and in the classic ‘watershed’ regions of the splenic flexure and sigmoid colon []. Generally hemorrhagic colitis is self-limited. If endoscopic evaluation is considered necessary, it should be performed within h of the athletic stress. These lesions in the stomach and colon are typically transient and will resolve rapidly with rest. NSAID medications, while inconsistently associated with GI blood loss in runners, may contribute to gastritis and gastric ulcers, and less commonly to small bowel or colon lesions and GI bleeding. Aspirin has been shown to enhance increased intestinal permeability associated with running []. It is always important to review the use of these medications in the athlete with gastrointestinal complaints. Trauma has been proposed as an alternative etiology for GI bleeding. Athletes may be more prone to abdominal trauma. Cyclists can suffer abdominal trauma with falls that may be overlooked in the face of other injuries []. Runners are often thin and may have an increased incidence of redundant colon. This can lead to an increased susceptibility to cecal volvulus, which could also cause bleeding and abdominal pain. A recent
Gastrointestinal Considerations case report of a man with recurrent abdominal pain with exertion was felt to be due to redundant colon and resolved after right hemicolectomy []. No instances of esophagitis, esophageal ulcers or small bowel ischemia causing bleeding have been observed to date. Exercise-associated mesenteric infarction has been reported []. Anorectal disorders, such as hemorrhoids or fissures, may be aggravated by local trauma, are common and may cause bleeding in some runners and cyclists, although the incidence is unknown. Participation in exercise programs is part of a healthy lifestyle but does not confer immunity from underlying diseases that may manifest with GI bleeding. Evaluations for diseases such as colon cancer should be performed on individuals at risk for these conditions or in any athlete who develops recurrent GI bleeding of uncertain etiology. The therapy of exercise-associated GI bleeding is dependent on the location and severity of the bleed. Most cases appear to be self-limited and spontaneously resolve. Abdominal pain associated with many of these injuries may limit damage in most athletes, although more severe injury has been seen in elite athletes who persist in the face of pain []. Some cases of HG may recur and these individuals may be treated with an H2RA or perhaps a proton pump inhibitor. Treatment for hemorrhagic colitis is uncertain, though it appears not to generally recur.
Effects of exercise on patients with GI disorders The esophagus Exercise has been reported to cause heartburn associated with gastroesophageal reflux (GER) [,] and chest pain of esophageal origin. However, chest pain, whenever it occurs in the setting of exertion, demands an evaluation for cardiac cause prior to specific esophageal evaluation. Esophageal motility changes occur with exercise. However, it is difficult to quantify physiologic manometric changes in the face of movement artifact induced by running and many studies have used a cycling model. The clinical relevance of these exercise-induced motility changes is uncertain. Heartburn is relatively common among athletes and
Case study 4.8.2–The stomach A -year-old man was referred for recurrent vomiting during and following a run. He was employed as a military recruiter and did not participate in regular athletic activities. During rest and submaximal activities he was asymptomatic. However, during a physical fitness test, he was unable to complete a mile run for time due to vomiting. His past history and physical examination were unremarkable. He was on no medications. An evaluation including an endoscopy, esophageal manometry and -h pH testing during exercise was normal. A graded exercise cardiac stress test did not show ischemic changes. A pulmonary exercise tolerance test showed poor exercise tolerance and his symptoms of nausea and vomiting were reproduced with supermaximal exercise efforts. He was placed on a retraining program, gradually improved his fitness level, and was able to complete his fitness testing successfully.
esophageal pH monitoring has demonstrated that GER occurs more frequently with exercise, notably running. Both the number of reflux episodes and the duration of acid exposure increase with running. Exercise-associated GER is increased postprandially vs. fasting and among those individuals who have an underlying predilection for GER []. The clinical relevance of these changes in uncertain. The symptoms are generally not severe and medical therapy for GER, including antacids, histamine receptor blockers and proton pump inhibitors, effectively reduces acid exposure in these circ*mstances. In rare cases exercise-associated regurgitation can lead to vomiting and impair athletic performance. (See Case Study ..)
The stomach Exercise causes effort-dependent changes in gastric emptying (GE) and may lead to symptoms of nausea, bloating and vomiting. GE may fall significantly dur-
Chapter . ing intense (≥ % V˙2 max) exercise but is generally unaffected or even increased with mild to moderate (< % V˙2 max) intensity exercise. GE is the limiting factor in rehydration during and after endurance events and much research has been done to maximize GE in these settings [,]. Characteristics of the meals are the major factors controlling GE. Liquid meals empty quicker than solid meals. Larger gastric volumes are associated with accelerated GE. Increasing meal calories, osmolality and fat progressively delay GE. The athlete’s hydration state, body temperature, sex, menstrual cycle and smoking status and even the time of day may all affect GE. Liquid GE has been more thoroughly studied. Several studies have shown little change or even accelerated GE of water or glucose solutions at moderate or submaximal intensity levels [–]. GE rates of > L/h of water during exercise may be achieved in laboratory settings when gastric volumes are kept high. Thus GE rates are able to match sweat rates of many, but perhaps not all, athletes. Energy delivery is likewise more than sufficient to match requirements when fluids containing % glucose are used. Surveys have noted that runners are more troubled by gastric symptoms than cyclists or most other athletes. GE of solids is more complex and the literature is less robust. However, exercise appears to have similar effects on GE of solids. Studies have shown mild acceleration of GE of mixed solid meals with both low- and moderateintensity cycling and walking [,]. Some have suggested that runners have significantly accelerated basal GE when compared to sedentary controls. Treatment for GE disorders is primarily preventative. Athletes should ‘train their gut’ to tolerate fluids and meals during training, and avoid fluids and foods in the diet known to adversely affect GE or historically to cause symptoms. Athletes should consume fluids early and often to avoid dehydration and hyperthermia. Once an athlete is dehydrated by ≥ % of body weight, GE rates fall. In one study after min exercise, euhydrated athletes had % GE compared to % in dehydrated athletes []. Performance levels will fall with dehydration and intensity may need to be reduced before oral rehydration can effectively proceed. Medications to accelerate gastric emptying are probably of limited value.
The colon Symptoms attributed to the effects of exercise on the colon are the most commonly reported and seem to be most frequent among runners []. ‘Nervous’ diarrhea (%), defecation with running (%), diarrhea during racing (%), diarrhea associated with severe cramps, rectal bleeding (%) and even fecal incontinence (%) were reported in a runners’ club survey []. While symptoms are common, colonic physiology during exercise is obscure, conflicting and difficult to analyse. Probes are difficult to place and maintain during exercise. Motion artifact is more prominent and transit time is measured in many hours instead of minutes. No change in fecal transit time was found when measured by radioisotope markers in a controlled metabolic laboratory during a -week training period []. However, the training regimen was moderate, the subjects remained asymptomatic and inter- and intrasubject variability was high. In another study, no significant change was found in groups of varying degrees of athletic activity []. Others have found transit time to decrease with treadmill walking or riding a bicycle ergometer []. The mechanism of these changes, if any, is speculative at this time. Colonic symptoms may be treated in various ways. ‘Nervous’ or prerace diarrhea is generally self-limited and may respond to low-residue diets. Some have used prophylactic antidiarrheal medications. Ultraendurance athletes report that it is possible to ‘train the gut’ by reducing exercise duration and intensity to subsymptomatic levels and gradually increasing effort. Prerace cathartics should be avoided due to the possibility of dehydration. Race-associated diarrhea generally responds to reduction in effort. However, severe watery diarrhea associated with racing has not been well studied and will require intensive investigation in symptomatic runners. Exercise is said to benefit patients with functional constipation. Acute graded exercise reversibly reduces colonic pressure waves which may explain some lower GI symptoms associated with exercise []. However, recent studies found no obvious effect [–] of exercise on bowel transit or delayed transit with inactivity []. Medications such as NSAIDs may also be associated with colonic mucosal damage.
Gastrointestinal Considerations Reduced GI malignancy rate Epidemiologic studies have demonstrated that colon cancer is associated with a sedentary lifestyle and that those individuals who remain more active, ingest lower fat and higher fiber diets, and maintain a lower body mass index (BMI) are at a lower risk of colonic neoplasia [,]. Most of these studies have evaluated jobrelated physical activity. However, some have also shown that recreational activity may confer similar benefits. These epidemiologic findings are supported by several experimental findings. Shortened intestinal transit time, which has been noted in more active individuals, has been associated in several studies with a reduced rate of colonic cancer. Furthermore, active individuals frequently consume higher amounts of fiber, which may also accelerate GI transit. Increased fiber may also reduce the concentration of fecal bile acids and alter the ratio of secondary to primary bile acids. NSAID medications are often used by habitual exercisers. Some of these drugs have been shown to reduce colonic neoplasia in certain individuals with increased genetic risk and may alter cancer risk in selected cases.
Summary Exercise can alter gastrointestinal (GI) function of athletes and also cause symptoms in patients with GI diseases. Exercise has been associated with improved gastric emptying, decreased rates of constipation and lower incidences of GI malignancy. More often exercise has been linked to abdominal pain, diarrhea, GI bleeding and ischemic bowel disease. Endurance athletes depend upon a functioning GI tract to sustain volume and energy requirements during competition. GI symptoms may adversely affect athletic performance or be associated with sustained morbidity or even mortality. Gastroesophageal reflux (GER) is more common in runners than other athletes and is particularly frequent when exercise is performed after meals. GER symptoms are generally controlled by reducing gastric acid production. Chest pain of esophageal origin may also occur although the mechanism is uncertain. Lower GI symptoms are more commonly seen and have been reported in over half of runners in some series. In most instances, the etiology of exercise-associated GI
symptoms such as abdominal pain or diarrhea is uncertain. In severe cases, or when the exercise is sustained, GI bleeding secondary to ischemic bowel disease may occur in either the stomach or colon. Hemorrhagic gastritis may recur with repeated exercise and may be inhibited by gastric acid suppression. Hemorrhagic colitis is generally not recurrent but may be severe, leading to colon strictures or surgical exploration.
Multiple choice questions For each question, please indicate which of the statements a–e is correct. Exercise-induced chest pain and heartburn: a are more common in weight lifters and swimmers than runners b are difficult to manage medically c require adequate evaluation to exclude a cardiac cause d occur more often fasting than after meals e are best treated with anticholinergic or sedative medications. Exercise-associated abdominal pain: a is generally worse during training than competition b may be associated with diarrhea or a strong urge to have a bowel movement c can be cured with cimetidine or fasting d is often a marker of underlying GI pathology e is generally worse if exercise is done fasting. GI bleeding associated with exercise: a may occur in one-third of runners after a marathon b may be manifest as hematemesis, melena or chronic anemia c is never a marker of underlying GI disease such as malignancy d can be prevented by gastric acid blockade in some cases e may be associated with ischemic lesions of the colon. Gastric emptying during exercise is important for rehydration during endurance events. a Liquids empty from the stomach faster than solids. b Carbohydrates and salts may be added to liquids to promote quicker water absorption. c Fat delays gastric emptying. d The volume of ingested fluid does not affect the gastric emptying rate.
Chapter . e Athletes should determine their personal preferences for fluid drinks prior to competition. Exercise may alter intestinal transit. a Intestinal transit is determined in part by the amount of fiber ingested. b The majority of intestinal transit time is determined by the colonic transit. c Exercise cures functional constipation. d Running is frequently associated with diarrhea or increased urgency of bowel movements. e Medications are of minimal value in managing symptoms caused by changes in intestinal transit during exercise.
References Clausen JP. Effects of physical training on cardiovascular adjustments to exercise in man. Physiol Rev ; : –. Qamar MI, Read AE. Effects of exercise on mesenteric blood flow in man. Gut ; : –. Morton DP, Callister R. Characteristics and etiology of exercise-related transient abdominal pain. Med Sci Sports Exerc ; : –. Rehrer NJ, Janssen GM, Brouns F, Saris WH. Fluid intake and gastrointestinal problems in runners competing in a -km race and a marathon. Int J Sports Med ; (Suppl. ): S. Peters HP, Zweers M, Backx FJ, Bol E, Hendriks ER, Mosterd WL, de Vries WR. Gastrointestinal symptoms during long-distance walking. Med Sci Sports Exerc ; : –. Eichner RE, Scott WA. Exercise as Disease Detector. Physician Sportsmed ; : –. Scobie BA. Gastrointestinal emergencies with marathontype running: omental infarction with pancreatitis and liver failure with portal vein thrombosis. N Z Med J ; : –. Lucas W, Schroy PC. Reversible ischemic colitis in a high endurance athlete. Am J Gastroenterol ; : – . Balaban EP. Sports Anemia. Clin Sports Med ; : –. Abarbanel J, Benet AE, Lask D, Kimche D. Sports hematuria. J Urol ; : –. Baska RS, Moses FM, Graeber G, Kearney G. Gastrointestinal bleeding during an ultramarathon. Digestive Dis Sci ; : –. Cooper BT, Douglas SA, Firth LA, Hannagan JA, Chadwick VS. Erosive gastritis and gastrointestinal bleeding in a female runner. Prevention of the bleeding and healing of the gastritis with H2-receptor antagonists. Gastroenterology ; : –. Gaudin C, Zerath E, Guezennec CY. Gastric lesions sec-
ondary to long-distance running. Digestive Dis Sci ; : –. Schwartz AE, Vanagunas A, Kamel PL. Endoscopy to evaluate gastrointestinal bleeding in marathon runners. Ann Intern Med ; : –. Suck-Chei C, Kyoung-Hoon Y, Chang-Su C et al. Gastrointestinal endoscopy is helpful in long distance runner with gastrointestinal blood loss and/or anemia. Gastrointest Endosc ; : AB. Moses FM, Baska RS, Peura DA, Deuster PA. Effect of cimetidine on marathon-associated gastrointestinal symptoms and bleeding. Digestive Dis Sci ; : –. Beaumont AC, Teare JP. Subtotal colectomy following marathon running in a female patient. J Royal Soc Med ; : –. Moses FM, Brewer TG, Peura DA. Running-associated proximal hemorrhagic colitis. Ann Intern Med ; : –. Ryan AJ, Chang RT, Gisolfi CV. Gastrointestinal permeability following aspirin intake and prolonged running. Med Sci Sports Exerc ; : –. Lauder TD, Moses FM. Recurrent abdominal pain from abdominal adhesions in an endurance triathlete. Med Sci Sports Exerc ; : –. McMahon JM, Underwood ES, Kirby WE. Colonic spasm and pseudo-obstruction in an elongated colon secondary to physical exertion: diagnosis by barium enema. Am J Gastroenterol ; : –. Kam LW, Pease WE, Thompson PD. Exercise-associated mesenteric infarction. Am J Gastroenterol ; : –. Kraus BB, Sinclair JW, Castell DO. Gastroesophageal reflux in runners. Characteristics and Treatment. Ann Intern Med ; : –. Soffer EE, Merchant RK, Duethman G, Launspach J, Gisolfi C, Adrian TE. Effect of graded exercise on esophageal motility and gastroesophageal reflux in trained athletes. Digestive Dis Sci ; : –. Murray R. The effect of consuming carbohydrateelectrolyte beverages on gastric emptying and fluid absorption during and following exercise. Sports Med ; : –. Noakes TD, Rehrer NJ, Maughan RJ. The importance of volume in regulating gastric emptying. Med Sci Sports Exerc ; : –. Fordtran JS, Saltin B. Gastric emptying and intestinal absorption during prolonged severe exercise. J Appl Physiol ; : –. Neufer PD, Young AJ, Sawka MN. Gastric emptying during walking and running: effects of varied exercise intensity. Eur J Appl Physiol ; : –. Marzio L, Formica P, Fabiani F, LaPenna D, Vecchiett L, Cuccurullo F. Influence of physical activity on gastric emptying of liquids in normal subjects. Am J Gastroenterol ; : –. Cammack J, Read NW, Cann PA, Greenwood D, Holgate
Gastrointestinal Considerations
AM. Effect of prolonged exercise on the passage of a solid meal through the stomach and small intestine. Gut ; : –. Moore JG, Datz FL, Christian PE. Exercise increases solid meal gastric emptying rates in men. Digestive Dis Sci ; : –. Rehrer NJ, Beckers EG, Brouns F, Ten Hoor F, Saris WHM. Effects of dehydration on gastric emptying and gastrointestinal distress while running. Med Sci Sports Exerc ; : –. Peters HPF, Bos M, Seebregts L, Akkermans LMA, Van Berge Henegouwen GP, Bol E, Mosterd WL, de Vries WR. Gastrointestinal symptoms in long-distance runners, cyclists, and triathletes: prevalence, medication, and etiology. Am J Gastroenterol ; : –. Sullivan SN, Wong C. Runner’s diarrhea: different patterns and associated factors. J Clin Gastroenterol ; : –. Bingham SA, Cummings JH. Effect of exercise and physical fitness on large intestinal function. Gastroenterology ; : –. Lampe JW, Slavin JL, Apple FS. Iron status of active women and the effect of running a marathon on bowel function and gastrointestinal blood loss. Int J Sports Med ; : –.
Oettle GJ. Effect of moderate exercise on bowel habit. Gut ; : –. Rao SS, Beaty J, Chamberlain M, Lambert PG, Gisolfi C. Effects of acute graded exercise on human colonic motility. Am J Physiol ; ( Pt ): G–. Sesboue B, Arhan P, Devroede G et al. Colonic transit in soccer players. J Clin Gastroenterol ; : –. Meshkinpour H, Selod S, Movahedi H, Nami N, James N, Wilson A. Effects of regular exercise in management of chronic idiopathic constipation. Digestive Dis Sci ; : –. Robertson G, Meshkinpour H, Vandenberg K, James N, Cohen A, Wilson A. Effects of exercise on total and segmental colon transit. J Clin Gastroenterol ; : –. Liu F, Kondo T, Toda Y. Brief physical inactivity prolongs colonic transit time in elderly active men. Int J Sports Med ; : –. Bartram HP, Wynder EL. Physical activity and colon cancer risk? Physiological considerations. Am J Gastroenterol ; : –. Giovannucci E, Ascherio A, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Physical activity, obesity, and risk for colon cancer. Ann Intern Med ; : –.
Part 5 Imaging in Sports Medicine
Chapter 5.1 Imaging of Sports Injuries INGE-LIS KA NS TRUP, HOLL I S G. POTTE R & WAYNE GIBB ON
Classical reference Glashow JL, Katz R, Schneider M, Scott WN. Double-blind assessment of the value of magnetic resonance imaging in the diagnosis of anterior cruciate and meniscal lesions. J Bone Joint Surg (Am) ; ():–. A prospective double-blind study was undertaken to evaluate the usefulness of magnetic resonance imaging (MRI) in the accurate interpretation of pathologic intra-articular changes in the knee. Forty-seven patients who were scheduled to have arthroscopy and three patients who were to have arthrotomy volunteered for magnetic resonance imaging preoperatively. The radiologists had no clinical or roentgenographic information about the patients before the evaluation of the magnetic resonance images, and the radiologists’ interpretations were unknown to the surgeon before the arthroscopy or arthrotomy was done. Our impor-
tant observations were limited to the findings in the menisci and in the anterior cruciate ligament. Magnetic resonance imaging had a positive predictive value of %, a negative predictive value of %, a sensitivity of % and a specificity of % for pathologic findings in the menisci. For complete tears of the anterior cruciate ligament, the positive predictive value was %, the negative predictive value %, the sensitivity % and the specificity %. We believe that magnetic resonance imaging, when combined with clinical and roentgenographic examination, provides the most accurate non-invasive source of information that is currently available for pathologic findings in the menisci and in the anterior cruciate ligament. The authors further noted that since the interpretation of the MR images were done in a ‘blinded’ fashion the results will likely improve considerably when combined with clinical history (Table ..).
Table .. Correlation of the findings of the magnetic resonance imaging with the surgical findings. (From Glashow et al. Table II.) Surgical findings (no.)
Correctly interpreted in MRI (no.)
False positive (no.)
Medial meniscus Normal Torn
28 22
20 17
8
Lateral meniscus Normal Torn
36 14
34 13
2
Anterior cruciate ligament Normal 27 Torn 23
22 14
5
False negative (no.)
Positive predictive value (%)
68 5 87 1 74 9
Chapter . Introduction Diagnostic imaging plays a great role in practical sports medicine today, as discrimination between related injuries may influence the decision about treatment and clarify the prognosis. Also, an exact staging is of importance in classification and evaluation of various treatments. The clinician is offered different modalities for imaging, and when choosing between these not only must the question of which method is optimal be taken into account, but also accessibility, prices, waiting time, irradiation or other patient drawbacks must be considered. Furthermore, it is a great advantage if the clinician is familiar with the diagnostics in choice, as well as the imaging specialist. A good result is based on a dialogue between the clinician and the imaging specialist. A relevant patient history is a must, even on admissions to plain X-rays, so the imaging specialist can adjust the investigation to optimize it for the injury in question. It also optimizes the conditions for a relevant answer from the imaging specialist. In addition, subsequent feedback to the imaging specialists about the final result of the diagnostic procedure or the consequences of the investigation is important in order to improve the learning experience for the future. It is essential to remember that all imaging modalities have their pitfalls. All investigations are able to produce many irrelevant findings as their sensitivity and specificity are almost never .. Therefore lots of irrelevant diagnoses can be made if there is not a dialogue between the clinician and the imaging specialist, and these will confuse, delay and increase the cost of the treatment.
Questions the clinician should ask when considering imaging: • What is the problem to be solved? • Is quantification/classification needed? • Will the imaging result influence treatment?
A rough survey of the indications for using the various methods is given in Table ...
New possibilities/techniques in the future — perspectives When it comes to future possibilities, ‘hot’ research areas need to be considered. While currently MR images anatomic disorders, in the future tools will also be developed for functional diagnostics of various conditions, perhaps even metabolic activity in selected tissues. As the number of MR scanners increases rapidly, access to this investigation will be facilitated and the costs reduced. This will increase the implementation dramatically. Dynamic imaging with ultrasound (US) will expand — perhaps with small portable sound-heads for transmission of signals on line. Three-dimensional imaging with US is already possible, and this technique will be transferred to allow for dynamic movement analysis. Scintigraphically, a new era has begun with the possibilities for quantitative flow and metabolism measurements with various positron-labeled markers (PET technique). The first results of muscle metabolism and selective muscle involvement in selected sports have been reported by use of the glucose-analog 18F-fluorodeoxyglucose [].
Conventional radiography
Conventional radiography • Bone fractures • Eliminates bone fractures • Each film involves irradiation, but generally low dose • Static images • Cheap.
Conventional radiography is without doubt the most cost-effective and simple way of diagnosing acute fractures. It is also the most specific investigation. It is not, however, the most sensitive so that if a fracture is still clinically suspected in the presence of an apparently normal radiograph further investigation should be
Imaging of Sports Injuries
Table .. Survey of indications for diagnostic imaging. Ordinary X-ray
CT scan
MR scan
Ultrasound
Scintigraphy
Price
x
xx
xxxx
x
x
Waiting time
Low
Moderate
High
Low–moderate
Low–moderate
+++ ++ + +
+++ + (+)
Bones Ordinary fractures Comminuted or complex fractures Osteochondral fractures Stress fractures Shin splints Vascularization Joints Arthritis Meniscus Collateral ligaments Cruciate ligaments Cartilage injury Osteochondritis Coalitio Menisceal cyst Ganglions Baker’s cyst Inflammation Labral injuries Hill-Sachs lesions Muscle/tendon Sprain — acute Sprain— chronic Bursitis— acute Bursitis— chronic Tendon ruptures Enthesopathies Myotendinitis Myositis ossificans
++
+
++ ++
++ ++
++
+
considered. The X-ray beam needs to be tangential to an abnormality for it to be visible. Conventionally only two radiographic views tend to be performed: usually a lateral and frontal projection (using an X-ray beam passing either from the front to the back of the patient, i.e. anteroposterior — AP, or from the back to the front, i.e. posteroanterior — PA). Using such orthogonal projections will normally demonstrate most fractures. If the bony anatomy is complex, as occurs in the spine and joints, then fractures may be obscured by overlying bone. Similarly if the structure is cylindrical, as is the
If problems
+ + + (special)
+++ +++ ++ ?
++ +++ +++ +++
+++ +++ +++ +++ ++ +++ +++ ++ ++ ++ + + (?) ++
+ ++ +
++ +
++ +++ +++ +++ ++ ++
++ ++ +
++ + +++ ++ +++ ? + +
+++ +++ +++ +++ +++ ? +++ +++
++ +++
case with many bones, small structures such as avulsed bone fragments may be missed as the beam may not be tangential to it if only two projections are used. In such circ*mstances additional oblique projections may be helpful or alternatively a tomographic technique may be successfully used, e.g. conventional linear tomography, computed tomography (CT), MRI or ultrasound imaging. Conventional radiographs are also poor at demonstrating marrow pathology as they rely on alteration to cortices or a large area of spongiosa in order for the
Chapter . abnormality to be conspicuous. This inability to demonstrate bone marrow or periosteal edema means that radiographs are only able to demonstrate stress fractures or osteochondritis at a relatively late stage, i.e. when there is cortical breakdown or subchondral bone fragmentation or if sufficient time has occurred for an osteoblastic repair response to have taken place. Accordingly correctly tailored MR imaging is more appropriate for demonstrating these conditions early in their evolution. Joint radiographs are able to demonstrate degenerative arthrosis but again usually only at a late stage in its evolution. The classical radiographic diagnostic signs are loss of joint space, subchondral cyst formation, marginal osteophytosis and subchondral sclerosis. All of these features when present usually reflect disease of reasonably long duration. In cases of tarsal coalition specific oblique radiographic projections will often confirm the presence of bony (but not fibrous) bars. In many cases, however, CT or occasionally MR imaging is required for a definitive diagnosis. Conventional radiographs are good at demonstrating established myositis ossificans but of limited use early in its evolution. The fact that US demonstrates the condition at an earlier phase may be helpful in terms of treatment. If myositis ossificans is present on US then a radiograph should be obtained. If the radiograph is positive then it confirms the diagnosis. If it is negative then the calcification is early and presumably more susceptible to benefit from therapies aimed at halting its progress.
Computed tomography (CT)
Computed tomography • X-rays with higher radiation than conventional radiography • Tomography and three-dimensional reconstruction possible • Comminuted or complex fractures visualized • Less relevant in sports medicine.
Although contrast resolution is greater in computed tomography than conventional radiographs the spatial resolution is significantly less. The contrast resolution is higher as the provision of a nominal (Hounsfield) scale for radiographic densities produces a broader spectrum of densities even though in real terms it is still only fat, soft tissue, bone, air and metallic densities that are seen. The spatial resolution is lower due to the larger size of the pixels of CT scans, those of conventional radiographs being much smaller, i.e. reflecting the size of the silver crystals forming the film. Acquisition of a volume data set using a spiral scanner allows multiplanar reconstruction although even with modern reconstruction algorithms a much greater resolution occurs in the plane of acquisition. There are only a few specific indications for CT imaging of sports injuries. Comminuted or complex fractures of the calcaneus, tibial plateau or proximal humerus whether due to athletic injury or not may require CT imaging to assess whether surgery is required and, if so, to plan the surgical technique. It may also be used to demonstrate significant but small fractures, e.g. bony Bankart-type glenoid fractures. Ostochondral fractures can be demonstrated on CT imaging in order to assess their presence and chronicity, e.g. talar dome osteochondral fractures, although MR imaging is probably preferable in most circ*mstances. Fractures are usually only seen on CT images where they are perpendicular rather than parallel to the acquisition plane. Stress fractures in long bones are usually transverse to the bone’s axis and as such not well demonstrated. The exception is the relatively rare longitudinal stress fracture. Stress fractures to non-long bones, on the other hand, are often well demonstrated by CT. Tarsal bone fractures, for instance, run in a sagittal plane and are well demonstrated in the transverse axial plane. Similarly, stress fractures through the pars interarticularis of vertebrae are very well seen on transverse axial images, especially if the images are acquired using a ‘reversed-angle’ plane, i.e. not parallel to the disk but in a plane ° coronal to the disk. CT may be used to assess areas of osteochondritis, particularly to see if there is a ‘free’ fragment which may require removal. It is extremely good at ‘untangling’ complex bone anatomy such as tarsal
Imaging of Sports Injuries fusions. It is also very good at confirming the diagnostic centrifugal nature of myositis ossificans circ*mscripta. CT may also be performed following injection of intra-articular contrast, either positive contrast (iodinated contrast agent), negative contrast (air) or both (double-contrast study). CT arthrography is the best imaging method for demonstrating small intraarticular loose bodies and is good at demonstrating labral injuries, e.g. double-contrast CT arthrography of the glenohumeral joint performed with the patient in the prone-oblique position for demonstrating soft tissue (and bony) Bankart lesions in athletes with recurrent subluxation. Adsorption of contrast onto retropatellar articular cartilage and/or demonstration of surface irregularity on double-contrast CTarthrography of the knee are diagnostic signs in athletes with chondromalacia patella.
Ultrasound Ultrasound • Sound waves, echo sounder • Soft tissue: tendons, muscles, fluid accumulation in joints, bursae • Real-time investigation: functional element • Intervention possible (biopsy, local injections) • Cheap • Difficult, demands high skill • Success dependent on investigator.
Fig. .. Anisotropy — beam obliquity artifact. (a) Perpendicular beam; (b) oblique beam; (c) curved array.
(a)
Introduction The last two decades have seen spectacular developments in ultrasound equipment technology which has now resulted in production of ultrasound systems capable of high-resolution imaging of superficial structures, particularly superficial tendons. Initially problems arose due to the use of sector scanners with a narrow near field of view. Sector scanners also produced areas of artifactually low echogenicity at the extremes of the beam due to beam obliquity artifact (anisotropy, Fig. ..). Both of these problems have been overcome by production of high-quality linear array transducers and recognition of the necessity for the operator to maintain a perpendicular incident beam to the structure being examined. When tendons were originally examined they were thought to be hypoechoic relative to adjacent structures whereas now due to improvements in high-frequency transducer technology tendons are normally echogenic and exhibit an internal fibrillar pattern. The change in perception reflects the ability of a transducer to elicit separate collagen bundle interfaces within the tendon. If normal tendons are examined in vitro at different frequencies (., , and MHz), the tendons will show an internal network of fine parallel and linear fibrillar echoes which become more numerous and thinner as the US frequency is increased. It is possible that our perception of the tendon internal architecture will change again as the spatial resolution continues to improve.
Symmetry of tendinopathy The contralateral limb should always be scanned for comparison, but it cannot be assumed that the asymp-
(b)
(c)
Chapter . tomatic side is normal. In a study of patients with unilateral Achilles tendon rupture all patients had sonographic evidence of degeneration of the ipsilateral tendon remote from the rupture point and % had degenerative changes in the contralateral asymptomatic heel. The contralateral limb, however, may provide information with regard to the underlying disease mechanism, and particularly when changes on the symptomatic side are severe as it may be easier to assess the more subtle sonographic changes on the less severely involved side.
Tendon damage accumulation Tendon is not a static tissue but appears to be constantly remodelling itself by a process of minor injury and repair. Normal asymptomatic tendons in non-athletic individuals will exhibit occasional small hypoechoic foci on sonographic examination which appear to reflect either microdefects or foci of altered collagen architecture. These presumably reflect a natural cycle of minor injury and repair. The sonographic appearances of the asymptomatic Achilles, patellar and plantar aponeurotic tendons of all members of the playing staff at a single professional soccer club were compared with non-athletic controls []. Three soccer players and two control subjects were then excluded from the study due to previous tendon symptoms. Seventy per cent of soccer players demonstrated sonographic evidence of Achilles tendon disease compared to % of age- and sex-matched controls, % of players demonstrated patellar tendon disease compared to % of controls and % of players plantar fasciitis compared to no control subjects. In the patellar tendon in elite volleyball players ultrasound changes were observed in % of the knees of athletes without symptoms. In addition, specific ultrasound findings such as paratenon changes, hypoechoic zones or pathologic tendon thickness proximally did not correlate significantly with the degree or the duration of symptoms []. Patellar tendon sonographic hypoechoic areas can resolve, remain unchanged, or expand in active athletes and are not directly related to symptoms. Therefore these sonographic changes should not in isolation be an indication for surgery [].
Distribution of sonographic tendon changes Achilles tendon With ultrasound two distinct findings are seen, depending on whether the proximal two-thirds or the distal third of the Achilles tendon is involved. In tendons exhibiting proximal/middle-third Achilles tendinosis with subtotal tendon cross-section involvement, over % exhibit changes in the medial segment, and isolated changes in the lateral segment are never seen. The medial distribution suggests that the tendinosis at least in part reflects increased tensile forces over the medial side of the tendon which in turn could reflect underlying hindfoot hyperpronation (see Fig. ..). Also, most tendons exhibit changes in the superficial segment and few in the deep segment. This may partially reflect the fact that the Achilles tendon’s transverse axis is not transverse to the body axis, with the superficial segment being medial relative to the deep segment, which may increase the tensile forces along this superficial part of the tendon (Fig. ..). In patients with mechanical symptoms in the distal Achilles tendon calcaneal insertion region the vast majority have distal Achilles tendon or paratenon changes associated with a retrocalcaneal bursitis, with predomination of changes in the deep portion of the tendon immediately adjacent to the posterior– superior calcaneal tuberosity. This is not surprising, as the retrocalcaneal bursa lies between the distal Achilles tendon and the posterior–superior calcaneal tuberosi-
Neutral
L
Hyperpronation
M
L
Fig. .. Increased tensile forces on the medial side of the Achilles tendon in hyperpronation.
M
Imaging of Sports Injuries
Reduced dorsiflexion
Increased dorsiflexion
Exacerbated by Haglund’s syndrome
Exacerbated by high ‘heel tab’ footwear
Fig. .. Segmental distribution of changes.
ty. Ankle dorsiflexion produces compression of the retrocalcaneal bursa, protecting the distal tendon from direct contact with the calcaneal tuberosity. These compressive forces may be increased in excessive repetitive dorsiflexion, e.g. during running or jumping. In patients with severe retrocalcaneal bursitis there are usually also sonographic changes in the superficial segment of the proximal/middle-third of the tendon, which is not surprising as the posterior calcaneal impingement is likely to increase the tensile forces over the superficial portion of the tendon relative to the forces incident on its deep portion. This may be increased if a high ‘heel-tab’ is present on an athlete’s footwear (Fig. ..). This phenomenon is well recognized by most elite track athletes who remove these ironically named ‘Achilles tendon protectors’ as soon as they purchase a new pair of running shoes!
Patellar tendon The patellar tendon also exhibits characteristic patterns of change. Jumper’s knee. Focal tendon degeneration in the midline deep surface of the patellar tendon at the inferior pole of the patella with relative sparing of the medial, lateral and superficial portions of the proximal tendon. The distribution suggests an impingement phenome-
Rest
?Active flexion
?Active early extension
*
Fig. .. Proximal and distal third patellar tendon changes. *Region of deep pretibial bursa.
non (Fig. ..) sometimes even resulting in a compression fracture or fragmentation of the inferior pole of the patella, i.e. Sinding–Larsen-type injury. Occasionally, changes occur slightly to the medial or lateral side of the midsagittal plane. Proximal tendon distribution is seen in –% of cases. Mid-tendon disease. Focal degeneration of the mid-tendon is usually localized to either the medial or lateral half of the patellar tendon and appears to reflect increased tensile forces to these areas, which may be due to patella maltracking (Fig. ..). This is an uncommon distribution and represents only approximately % of focal patellar tendinosis.
Chapter . Neutral
Medialization
Lateralization
Genuvarum
Genuvalgum
Distal tendon disease. These changes usually occur on the deep tendon surface and are almost inevitably associated with a deep pretibial bursitis. This is akin to the Haglund phenomenon with the tendon being impinged upon by the anterior tibial plateau during forced knee flexion. There are typical sonographic appearances in Osgood–Schlatter disease: distal patellar tendinitis, deep pretibial bursitis and osseocartilaginous fragmentation at the osseotendinous junction. Distal patellar tendon degeneration represents approximately % of focal tendinosis.
Fig. .. Middle third patellar tendon changes.
flow in these paratenon vessels which may be demonstrated extending deep into the tendon substance. In cases of the distal Achilles tendinitis hyperemia may also be demonstrated in the inferior portion of Kager’s fatty triangle surrounding an inflamed retrocalcaneal bursa.
Tenosynovitis
After removal of its central third for anterior cruciate ligament (ACL) reconstruction the ultrasonographic changes in the patellar tendon extend with time to involve the entire donor tendon. It becomes diffusely enlarged, hypoechoic and inhom*ogeneous compared with the presurgical state. The tendon thickening is maximal in the anteroposterior axis and peaks months post surgery [].
Although vincula and synovial sheath vessel flow may not be seen on CDI or power Doppler imaging in normal tendons there may be markedly increased flow in an acute severe tenosynovitis whether due to inflammatory arthropathy or tendon sheath infection. The problem, however, with using CDI to monitor disease activity is the inability to demonstrate flow in nondiseased tendons and subsequently the difficulty in obtaining a baseline by which to assess hyperemia. The advent of inexpensive and reproducible ultrasound contrast agent studies may help to overcome this problem in the near future.
Tendon inflammation
Muscle injury
Repair of tendon injury Color Doppler imaging (CDI) may be helpful in assessing tendon disease activity. Under normal circ*mstances it is not possible sonographically to demonstrate flow in the paratenon vessels of the large tendons, i.e. Achilles and patellar tendons. In a severe tendinitis or acute exacerbation of tendinosis there may be marked hyperemia and dramatically increased
Ultrasound investigation after muscle injury provides information useful for planning rehabilitation. If sonographically no abnormality is demonstrated in an athlete who clinically has an acute muscle tear, then significant muscle injury is unlikely and the athlete should be able to return rapidly to sporting activity. Sonography may reveal a small hematoma dissecting between muscle groups or a small focus of heterogeneous muscle echogenicity occasionally
Imaging of Sports Injuries with associated minor mass effect on adjacent connective tissue interfaces in more significant tears. Partial or complete muscle discontinuity, or an area of muscle architecture disorganization involving a major portion of that muscle cross-section, usually means that the athlete will have to rest from sporting activity for – weeks and occasionally even longer depending on the precise anatomic site. Interestingly, partial tears often produce greater symptoms than full-thickness tears especially where other muscles in the same group are able to maintain muscle power, e.g. rectus femoris tears. Occasionally a large intramuscular hematoma occurs following muscle tear and aspiration may readily be performed under ultrasound. Ultrasound is the most sensitive method of imaging early soft tissue calcification whether in muscle or tendon. In its early stage myositis ossificans appears as an echogenic area within a heterogeneous area of muscle which subsequently produces acoustic shadowing as the calcification/ossification progresses. The calcification usually tends to be peripheral, i.e. centrifugal, but a herring bone pattern may be seen along the line of the injured muscle. In myositis ossificans US will usually demonstrate an echogenic focus at – days compared to – weeks on CT and slightly longer for conventional radiography. Isotope bone scans may demonstrate calcification as early as US but these appearances are non-specific. MR imaging will not usually show the calcification unless it is extremely large and appears as a very aggressive, possibly neoplastic, soft tissue abnormality.
Future A number of technologic developments currently reaching fruition will help to further develop tendon US imaging. Manufacturers are now starting to produce inexpensive high-resolution systems dedicated for musculoskeletal ultrasound. These are being combined with very high frequency (– MHz) linear array transducers with optimized near field for demonstration of very superficial structures such as the peripheral limb juxta-articular tendons. Finally hand-held US systems with the same imaging capabilities as the current top-of-the-range system will further expand the role of ultrasound in the clinical management of patients with tendinopathies.
Magnetic resonance imaging (MRI) Magnetic resonance imaging • Radio waves, magnetism • Soft tissue, bones, cartilage • Joint injuries • Limited capacity • Expensive • Static images
Introduction Due to its multiplanar capabilities, lack of ionizing radiation and superior soft tissue contrast, MR imaging is an important adjunct to conventional diagnostic examinations such as plain radiography, bone scintigraphy and ultrasound in assessing the magnitude and extent of soft tissue injury. Compared to bone scintigraphy, MR imaging has superior spatial resolution in localizing soft tissue injury, yet does not provide a direct measure of bone turnover. As such, these imaging tests are often complementary, rather than mutually exclusive.
Principles of MR imaging MR imaging is founded on the principle that certain nuclear species, such as hydrogen, possess inherent magnetic properties. When placed in a high-strength external magnetic field these nuclei will precess, which is a resonance phenomenon, according to the axis of the external field. In order to obtain diagnostic information from these precessing protons, radiofrequency pulses are sent into the patient, which convert these nuclei to a higher energy state, by ‘flipping’ them from the longitudinal to the transverse plane. Once the disturbing radiofrequency (RF) pulse is turned off, thermal equilibrium is restored and the released electromagnetic energy induces a voltage in a receiver coil that is placed around the body part of interest. Based on the resistance of the imaging coil, this generates a current. This current, when sent through an analog to digital converter, creates digitized data that undergo a mathematical progression known as Fourier transformation, yielding an MR image.
Chapter . Table .. Simplified MR signal characteristics of joints.
Cortical bone Fat (marrow, subcutaneous) Type I collagen (normal ligament, tendon, meniscus, labrum) Fluid (normal joint) Muscle Articular cartilage*
T1-Weighted
T2-Weighted
Low High
Low High
Low
Low
Low Intermediate Intermediate
High Intermediate Slightly lower
* Signal characteristics are pulse-sequence and image-parameter dependent.
absence of additional fat suppression techniques) and yield a phenomenon known as flow-related enhancement, which may be exploited for vascular MR pulse sequences. Fat suppression techniques ‘rescale’ the contrast range, as fat is characteristically conspicuous on most MR pulse sequences. Such sequences are essential in orthopedic imaging to disclose subtle areas of trabecular microfracture or subchondral edema secondary to osteochondral impaction. They also accentuate the high signal from soft tissue fluid collections such as ganglion cysts of the menisci or shoulder labrum.
Imaging of specific injuries By varying the time between successive disturbing RF pulses (repetition time or TR) and the time between the disturbing RF pulses and the time at which echo information is recorded (echo time or TE), pulse sequences of varying soft tissue contrast may be generated. A simplified table of MR signal characteristics is provided in Table ... T1 relaxation time refers to the recovery of the initial magnetization following the disturbing RF pulse, which fat protons achieve quickly, thus yielding bright signal on a T1-weighted sequence. T2 relaxation time refers to the decay process which occurs in the transverse plane. Commonly used MR pulse sequences for orthopedics include spin echo and fast or turbo spin echo, the latter of which yield rapid acquisition of images, often with superior soft tissue contrast. As the latter images are obtained more quickly, superior spatial resolution may be achieved by use of a higher resolution matrix. It should be remembered that all MR images are digitized; therefore, spatial resolution is dependent on the size of the picture element or pixel, which is in turn determined by the field of view, or area of study, divided by the imaging matrix. Maintaining an adequate field of view to cover diagnostic information may be performed with no sacrifice to spatial resolution, when an appropriate imaging matrix is chosen. Gradient echo sequences are also commonly utilized, which provide a coarsened appearance to trabecular bone, as they have little correction for field inhom*ogeneities. Such pulse sequences typically have poor contrast between fat and muscle (in the
Knee MR imaging has been shown to be accurate in depiction of meniscal and ligament tears of the knee [,]. Meniscal tears are classified by an intrameniscal grading system for internal signal [] or by the presence of abnormal meniscal pathology, in which the diagnosis of a radial split, displaced fragment or bucket-handle tear may be seen (Fig. ..). An awareness of normal meniscal vascularity is essential in order to aid in preoperative planning for potential meniscal repair. While a high prevalence of meniscal tears have been noted in asymptomatic patients, particularly those of middle to older age [], this does not invalidate the utility of this same imaging test in a symptomatic patient. In older athletic patients, MR imaging will disclose the degree of cartilage degeneration, and assess for the presence of degenerative meniscal tears, as well as the potential for underlying osteonecrosis. Following meniscectomy, MR imaging is helpful in assessing for re-tears of a remnant [] or an associated degenerative change. Following primary meniscal repair, fluid imbibition into the repair site can be distinguished from the fibrovascular response of the normal intact meniscus, and thus MRI may be efficacious in assessing the degree of meniscal healing or re-tear through the repair site [,]. Pulse sequences which are utilized to assess meniscal healing and evaluate the postoperative meniscus accentuate water, either through the use of frequency-selective fat suppression or by exploiting the inherent magnetization transfer found in fast spin echo sequences. This
Imaging of Sports Injuries does not require prototype software and is available on all high field strength units. Following ligamentous injury, MR is helpful in assessing the degree and location of cruciate ligament tear, as well as associated cartilage or meniscal injury (Fig. ..). Similar accuracies have been reported with mid- and high field strengths with regard to anterior cruciate ligament injuries []. While primary distal avulsion of the tibial eminence may be noted on the plain film, MR is helpful in determining the degree of displacement and may aid in determining whether surgical reduction of the eminence is warranted. It is important to remember that MRI is an anatomic test which assesses the anatomic continuity of ligaments and tendons at the time of imaging. Based on the signal characteristics, MR also reflects the histopathology of the tissue being excited. It is essential for the clinician to correlate those anatomic and histopathologic changes gleaned from the MR examination with their clinical assessment of joint function. For example, a high-grade partial cruciate ligament tear on MR examination of the knee may yield functional complete discontinuity at the time of exam under anesthesia, with a wide-based pivot shift. In addition, a discrete full-thickness tear of the medial collateral ligament of the knee, seen on one tomographic MR image, may not yield overt valgus instability on valgus stressing of the knee. Thus, global assessment of the injured extremity is best performed with a comprehensive physical examination to assess ligament function, as well as anatomic assessment of tissue continuity based on the MR examination. Assessment of the multiple ligament injured knee is crucial, as MR may disclose the degree of posterolateral corner injury with concomitant cruciate tear, the severity of which may warrant a formal posterolateral corner reconstruction or, in some cases, primary repair []. Following ligament reconstruction, MR is helpful in assessing the position of the graft as well as the magnetic characteristics of the graft tissue which are a reflection of the status of the collagen, disclosing areas of either elastic deformation or traumatic disruption []. Stress fractures. Stress fractures are denoted as diminished signal intensity fracture lines surrounded by marrow edema, the latter of which are accentuated using fat suppression techniques. Due to its tomo-
(a)
(b) Fig. .. Bucket-handle tear of the medial meniscus. (a) Sagittal fast spin echo sequence demonstrates foreshortening of the posterior horn of the medial meniscus, with fraying at the anterior edge (arrow). (b) Coronal image confirms the displaced bucket-handle fragment in the medial aspect of the intercondylar notch (arrow).
graphic nature and superior soft tissue contrast, MR imaging is more sensitive than plain film in disclosing stress fracture, and will disclose the continuum of stress-induced injury to bone, particularly that in competitive runners. This includes soft tissue periostitis
Chapter .
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Fig. .. Acute twisting injury to the right knee in a -year-old athlete. (a) Sagittal fast spin echo sequence through the intercondylar notch demonstrates complete disruption of the anterior cruciate ligament (arrows). (b) Sagittal fast spin echo sequence at the lateral aspect of the knee in the same patient demonstrates transchondral fracture to the posterior margin of the lateral tibial plateau with a full thickness cartilage defect (long straight arrow). Note the displaced chondral fragment in the meniscosynovial recess (curved arrow). Also note the additional osteochondral impaction of the lateral femoral condyle (small straight arrow). (c) The subchondral reaction is made more conspicuous using fat-suppression techniques, which ‘rescale’ the contrast range, thus making the edema in the subchondral bone more apparent. (d) Coronal fast spin echo sequence in the same patient discloses a high-grade partial tear of the medial collateral ligament at the femur, involving both deep and superficial components (short straight arrows). Also note the moderately high grade partial tear of the fibular collateral ligament (long straight arrow). The popliteus tendon is intact at the femur (curved arrow).
Imaging of Sports Injuries and endosteal callus as well as the presence of a frank cortical or medullary fracture. Bone scintigraphy is helpful in assessing for stress fracture; however, in older patients the presence of occult fracture may be more readily noted on MR imaging [].
Cartilage imaging One of the most recent developments of MR imaging has been the advent of dedicated cartilage pulse sequences [,]. These have been well validated in both the imaging and orthopedic literature, using either fat-suppressed T1-weighted gradient echo techniques [,] or optimized fast spin echo techniques []. Using appropriate pulse sequences, the degree of transchondral fracture sustained during tibial translation in the presence of ACL insufficiency may be noted, as well as the appearance and status of the articular cartilage over osteochondritic lesions. It is important to remember that the so-called ‘bone bruise’, seen in the setting of an ACL insufficiency, is indeed a transchondral fracture of varying severity. The importance of standardized cartilage pulse sequencing in every MR evaluation of the joint cannot be overstated, as seemingly innocuous bone bruises may in fact herald traumatic delamination of cartilage, yielding focal post-traumatic arthrosis of the knee which may have prognostic significance for the patient’s outcome. Following surgical manipulation of articular cartilage defects with mosaicplasty, autologous cartilage implantation or microfracture, MR imaging provides an objective measure of treatment outcome. Following cartilage transplantation, MR will assess the integrity of the periosteal flap, morphology of the transplant and interface with the native cartilage, as well as providing some tissue characterization of the substance ‘filling the defect’ []. With appropriate pulse sequencing, it is hoped that hyaline cartilage may be distinguished from reparative fibrocartilage [].
Shoulder imaging MR imaging is helpful in assessing the degree of rotator cuff tear, and has been proven accurate in distinguishing partial from full-thickness tears []. In addition to assessing the degree of rotator cuff deficiency, MR may also disclose the degree of osteoarthrosis, which may confound the clinical
assessment of older athletes with cuff weakness []. In the presence of shoulder instability, MR is accurate using either optimized non-contrast techniques or MR arthrography in detecting labral detachment [,]. Following initial dislocation, MR imaging can distinguish labral lesions (Fig. ..) from primary capsular failure, thus aiding in the selection of those patients best suited for prompt arthroscopic debridement []. The diagnosis of isolated capsular tears requires high spatial resolution, in order to depict the glenohumeral ligaments as structures discrete from the adjacent capsule. Superior labral anterior and posterior (SLAP) lesions may also be visualized either using MR arthrography or optimized non-contrast techniques []. In the setting of poorly defined shoulder pain without overt anterior instability, MR can be helpful in distinguishing isolated biceps lesions from superior labral lesions.
Elbow Evaluation of the athlete’s elbow is difficult, particularly in the throwing athlete, as flexor or pronator tendinopathy, medial collateral ligament pathology, and posteromedial cartilage injury may be difficult to distinguish as distinct clinical entities []. Using high spatial resolution and thin slice (.– mm) thickness, MR imaging may disclose subtle lesions of the medial collateral ligament (Fig. ..). Dedicated cartilage pulse sequencing is mandatory in these athletes as significant chondral wear may be seen, particularly of the posteromedial margin of the elbow in the throwing athlete, in the absence of plain radiographic change []. Posteromedial impingement, attributed to valgus extension overload, is denoted radiographically as a prominent posteromedial osteophyte []. Concomitant thickening of the posterior capsule and/or fracture of the osteophyte may be seen, as well as chondral wear over the posterior aspect of the trochlea []. Medial epicondylitis, or degeneration of the origin of the flexor and pronator tendons, is characterized by signal hyperintensity with variable amount of intratendinous disruption at the tendon origin. Similarly, lateral epicondylitis, or tennis elbow, is similarly diagnosed by degeneration and signal hyperintensity of the
Chapter .
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Fig. .. (a) Axial fast spin echo sequence in the right shoulder in a -year-old collegiate athlete who sustained an anterior dislocation while skiing. There is displacement of the anteroinferior labrum (long arrow) in an inferomedial direction, with a partial tear of the anterior band of the inferior glenohumeral ligament (curved arrow). Note that the labrum is tethered medially by the stripped periosteum at the capsular attachment of the capsule (short straight arrow), indicating an anterior labral periosteal sleeve avulsion (ALPSA). (b) Axial fast spin echo sequence at a more cephalad level discloses a split (straight arrow) in the midanterior labrum. Note the frayed appearance of the middle glenohumeral ligament (curved arrow).
Fig. .. (a) Medial elbow pain in a competitive throwing athlete. Coronal MR image discloses a non-acute high-grade tear at the ulnar attachment of the anterior band of the medial collateral ligament (arrow). Note the poor tissue remodeling, with residual signal hyperintensity. (b) Axial fast spin echo sequence in the same patient discloses an osteophyte (curved arrow) off the posteromedial margin of the elbow joint. Note the thinning of cartilage over the posterior margin of the trochlea with subchondral sclerosis (short arrow).
Imaging of Sports Injuries origin of the extensor carpi radialis brevis. The high signal intensity reflects the mucoid degeneration and vascular infiltration, without acute or chronic inflammatory response []. The utility of MR in the setting of elbow tendinosis lies in its ability to detect not only the degree of degeneration, but also the presence of associated partial or full-thickness disruption, the latter of which may warrant primary tendon reattachment. Associated chondral injuries may be noted, thus prompting preliminary MR arthroscopy prior to open tendon debridement. While MR imaging is also efficacious in assessing the degree of biceps rupture, these elbow tendinopathies may also be nicely disclosed by dedicated musculoskeletal ultrasound, where the biceps muscle may be loaded in a provocative measure to detect the degree of retraction. The use of ultrasound will obviate the need for potential surface coil repositioning in the setting of biceps retraction [].
Bone scintigraphy Bone scintigraphy • Injection of radioactive pharmaceutical • Actual bone metabolism • Very sensitive, but not specific • Stress fractures, shin splints, vascularization • Can eliminate or localize skeletal involvement including joint disease • Static images, tomography possible • Semiquantification of local metabolism with uptake ratios.
Bone scintigraphy is an atraumatic, easily applied and relatively inexpensive technique. The method is very sensitive, reflecting the actual bone metabolism, and thus sites of rebuilding, mechanical stress, growth and reorganization are shown. In many cases, it is difficult or impossible to diagnose minor disturbances in bone metabolism by conventional radiography, whereas bone scintigraphy more easily detects these. Scintigraphy is abnormal within h after even minor trauma (a
little longer in the elderly). Therefore it offers the advantage of wide availability and high sensitivity, but its lack of specificity means that it often only points out the areas where further diagnostics/treatment should be concentrated.
Method Bone scintigraphy is performed – h after an intravenous injection of Tc-m diphosphonate, a boneseeking radionuclide, in an amount of – MBq, lower in children. Technetium-m is a g-emitting isotope with a half-life of h. The radiation dose is – mSv, thus about twice the natural background radiation per year and comparable to the dose received by conventional X-ray pictures. In principle, an investigation may be repeated after only – days, but the method is not suited to following a healing process as microstructural remodelling continues to take place long after clinical healing. The uptake of the technetium phosphate complexes into the skeleton is related to the bone blood flow and especially the osteoblast activity. Increased blood flow leads to a certain, but not linearly increased, uptake, but of more importance is that compromised blood flow obstructs the supply of radionuclide, which leads to activity defects. The radionuclide is selectively localized below the laminar osteoid at the hydroxyapatite crystal surface, i.e. the actively bone-forming mineralizing layer. In addition, supplementary binding sites to, for example, immature or altered collagen or deposition in necrotic or otherwise damaged muscular tissue have been reported. A focally increased uptake in bone scintigraphy most often reflects the osteoblastic response of bone to a local insult irrespective of the actual etiology, i.e. a reparative proces, but even in bone destruction with osteoclastic activity attempts at bone repair are involved, leading to ‘hot spots’. Thus, bone scintigraphy is positive (shows focal increased uptake) in many diseases of the skeletal system, such as bone tumors, metastases, fractures including stress fractures, infections, etc. and is in this way unspecific. However, the scintigraphic findings in many of the frequent benign disorders in the skeletal system are typical, which is of interest to the sports physician. Evaluation of the regional vascularity may be
Chapter . valuable in patients with localized problems and may be obtained by a ‘three-phase’ scintigram, where sequential images are obtained for the first s (‘flow phase’), and a ‘blood pool image’ representing the bone extracellular fluid is obtained at min in addition to the -h standard static views. In cases of avascularity (i.e. of the femoral head) no uptake is seen in any of the images. Bone tomography, SPECT (single photon emission computed tomography), may be performed in order to obtain a more precise location in any area of the skeleton, e.g. in the spine where planar imaging is often normal, or to visualize the internal disturbances in a knee joint (Fig. ..).
Stress fractures Suspicion of stress fractures (or fatigue fractures) is one of the main reasons for referral for bone scintigraphy in sports medicine. The most frequent localization for stress fractures has in several investigations been found to be the tibia (Fig. ..), accounting for about % of stress fractures [,]. Other frequent localizations are the tarsometatarsals (Figs .. & ..), fibula and femur, but stress fractures have been described in almost all bones (Figs .. and ..) — except the skull!
The typical finding in bone scintigraphy is an intense fusiform focus (Fig. ..), in the tibia often localized posteromedially. If an anterior margin stress fracture is (rarely) found, a much more serious and prognostic dubious condition exists []. A graduating system to classify the injury extension has been proposed among others by Matin [] as a five-stage graduation, representing a continuous spectrum of injury from normal (minimal periosteal reaction, involving –% of the bone) to stage V which is a full-thickness stress fracture. This differentiation demands scintigraphy in two projections. The less serious stages I and II will not be detected radiographically, while stages IV and V will most often show periosteal or endosteal thickening in X-rays – days after onset of symptoms. Scintigraphically, the minor injuries are normalized in – months, while the major ones are often visible for more than months. The graduation thus gives a prognosis with regard to time for healing and guidance for loading. A special problem is stress fractures in the femoral neck because of a potential risk for development of head necrosis. Spontaneous fractures here have been described in female athletes with long-lasting amenorrhea implying that bone scintigraphy should be performed with only a weak indication in athletes with
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Fig. .. Two-headed gamma camera (a) for (b) whole-body scintigraphy, (c) single acquisitions or (d) tomography (SPECT).
Imaging of Sports Injuries
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Fig. .. Stress fracture in the fifth metatarsal, arising during a -m run in a -year-old female elite runner.
nostic tool applied for fractures, it may help in the evaluation of certain cases. It has been shown to be especially valuable in the investigation of wrist pain to exclude scaphoid (‘navicular’) fractures (Fig. ..) or to identify fractures in other carpal bones [].
Tibial stress syndrome (‘shin splints’) (b) Fig. .. Stress fracture posteromedially in the right tibia in a -year-old male soccer player.
pain in the pelvis, groin, femur and knee []. The bone scintigraphy shows activity accumulation at the location of the stress fracture, but concomitantly a defect in the femoral caput if the blood perfusion is interrupted (Fig. ..). Repeated stress fractures or stress fractures in female athletes with secondary amenorrhea and disordered eating may warrant an investigation of the general bone mineral content (Fig. ..).
Other fractures Although bone scintigraphy is not the primary diag-
Scintigraphically, the condition presents as an elongated region of moderately increased activity in the periosteum, usually of the mid- or lower tibia, related to the insertion of the tibialis posterior or soleus (Fig. ..). We have found a similar condition in the ulna (‘ulnar splint’) in a kayak rower, performing intensive strength training of the wrists. The condition may be differentiated scintigraphically from stress fractures or chronic compartment syndrome, other frequent causes of lower extremity pain, and is thought to result from increased stress from the muscles or connective tissues on the superficial portion of the bone cortex, leading to increased bone metabolism. Increased perfusion in the lesion is rare in contrast to stress fractures; thus a ‘three-phase bone scan’ may help to discriminate between the two conditions.
Chapter .
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Fig. .. Stress fracture of the left os naviculare pedis in a -year-old male elite runner. This is one of the few stress fractures that may demand total immobilization because of the risk of later necrosis.
medial (a)
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changes appear earlier and are more sensitive than Xrays. Focal abnormal uptake is seen in the lateral epicondyle in cases of lateral epicondylitis (‘tennis elbow’), and around the medial tuberosity of the calcaneus in the case of plantar fasciitis. Also, in Achilles tendinitis an increased uptake at the upper insertion of calcaneus as well as in the tendon may be found (Fig. ..). In athletes with groin pain, increased activity in the symphysis pubis, often with focal ‘hot spots’, is connected with inflammation of the symphysis, osteitis pubis (Fig. ..) [].
Joint injuries
Fig. .. Stress fracture in the ribs in a -year-old elite rower, following change of equipment to a new sweep-oar [].
Other enthesopathies The term ‘enthesopathy’ refers to calcification and bone formation due to aseptic inflammation at the site of tendon and ligament attachment. Scintigraphic
Bone scintigraphy may in many cases assist in the diagnostic evaluation of especially longer-lasting jointrelated pain/problems. Being very unspecific, scintigraphy cannot discriminate between joint injury due to inflammatory or degenerative joint diseases. However, the investigation is so sensitive that it is well suited to determining whether a joint is affected or not []. In a prospective study of younger patients referred for arthroscopy with a suspected meniscus tear, an accuracy of . was found for the bone scintigraphy in discriminating between potentially surgerydemanding lesions and minor injuries/healthy knees where arthroscopy and surgery could be avoided []. Thus, the investigation may be useful as a tool to ex-
Imaging of Sports Injuries
Fig. .. Radial stress fracture in a -year-old female from knitting.
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Right elbow (b)
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Fig. .. Avascularity in the right caput femoris (arrow) after a collum femoris fracture illustrated in a -year-old female. (The big circular defect in the middle represents a lead shield covering the bladder.)
clude invasive diagnostics, but is not very valuable for obtaining a specific diagnosis in injured or degenerated joints (Fig. ..). Tomography may, however, improve this []. Bone scanning has been used in the follow-up after ligament reconstruction as an indicator of the mechanical stability of the joint []. In the shoulder, scintigraphy has been shown to be of no value in the detection of lesions caused by
anterior shoulder dislocation apart from acute Hill– Sachs lesions []. Thus, labral injuries were not detected. In very rare cases bone scintigrams have revealed severely decreased perfusion to joint-related parts of the long bones in the lower extremity as an explanation of long-lasting pain (Fig. ..) []. This points to the ability of the investigation to demonstrate viability (perfusion), an ability which is also utilized in the diagnosis of Calvé–Legg–Perthe’s disease (Fig. ..) and avascular necrosis of the femoral head (Fig. ..). Although the latter investigation is mainly of interest in older patients, the possibility should be taken into account when dealing with young subjects with hip pains. In the case of osteochondritis dissecans, focal hyperemia and intense radionuclide accumulation is seen in the site of the subchondral lesion (Fig. ..), with no uptake in avascular bone fragments.
Back pain Back pain is extremely common, even in athletes. Repetitive, vigorous exercise such as gymnastics or high dives induces considerable spinal torques and stress over the pars interarticularis which may develop into microfractures and subsequently a bone defect. This defect (spondylolysis) may persist and, being painful, limit activity. With SPECT spatial separation of overlapping bony structures is possible improving the diagnostics of the anatomic localization of abnormal findings []. With radiographic evidence of spondylolysis a
Chapter . Right wrist
Radial
Ulnar
Fig. .. Fracture of the scaphoid (‘navicular’) in the right wrist in a -year-old male (‘pin-hole’ acquisition).
Mb. Bechterew (sacroiliitis). However, other conditions such as rheumatoid arthritis, arthrosis and training overload may also lead to increased ratios.
(a) L2–L4 Comparison to Reference 1.44
Muscle uptake Mean
BMD (g/cm2)
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0.96
0.72 20 (b)
40
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Fig. .. Pelvic stress fractures in a -year-old female with long-lasting secondary amenorrhea and markedly reduced bone mineral content, shown here in the lumbar spine.
scintigraphically active pars interarticularis defect is associated with a healing process which may be causing pain (Fig. ..), while a normal bone scan in the presence of a radiographically demonstrable pars defect is consistent with an old, healed process, not likely to explain the low back pain []. A semiquantification of the activity accumulation in the sacroiliac joints compared to the os sacrum by an ‘activity profile’ has been applied in the diagnostics of
A muscular focus may represent rhabdomyolysis, following unusual or excessive exertion leading to muscle injury. But abnormal muscle uptake is most frequently the result of heterotopic bone formation as in myositis ossificans. After a muscle lesion the initial inflammatory response probably leads to transformation of primitive mesenchymal-derived cells into boneforming cells with subsequent ossification within the muscle (Fig. ..).
Bone tumors Bone tumors, primary as well as metastases, will present in bone scintigrams as regions with focally increased uptake, often disseminated as in the case of prostate and breast cancer. However, single tumors may be difficult to discern from benign skeletal lesions and may demand further evaluation. Malignant tumors often appear irregular and ‘invasive’ centrally in the bone (Fig. ..), while benign lesions often involve the superficial bone tissues, and anamnestically are associated with overloading of the skeleton. Benign bone tumors (osteoid osteoma) are more well defined (Fig. ..). Scintigraphic suspicion of a bone tumor must always elicit a further diagnostic evaluation.
Imaging of Sports Injuries
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Fig. .. Bilateral tibial ‘shin splints’ in a -year-old male runner.
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Fig. .. Focal uptake on the upper part of the calcaneus and the adjacent Achilles tendon in a -year-old male runner, referred for uncharacteristic heel pains. Fig. .. Asymmetric especially left-sided increased pubic activity in a -year-old male football player with predominantly left-sided groin pains.
Summary A number of modalities are available for diagnostic procedures in sports medicine and traumatology. Conventional radiography is widely available and cheap. It is the first choice for fractures and is useful for demonstrating degenerative joint disease and calcifications. Computed tomography is useful for mapping comminuted fractures. Ultrasound is a dynamic, real-time investigation with a high sensitivity for soft tissue pathologies, especially in tendons, muscles, bursae and joints. Biopsy
and injection are possible under ultrasonographic guidance. It is cheap but demanding. With appropriate pulse sequencing, MR imaging is efficacious in detecting the extent and location of most soft tissue injuries. Subchondral damage can be visualized (bone bruise), and dedicated cartilage pulse sequencing can demonstrate chondral injury. It is an important adjunct to bone scintigraphy, plain radiographs and, in some cases, musculoskeletal ultrasound.
Chapter . Left medial R
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(b) Fig. .. (a) Focally increased uptake in the left medial tibial joint surface in a -year-old male with a bucket-handle medial meniscus tear (the focus marks the mechanical disorder and is not an uptake in the torn meniscus). Normal right knee scintigraphy. (b) Markedly increased irregular activity in the left knee, where arthroscopy showed ACL rupture and synovitis.
Fig. .. Bilateral ischemia of the knee region in a -yearold male with knee pain of months’ duration. A core biopsy from the left distal femoral condyle verified avascular necrosis. Spontaneous recovery occurred after months, and normalized bone scintigrams were obtained months later [].
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Fig. .. Avascularity in the left caput femoris in an -year-old boy with Calvé–Legg–Perthe’s diseaase. In the right hip a normal growth-zone is seen (‘pin-hole’ acquisitions). (a)
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Fig. .. Osteochondral lesion in the medial femoral condyle in the left knee in a -year-old male.
Imaging of Sports Injuries
Bone scintigraphy is a cheap and very sensitive method for the evaluation of disorders in bone metabolism. A negative bone scintigram can exclude pathologic conditions. Stress fractures can be graded, allowing for prognostic interpretation. With back pain and radiographically demonstrated spondylolysis, tomography of bone scintigrams (SPECT) can distinguish between an active process, which may cause pain, and an inactive, healed process not likely to give back pain.
Multiple choice questions
Fig. .. SPECT of the lumbar vertebrae in a -year-old male soccer player, showing a focus in the right processus spinosus in L.
One or several answers are correct. Stress fractures in athletes: a are best demonstrated with computed tomography b are most commonly seen in the tibia but have been described in nearly all bones c will show as diffuse activity of all of the posteriomedial border of the tibia in scintigrams d of the femoral neck should be suspected and further investigated on a loose indication because of the risk for necrosis of the femoral head e may only show on scintigraphy. A traumatic cartilage injury: a examined weeks after injury will show as a narrowing of the joint space on X-rays b can be demonstrated on standard T1- and T2weighted MR sequences c is not associated with bone bruise d will show as subchondral activity on scintigrams e repaired with a periosteal flap can be followed on MRI which can demonstrate filling of the defect with hyaline cartilage. On MRI: a meniscal lesions can be identified with high specificity and can be graded –, but only grade meniscal changes can be identified as tears by arthroscopy b a healed meniscus lesion will not show c multiple ligament injuries can be verified, enabling better planning of the acute treatment d a ligamentous tear will always represent a clinical instability e there are typical findings in the tennis elbow. Ultrasound: a is a very sensitive method for detecting tendinitis and tendinosis b verified changes in Achilles and patella tendons are
Chapter .
Fig. .. Myositis ossificans in the right quadriceps in a -year-old male handball player after a blunt trauma.
R
L
Fig. .. Malignant tumor in upper left tibia. Note the irregular appearance and central location.
Fig. .. Osteoid osteoma in the right fibula in a -year-old male.
Imaging of Sports Injuries closely associated to symptoms and should be an indication for surgical intervention c is the most sensitive method for detecting calcifications in muscles and tendons d can clearly distinguish between insertional Achilles tendinitis and tendinitis of the free tendon – cm above the insertion e is cheap but examiner dependent. Regarding shoulder disorders: a X-rays can be used to distinguish between a traumatic (Bankart) and non-traumatic (multidirectional) instability of the shoulder. b SLAP lesions and other labral lesions can nearly always be demonstrated on standard MRI. c Clinically suspected partial or total rotator cuff tears are best verified with standard CT. d Ultrasonography is the investigation of choice in rotator cuff tendinitis. e Arthrography is never used in shoulder diagnostics.
References Pappas GP, Olcott EU, Orace JE. Imaging of skeletal muscle function using FDG PET: force production, activation, and metabolism. J Appl Physiol ; : –. Gibbon WW, Long G. US prevalence of lower limb tendon degeneration in professional soccer players. Presented at: rd Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago IL, USA, . Lian O, Holen KJ, Engebretsen L, Bahr R. Relationship between symptoms of jumper’s knee and the ultrasound characteristics of the patellar tendon among high level male volleyball players. Scand J Med Sci Sports ; : –. Khan KM, Cook JL, Kiss ZS et al. Patellar tendon ultrasonography and jumper’s knee in female basketball players: a longitudinal study. Clin J Sport Med ; : –. Wiley JP, Bray RC, Wiseman DA et al. Serial ultrasonographic imaging evaluation of the patellar tendon after harvesting its central one third for anterior cruciate ligament reconstruction. J Ultrasound Med ; : –. Crues JV, Mink J, Levy TL, Lotysch M, Stoller DW. Meniscal tears of the knee: accuracy of MR imaging. Radiology ; : –. Lee JK, Yao L, Phelps CT, Wirth CR, Czajka J, Lozman J. Anterior cruciate ligament tears: MR imaging compared with arthroscopy and clinical tests. Radiology ; : –. Loytsch M, Mink J, Crues JV, Schwartz A. Magnetic resonance in the detection of meniscal injuries (abstract). Magn Reson Imag ; : . Kornick J, Trefelner E, McCarthy S, Lange R, Lynch K,
Jokl P. Meniscal abnormalities in the asymptomatic population at MR imaging. Radiology ; : –. Smith DK, Totty WG. The knee after partial meniscectomy: MR imaging features. Radiology ; : –. vanTrommel MF, Potter HG, Ernberg LA, Simonian PT, Wickiewicz TL. The use of noncontrast magnetic resonance imaging in evaluation of meniscal repair: comparison with conventional arthrography. Arthroscopy ; : –. vanTrommel MF, Simonian PT, Potter HG, Wickiewicz TL. Different regional healing rates with the outside-in technique for meniscal repair. Am J Sports Med ; : –. Vellet AD, Lee DH, Munk PL et al. Anterior cruciate ligament tear: prospective evaluation of diagnostic accuracy of middle- and high-field strength MR imaging at . and . T. Radiology ; : –. Potter HG. Imaging of the multiple ligament injured knee. In: Johnson DL, ed. Clinics in Sports Medicine. Philadelphia: W.B. Saunders, in press. Schatz JA, Potter HG, Rodeo SA, Hannafin JA, Wickiewicz TL. MR imaging of anterior cruciate ligament reconstruction. Am J Roentgenol ; : –. Rizzo PF, Gould ES, Lyden JP, Asnis SE. Diagnosis of occult fractures about the hip. J Bone Joint Surg ; -A: –. Disler DG, McCauley TR, Kelman CG et al. Fatsuppressed three-dimensional spoiled gradient-echo MR imaging of hyaline cartilage defects in the knee: Comparison with standard MR imaging and arthroscopy. Am J Roentgenol ; : –. Potter HG, Linklater JM, Allen AA, Hannafin JA, Haas SB. Magnetic resonance imaging of articular cartilage in the knee. J Bone Joint Surg (Am) ; -A: –. Recht MP, Piraino DW, Paletta GA, Schils JP, Belhobek GH. Accuracy of fat-suppressed three-dimensional spoiled gradient-echo FLASH MR imaging in the detection of patellofemoral articular cartilage abnormalities. Radiology ; : –. Potter HG. Imaging. In: Rosenberg AG, Mabrey JD, Woolson ST, Cole BJ, eds. The Articular Knee (CD-ROM). American Academy of Orthopaedic Surgeons: Rosemont, IL, . Bashir A, Gray ML, Hartke J, Burstein D. Nondestructive imaging of human cartilage glycosaminoglycan concentration by MRI. Magn Reson Med ; : –. Iannotti JP, Zlatkin MB, Esterhai JL et al. Magnetic resonance imaging of the shoulder. J Bone Joint Surg (Am) ; -A: –. Potter HG. Magnetic resonance imaging of the unstable shoulder. Techniques Shoulder Elbow Surg ; : – . Gusmer PB, Potter HG, Schatz JA et al. Labral injuries: accuracy of detection with unenhanced MR imaging of the shoulder. Radiology ; : –. Palmer WE, Caslowitz PL. Anterior shoulder instability.
Chapter .
Diagnostic criteria determined from prospective analysis of MR arthrograms. Radiology ; : –. Connell DA, Potter HG, Wickiewicz TL, Altchek DW, Warren RF. Noncontrast magnetic resonance imaging of superior labral lesions. cases confirmed at arthroscopic surgery. Am J Sports Med ; : –. Gaary EA, Potter HG, Altchek DW. Medial elbow pain in the throwing athlete: MR imaging evaluation. Am J Roentgenol ; : –. Potter HG, Sofka CM. Imaging of the athlete’s elbow. In: Altchek DW, Andrews J, eds. The Athlete’s Elbow. Philadelphia: Lippincott-Raven, : –. Wilson FD, Andrews JR, Blackburn TA, McCluskey G. Valgus extension overload in the pitching elbow. Am J Sports Med ; : –. Potter HG, Hannafin JA, Morwessel RM, DeCarlo EF, O’Brien SJ, Altchek DW. Lateral epicondylitis: correlation of MR imaging, surgical, and histopathologic findings. Radiology ; : –. Hulkko A, Orava S. Stress fractures in athletes. Int J Sports Med ; : –. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Stress fractures in athletes. Am J Sports Med ; : –. Christiansen E, Kanstrup I-L. Increased risk of stress fractures of the ribs in elite rowers. Scand J Med Sci Sports ; : –. Johansson C, Ekenmann I, Lewander R. Stress fractures of the tibia in athletes: diagnosis and natural course. Scand J Med Sci Sports ; : –. Matin P. Basic principles of nuclear medicine techniques for
detection and evaluation of trauma and sports medicine injuries. Semin Nucl Med ; : –. Clement DB, Ammann W, Taunton JE et al. Exerciseinduced stress injuries to the femur. Int J Sports Med ; : –. Patel N, Collier BD, Carrera GF et al. High-resolution bone scintigraphy of the adult wrist. Clin Nucl Med ; : –. Hölmich P, Uhrskou P, Ulnits L et al. Effectiveness of active physical training as treatment for longstanding adductorrelated groin pain in athletes: randomised trial. Lancet ; : –. Lohmann M, Kanstrup I-L, Gergvary I, Tollund C. Bone scintigraphy in patients suspected of having meniscus tears. Scand J Med Sci Sports ; : –. Murray IPC, Dixon J, Kohan L. SPECT for acute knee pain. Clin Nucl Med ; : –. Dye S, Chew MH. Restoration of osseous homeostasis after anterior cruciate ligament reconstruction. Am J Sports Med ; : –. Schydlowsky P. The value of non-invasive methods in the diagnosis of lesions caused by anterior shoulder dislocation. With special emphasis on labral lesions. PhD thesis, University of Copenhagen, . Zerahn B, Kanstrup I-L, Lausten GS. Transient ischemia of the distal femur and proximal tibia in a -year-old male. Clin Nucl Med ; : . Bellah RD, Summerrilee DA, Treves ST, Micheli LJ. Low back pain in adolescent athletes: detection of stress injury to the pars interarticularis with SPECT. Radiology ; : –.
Part 6 Sports Injury: Regional Considerations. Diagnosis and Treatment
Chapter 6.1 Lower Leg,Ankle and Foot JON KARLSS ON, CHRI STE R ROLF & SAJKARI ORAVA
Classical reference Freeman MAR. Treatment of ruptures of the lateral ligament of the ankle. J Bone Joint Surg (Brit) ; -B: –. Functional instability is the subjective symptom of repeated giving way noted by the patient. Functional instability is the most common and serious residual disability after ligament injuries of the ankle joint. The term functional instability was described by Freeman in . He found a high incidence of functional instability after rupture of the lateral ankle joint ligaments. He stated that increased mechanical laxity was not a primary decisive factor in ankle joint function. Subsequently it has been shown that functional instability is the most important subjective symptom and can be caused by a combination of mechanical laxity, proprioceptive deficit and peroneal muscle weakness.
Soft tissue overuse injuries of the lower leg in athletes Introduction Lower leg (Fig. ..) pain in athletes has several different etiologic factors. Clinical conditions causing lower leg symptoms include chronic compartment syndrome, tendinitis, medial tibial stress syndrome,
stress fractures, periostitis, fascial defects, musculotendinous injuries (ruptures, partial tears, scars) such as ‘tennis leg’, popliteal artery entrapment syndrome, claudication, effort-induced venous thrombosis, nerve injuries, entrapments and radiculopathies []. The proper treatment requires that an accurate diagnosis is made. Diagnosis can be established by a thorough history and by performing a physical examination with reference to the underlying anatomic structures. In order to make an exact diagnosis, radiologic and isotope examinations, ultrasonography, magnetic resonance imaging (MRI), neurophysiologic and tissue pressure measurements can be used. Clinicians should be familiar with the problems causing leg pain in order to prescribe specific treatment for each athlete.
The frequency of lower leg injuries Lower leg overuse injuries comprise approximately % of all overuse injuries in athletes. In younger athletes, the incidence is lower than in older. In runners, lower leg injuries account for approximately % of all injuries [,]. James et al. [] evaluated lower leg pain conditions in runners, of which % were lower leg overuse injuries. Some of these (%) were stress fractures of the tibia and/or fibula. The frequency of different pain syndromes of the lower leg varies according to different studies. Medial
Chapter . tibial syndrome was the most common lower leg overuse pain in athletes in the study of Puranen and Alavaikko [] in Finland. In other reports anterior tibial syndrome has been seen more often [,]. Posterior calf muscle pain, tennis leg and other pain syndromes are seen less frequently. The incidence of stress fractures of the lower leg is less than half the incidence of soft tissue leg pain [], but the clinical symptoms are often very similar. The term ‘shin splints’ has been used as a general name for overuse injuries of the lower leg, except stress fractures and compartmental syndrome [,]. The pain is induced by physical exercise and is located anterolaterally or medially on the leg. Rather than the diffuse term shin splints, the exact diagnoses of lower leg injuries in athletes with lower leg pain should be used. These include the medial tibial syndrome, anterior, lateral and posterior compartment syndromes, fascial defects, the tennis leg, the popliteal artery entrapment syndrome and effort-induced venous thrombosis in addition to stress fractures (see Table .., p. ).
Fig. .. Muscles of the lower leg and foot.
Medial tibial stress syndrome Pain at the medial and posterior aspect of the distal leg is called ‘medial tibial syndrome’ or ‘medial tibial stress syndrome’ [,]. This is caused by overuse and is seen especially in endurance athletes as runners, triathlonists, cross-country skiers, orienteers and joggers. It is seen also in athletes participating in jumping sports, such as basketball, volleyball and other indoor ball games. Some authors state that medial tibial (stress) syndrome begins as a tendinitis, but progresses to a periostitis. During the midstance phase of running the foot pronates and the tibia rotates internally, pulling the posterior tibial tendon and muscle at their attachments to both tibia and the interosseus membrane, which by means of powerful and frequent repetitions may result in overloading of these structures. Others, however, believe that the soleus muscle rather than the posterior tibial muscle is involved in medial tibial stress syndrome. Michael and Holder [] demonstrated in their anatomic study how the posterior tibial muscle originates a considerable distance from the medial border of the posterior tibia (the pain site) and that the muscle belly is higher in location than the usual site of pain. The soleus muscle has a tough aponeurotic covering, which extends directly to the posterior medial border of the tibia for three-quarters of its length where it attaches at the muscle’s origin. The insertion is complex, but its tendinous portion inserts on the medial third of the calcaneus. Biomechanically, this insertion makes the soleus vulnerable to excessive elongation when the heel is pronated [], and overloading may result in tibial leg pain. But there is great variation in the tibial origin of the plantar flexor musculature, and separate fascial compartments have been identified in the posterior tibial muscle and other medial flexors [], which may explain the variation in symptoms. Patients with medial tibial syndrome usually complain of exertional pain located at the medial (posterior) aspect of the leg. Usually the most painful area is the proximal part of the distal third of the tibial border, where palpation tenderness is also felt. There is some variation as to the location of pain [,,]. In addition, ‘medial tibial stress syndrome’ has been classified by Detmer [] into three subclasses: (i) bone stress reaction or stress fracture; (ii) periostitis from traction at
Lower Leg, Ankle and Foot the periosteal–fascial junction of the soleus muscle; and (iii) chronic posterior compartment syndrome. Clement has introduced the term ‘posterior tibial syndrome’ [], characterized by pain and tenderness along the posterior medial aspect of the tibia over the posterior tibialis muscle and tendon. To establish the diagnosis of medial tibial stress syndrome, radiographic evaluation, bone scintigraphy and compartmental pressure measurements can be used. Radiographs are usually negative, but they help to exclude other pathologic processes. Technetium pyrophosphate bone scanning can be very helpful in differentiating a stress fracture from ‘periostitis’ or ‘bone stress’ (Fig. ..). In the latter, the uptake of the tracer is longitudinal and diffuse along the posteromedial tibia, and not local as in the case of a stress fracture []. MRI has been found to be helpful in defining the degree and extent of bone involvement in tibial stress reaction. It also helps in follow-up of the patients. Elevated intracompartmental pressure in the deep posterior compartment has been noticed in some patients with medial tibial syndrome during exercise []. After fasciotomy the pressure levels during exercise did not rise above pressure during rest in some series [] but others have not been able to demonstrate elevated pressure values in patients with medial tibial syndrome [].
Fig. .. Scintigram of ‘shin splints’ (left) with disperse accumulation of activity along the medial border of tibia, and of a stress fracture of tibia (right) with distinct activity at the fracture. From Department of Clinical Physiology, Copenhagen University Hospital at Bispebjerg, Denmark.
Treatment of medial tibial syndrome is primarily non-surgical. In addition to reduction in the amount of impact activity, massage, stretching and aerobic training with cycling or rowing can have a positive effect on early medial tibial syndrome []. Insoles with an antipronation effect may also reduce symptoms. If these conservative measures fail, surgical intervention with fasciotomy is probably the best treatment. Fasciotomy for medial tibial syndrome was first done in . The results have been excellent or good in –% [,,]. During fasciotomy, the common crural fascia covering the deep posterior compartment should be opened, as well as the separate fascia of the posterior tibial muscle. The distal medial soleus muscle insertion can be freed from the medial tibial border at the same time and the soleus fascia opened proximally []. Recovery time to full training is approximately weeks, but there seems to be a longer recovery time and somewhat poorer results in female athletes after fasciotomy []. Complications related to the surgical treatment include injuries to saphenous nerve branches or the vein, postoperative hematoma and infection. The risk of complications can be reduced using careful operation technique.
Anterior tibial compartment syndrome Anterior tibial syndrome exists in both an acute and a chronic form, both caused by overuse []. The acute anterior tibial syndrome is an exertional pain syndrome with dramatic symptoms including pain and major swelling and should be treated by early fasciotomy. Ischemia and muscle necrosis may develop if the diagnosis is missed and treatment is delayed. The subcutaneous fasciotomy should not be used, in order to avoid the tourniquet effect by intact skin in the distal leg and ankle. Chronic anterior compartment syndrome is a typical chronic exertional compartment syndrome. The muscles of the anterior compartment of the leg are involved, causing burning pain in dorsiflexion of the ankle, especially during running, walking and jumping. The compartment is usually painful during palpation and the muscle mass may be hypertrophic. An elevated intracompartmental pressure has been found in several studies, during both rest and exercise [,,,,]. It is generally agreed that a pre-exercise
Chapter . pressure of mmHg or more, a -min postexercise pressure of mmHg or more and a -min postexercise pressure of mmHg or more is pathologic and proof of chronic compartmental syndrome []. During exertion the intracompartmental pressure can be higher than mmHg. Some non-invasive tests for the detection of chronic compartmental syndrome have been developed. These include radioisotope scintigraphy associated with emission tomography for regional muscle perfusion defects in the calf musculature. Fasciotomy of the affected compartment is the only definitive treatment, as rest and other conservative treatments affect the chronic form of this syndrome relatively little. The results after fasciotomy are good in more than % of cases [,,]. Patients are usually able to train normally – weeks after surgery. Surgical failures can be associated with too short fasciotomy, injury to the superficial peroneal nerve, postoperative hematoma and infection.
tients, massage, stretching and reduced intensity of training is usually effective treatment.
Lateral (peroneal) compartment syndrome
Tibialis posterior tendon dysfunction/rupture
Isolated chronic compartment syndrome in the peroneal muscles is rarely seen. But several authors state that when there is an anterior compartment syndrome, the lateral peroneal compartment is simultaneously affected. Therefore standard surgery has been fasciotomy of both the anterior and lateral compartments of the leg []. The necessity of the strategy has been questioned, and one study [] has shown that the results after fasciotomy of the anterior compartment alone were as good as when fasciotomy of both compartments were performed.
Posterior compartment syndrome This pain syndrome is mainly seen in middle-distance and endurance runners as well as in orienteers. Symptoms appear during and after running and may progress to a chronic compartment syndrome located at the gastrocnemius–soleus muscle complex. Intracompartmental pressure measurements can confirm the diagnosis, and in case of elevated pressure, fasciotomy is the ultimate treatment. The common crural fascia can be opened posteriorly at one or both sides. In some cases pain of the posterior compartment is caused by a partial calf muscle rupture. In these pa-
Fascial defects Fascial defects can be symptomatic in association with chronic compartment syndromes. Increased intracompartmental pressure may result in herniation of muscle through an attenuated fascial defect [,]. Reneman [] observed fascial defects in approximately % of patients with chronic compartment syndrome. Usually the herniation occurs in the distal third of the anterolateral leg, often at the fascial opening for the cutaneous branch of the superficial peroneal nerve. Not all fascial defects are symptomatic, though. If there is pain, local tenderness, compression neuropathy or ischemia of herniated muscle tissue, fasciotomy is recommended, avoiding damage to the nerve branches [,]. Closure of the defect is contraindicated as it can lead to increased symptoms and, in the worst case, to an acute compartment syndrome.
Tibialis posterior tendinopathy is most often seen as an overuse tendon injury. This condition is not an inflammatory tendinitis, but a degenerative tendinosis. The typical clinical sign is pain of the medial aspect of the ankle behind the medial malleolus. This pain may radiate along the tendon to the naviculare bone. The tibialis posterior tendinopathy is often associated with excessive pronation of the hindfoot. On examination there is pain on palpation of the tendon. The pain is increased by passive eversion and resisted inversion of the foot. In rare cases crepitation may be present. In the case of a total rupture of the tibialis posterior tendon a collapse of the medial arc of the foot is seen (Fig. ..). The patient is unable to increase the weight-bearing of the foot and there is marked valgus of the heel; the so-called ‘too many toes sign’ is present. Primary treatment is aimed at reduction of pain as well as strengthening of the tendon. Excessive tightness of the proximal tibialis posterior muscle should always be looked for and treated if present. As tibialis posterior tendinopathy is frequently associated with excessive pronation, a shoe correction and an insole should be used.
Lower Leg, Ankle and Foot
Fig. .. Valgus foot. At weight-bearing the heel is in valgus position compared to the normal foot.
In athletes with rupture of the tibialis posterior tendon, examination may reveal thickening of the tendon and/or absence of the tendon. There is inability to raise the heel. MRI and/or ultrasonography should be used in order to establish the diagnosis. Surgical repair is indicated in patients with subtotal or total rupture of the tendon. Direct suture of the tendon will usually not produce satisfactory results; instead transposition of either flexor hallucis longus or flexor digitorum longus is indicated. Rupture of the posterior tibialis posterior tendon in athletes is infrequent, but is, however, a serious injury.
Tennis leg The term ‘tennis leg’ is used for a partial rupture of the medial head of the gastrocnemius muscle, not to be clinically confused with a tear of the plantaris tendon []. Often the tear occurs at the musculotendinous junction. The injury occurs most frequently during running, jumping or ball games and usually results from an eccentric load placed across the ankle with the knee in extension. The injury mechanism is thus indi-
rect, but the patient may describe a direct trauma to the calf region, such as a kick or hit by the ball or bat to the calf. In physical examination of the painful calf swelling can be seen. A maximal point of tenderness with a palpable defect in the medial head of the gastrocnemius muscle can be recognized at examination. Ankle plantar flexion is weakened and painful. Sometimes deep venous thrombosis may exist simultaneously. Ultrasonographic or venographic investigation can be performed to establish the diagnosis and to exclude deep venous thrombosis. With MRI the location and extent of muscle injury can be visualized. Treatment of the tennis leg is non-surgical, including elevation, ice, compressive wrapping and partial weight-bearing. Heel lifts in the shoes may be used during the first week. A progressive calf stretching and strengthening program is undertaken as pain and swelling resolve. Usually full recovery occurs in a few weeks. However, some of the ruptures are so large that a permanent defect and muscle weakness remains. However, the results of late repair of the musculotendinous defect are not good, and operative treatment should be avoided.
Popliteal artery entrapment syndrome (PAES) Partial or complete compression of the popliteal artery as a result of aberrant anatomy in the popliteal fossa causes the popliteal artery entrapment syndrome, which is an uncommon reason for exertional leg pain. Usually the compression is caused by the gastrocnemius muscle. The various anatomic anomalies causing PAES include: the popliteal artery passing medial to the medial head of the gastrocnemius; an abnormal origin of the medial head of the gastrocnemius; the presence of an accessory band of the medial head of the gastrocnemius; and the popliteal artery passing deep to the popliteal muscle []. Popliteal artery entrapment syndrome usually affects younger male athletes, inducing calf pain during strenuous exercise. The symptoms are bilateral in more than % of patients []. Leg weakness and paresthesias may be associated with PAES. The pain
Chapter . appears after a certain amount of exercise, just as vascular claudication. Reduction of activity relieves the symptoms, whereas elevation of the leg makes them worse. The symptoms resemble posterior compartment syndrome, but there are normal intracompartmental pressures. In physical examination distal pulses can be weak or absent during maximal isometric ankle dorsiflexion and hyperextension of the knee. With non-invasive vascular investigations such as ankle/ brachial index and Doppler ultrasound the diagnosis can usually be established. However, angiography directly after exercise is the most precise diagnostic investigation. PAES is a progressive disease with increasing vascular occlusion over time. Treatment is surgical decompression of all constricting structures. The surgical procedure can range from musculotendinous sectioning and thrombectomy to resection of the damaged arterial section with saphenous vein graft interposition []. The prognosis is usually good, but is dependent on the extent of arterial damage and the vascular intervention required.
Stress fractures of the tibia Occurrence of stress fractures Breithaupt reported in metatarsal stress fractures in soldiers after long marches. A stress fracture is a dynamic, metabolic process of bone, in which remodelling dominates over repair, and is related to overuse impact. The character of the load and the degree of training seems to be of importance for the occurrence of stress fractures. Of consecutive patients with stress fractures % were athletes at district or national elite level, while the remaining % were sedentary individuals []. The incidence of stress fractures has been reported to be –% of all sports injuries in different populations, with a higher incidence among runners [,]. The tibia is the most common location of stress fractures. The incidence of stress fractures in the tibia among track and field athletes has been reported to be %, and among young elite orienteers lower than % during year, whereas among elite soccer players there were no stress fractures.
Predisposing factors Effort-induced venous thrombosis The etiology of effort-induced venous thrombosis is unknown, but it has been described in connection with the ‘tennis leg’, repetitive muscular use during jogging and kick boxing, in which intimal venous damage may occur as a result of knee hyperextension. There are also case reports of this syndrome occurring in American football and skiing []. Anatomic variations of the popliteal fossa veins may be an etiologic factor. The typical patient is the well-conditioned athlete who experiences a sudden calf pain unilaterally without any direct trauma. Swelling develops later. The symptoms and physical signs often mimic gastrocnemius muscle tear. However, there swelling is more pronounced and Homan’s sign is positive. The diagnosis is confirmed by ultrasonography. In the case of grave symptoms and negative ultrasound, venography should be performed. Immediate treatment with low molecular heparin and oral anticoagulants is important to prevent the development of serious complications such as clot propagation and pulmonary embolism. Initial treatment also includes bed rest and leg elevation.
Extrinsic factors, such as sudden changes in training or running surface, have been reported to cause stress fractures [,]. Previously relatively untrained recruits, committed to intensive military training, equipped with new military boots, carrying weapons and other equipment, running and jumping excessively daily, are at high risk of sustaining stress fractures. Intrinsic factors, such as leg length discrepancy, cavus foot, overpronation during running [] and osteopenia are referred to in the literature as contributing factors for stress fractures. Despite the fact that we often claim that these stress fractures are related to fatigue, we do not know whether good muscular function can decrease the local deformation of the bone. Many clinically important questions remain unanswered.
Clinical presentation, diagnosis and management There are two types of stress fractures in the tibia, classified in relation to their location as posteromedial or anterior stress fractures []. The diagnosis is based on clinical findings and veri-
Lower Leg, Ankle and Foot
fied by technetium- bone scan, radiography, computed tomography (CT) or MRI. The bone scan typically shows an increased bone turnover at the injury site a few days after injury and as X-rays are often normal for several weeks, bone scan may be the first examination to verify a clinical suspicion of a stress fracture. The anterior stress fracture is connected with an excessive cortical and fibrous formation and heals slowly. This injury was initially described by Burrows [] in ballet dancers. Three of these underwent biopsies of the lesion, showing ‘dense cortical bone with some evidence of granulation tissue’. The delay in healing has been suggested to be caused by the fibrous ingrowths which prevent bone-to-bone contact [–]. A low vascularity of the anterior cortex may also be an important pathophysiologic factor []. This injury is serious for the elite athlete, for in addition to the very slow healing, complete fracture may occur []. Athletes performing frequent jumps such as long-jumpers, basketball players, runners and dancers are at high risk of sustaining this type of stress fracture [–]. The diagnosis is often delayed because of the slow onset of symptoms. At later stages radiography shows a typical V-shaped cut into the cortical bone and also cortical hypertrophy as a consequence of the long-term excessive load. The treatment of this injury is still controversial. Despite long immobilization periods these fractures have a low healing potential. Various operative techniques including stabilization with plating, drilling proximal and distal of the fracture or intramedullary nailing have shown good results with healing of the fracture and resumption of sport activities [,]. Pulsating electromagnetic field therapy also seems to be effective [].
Fig. .. X-ray of stress fracture of tibia. The only indication of a fracture is a little callus formation on the medial side of the tibia (arrow).
attachments [], which to some extent may explain different clinical presentations depending on anatomic predisposition in each individual (Table ..). The medial tibial stress fracture usually heals easily with reduction in load and training intensity.
Achilles tendon injuries Chronic Achilles tendon disorders
The posteromedial stress fracture (Fig. ..) is located close to the site of the deep plantar flexor muscle attachments of the flexor digitorum longus, tibialis posterior and soleus muscles at the mid-diaphysis of the tibia. It has been debated whether this injury is a true stress fracture, periostitis, or a rupture of the musculotendinous attachment on tibia []. There is great variation in anatomy related to the deep plantar flexor
Chronic Achilles tendon pain is a common clinical feature [,]. Most acute Achilles tendon conditions heal with non-surgical and symptomatic treatment, but some patients do complain of longstanding pain and swelling of the Achilles tendon, stiffness and dysfunction, which makes it difficult for them to retain a desired level of activity. A chronic condition is defined as symptoms lasting more than – months. Even
Chapter . Table .. Characteristics of and differences between tibial stress syndrome, compartment syndrome and stress fractures.
Tibial stress syndrome
Chronic compartment syndrome
Stress fracture
History
Running on hard surface. Hyperpronation? Quite diffuse pain during weight-bearing and activity, but pain may decrease during activity
Increase or change of training No pain at rest Increasing pain with increasing activity. Paresthesia may occur
Huge increase of activity and load Can be progression of tibial stress syndrome Sudden onset Localized pain even during small load
Findings
Tenderness of tibial edges, small tender swellings on tibia
Tenderness of musculature
Localized tenderness of the bone
Investigations
Basically clinical examination Bone scan may show periosteal activity, and may be normal
Compartment pressure measurements: > 15 mmHg pre-exercise > 30 mmHg 1 min after exercise > 20 mmHg 5 min after exercise
Bone scan: activity in the bone X-rays MRI
Treatment
Conservative: Medial stress: antipronation support, muscle training, reduction of training load Anterior stress: shock absorption (shoes, surface) Operative treatment?
Surgical: Fasciotomy
Conservative: Medial fracture: reduce load and training for 3 months Anterior stress: full reduction of load Surgery: osteosynthesis
though reported as an overuse injury in the literature, up to % of cases with chronic Achilles tendon disorders are not related to sports or excessive loading. Rheumatologic disorders, immunologic and infectious diseases as well as adverse drug effects are also reasons to be considered. ‘Tendinitis’ is a term often used by clinicians to describe a painful Achilles tendon. An inflammatory reaction in the tendon, characteristic for acute tendinitis, is seldom found in chronic situations, however, even though an initial inflammation may have induced the condition, which later becomes chronic [–]. ‘Tendinosis’ is often used to describe chronic changes of the Achilles tendon. Tendinosis means that only degenerative, but no inflammatory, changes are found in the tendon. The etiology of tendinosis is unknown. It may pass through various stages of structural changes, clinical symptoms, weakening and finally microrupture. On the other hand, tendinosis may start with microruptures of the tendon and develop through a failed healing process. The processes of
inflammation, degeneration, and regeneration/repair form a functional spectrum of cell matrix responses, and the predominance of any of these responses depends on the mechanism of injury and the hemostatic balance of the tendon tissue. When tissue breakdown exceeds repair, the tendinosis cycle is initiated. In the development of Achilles tendinosis, it is likely that tissue microtrauma and dysfunction precede the moment of the first perception of pain, stiffness, tenderness, or discomfort. In other words, the tissue damage may have started to accumulate long before the first symptoms [–]. Kvist et al. [] carried out histopathologic and biochemical studies on chronic paratendinosis and suggested that it is caused by hypoxia, neovascularization and degeneration in interrelation, and that an inadequate circulation in the critical zones in the tendon could be the reason for subsequent ruptures. On the other hand, Åström and Rausing [] found only minor changes in the paratendinous tissue, but noted mucoid degeneration, neovascularization and disor-
Lower Leg, Ankle and Foot ganization of the collagen in the tendon itself. They observed with laser Doppler technique that chronic tendinosis was associated with an increased blood circulation. Leadbetter [] has suggested that a failure of the cell matrix to adapt to excessive changes in load could be one explanation for tendinosis, stimulating the local release of cytokines, resulting in both autocrine and paracrine modulation of further cell activity including cell deaths. However, an increased number of hyperactive cells in tendinosis tissue has also been described. Ultrasound imaging of chronic Achilles tendon disorders shows widening of the tendon and low echogenicity and correlates well with the histopathologic changes. Pathologic findings are often localized .– cm proximal of the distal insertion, mostly on the medial side of the tendon (Fig. ..). MRI with gadolinium contrast enhances the imaging further and shows a greater intratendinous volume than ultrasonography, indicating a more widespread pathology.
(a)
Management Chronic Achilles tendon disorders should be divided into conditions affecting the tendon insertion, the free tendon, the proximal tendon–muscle transition, and the paratenon. In clinical practice, there is often a combination of paratenon and tendon involvement. It is logical that there is some degree of relationship between paratenon and tendon disorders. There is a lack of controlled studies on operative and non-operative treatment of chronic Achilles tendon disorders. Clement et al. [] treated patients with rehabilitation including calf muscle training, medical treatment of inflammation and correction of various biomechanical dysfunctions and found good or excellent results in the majority of the cases. A program of hard eccentric muscle training has been found to have excellent short-term effect on the symptoms of chronic Achilles tendinosis [,], but the long-term effect is not known. Topical treatment has always interested athletes, but the scientific evidence for its effect is vague. Topically applied ketoprofen penetrates through the skin, the paratenon and into the tendon, where it is present in high concentrations, when compared to oral treatment. This treatment should probably only be
(b) Fig. .. Ultrasound investigation of (a) a normal Achilles tendon and (b) a painful, swollen tendon of a runner. Tendinosis is visible as hypoechoic areas inside the tendon, and the dark area at the top represents peritendinosis.
used for acute, inflammatory tendon conditions. Since chronic tendinosis is not an inflammation, it is not surprising that no study has been able to show any reliable clinical effect of anti-inflammatory preparations. Corticosteroid injection around the Achilles tendon is a common but controversial treatment for chronic
Chapter . Achilles tendon problems. In one study it has been reported that % of outpatients and % of inpatients with chronic Achilles tendon pain had received one or more cortisone injections, and this is in agreement with earlier published data of a frequency of around –%. During the s the first report on Achilles rupture after cortisone injection was published. Corticosteroid-induced changes in the tendon’s vicinity such as pigment changes and atrophy of the skin and subcutaneous tissue are probably more common than tendon ruptures. In Malmö, Sweden, two groups of patients with chronic achillodynia have been studied to assess the frequency of corticosteroidrelated complications; consecutive patients operated on during –; and consecutive cases who were evaluated as outpatients during –. In the surgically treated group, partial ruptures of the tendon were found in %, but the frequency was doubled in those patients who had previously had corticosteroid injections. In the outpatient group, an annual incidence of total Achilles rupture was found to be .% and .% for patients with and without earlier corticosteroid injections, respectively, compared to an incidence of .% for Malmö’s general population []. Two surgical methods have been described as treatment for problems at the tendon insertion: resection of the posterosuperior angle of the calcaneus (Fig. ..), and wedge osteotomy of the calcaneus. Some studies
have described good clinical results from these procedures while others find poorer results []. Chronic paratendinitis and tendinitis of the free tendon can be treated with excision, which has an excellent effect on the symptoms in large series. The tendon is incised longitudinally, followed by removal of the adhesions between the skin and paratenon, and those between the paratenon and the tendon. Ljungqvist [] operated on cases with partial ruptures and all these cases became free of symptoms, in cases after more than months. Nelen et al. [] studied cases of chronic tendinopathy who were operated with resection of macroscopic unhealthy tissue and half of the cases with a turndown flap. They found good results in % of the cases not operated with reinforcement, and in % of cases who had reinforcement, at follow-up more than years after the operation. The majority of these patients were operated on with excision of the macroscopically damaged tissue without any reinforcement. The operation can be performed under local anesthesia without the use of a tourniquet []. Postoperative treatment is individualized depending on the intraoperative findings. Below-the-knee cast or an individually produced brace can preferably be used during the wound healing period. Full weightbearing is allowed, with limited dorsal flexion, directly after the operation in most cases. Controlled studies of different rehabilitation protocols are lacking. Complications after surgery are seen in –%.
Achilles tendon ruptures
Fig. .. Removal of the superior–posterior edge of calcaneus in chronic bursitis/tendinosis due to prominent bone.
The incidence of Achilles tendon rupture is approximately / population per year. The incidence has increased – times during the last – years. The male dominance is from / to / in different studies. The average age of the patients is – years. Sports activity is the triggering factor in %. In Scandinavia, Achilles tendon ruptures most often occur during badminton. In the USA, Achilles tendon ruptures are related to basketball and tennis. In the elderly, underlying systemic disease or long-term corticosteroid medication are common contributing causes. Chronic degeneration of the tendon may be a predisposing factor. A number of studies have shown degenerative changes in the ruptured tendon, but in most cases the patient did not have any symptoms
Lower Leg, Ankle and Foot before the rupture occurred. An uncontrolled and strong contraction leads to the rupture. It is remarkable that the group which is most often affected is people who were physically active when they were younger. When they take up their sports activities again, they suffer an Achilles tendon rupture. The diagnosis is easily assessed in cases with complete rupture of the tendon. The history is typical: the patient feels as though something snaps in the calf, sometimes associated with a burning pain and is not able to continue with the ongoing activity. Despite this the diagnosis is primarily missed and detected later in up to % of the patients. A positive Thompson’s (Simmonds) test is present (Fig. ..). The patient lies in the prone position with bare legs and flexed knees. The examiner firmly squeezes the calf from side to side and observes the movement in the foot. If the tendon is intact, a plantar flexion movement is observed. By applying resistance to the plantar flexion, the absence of force is obvious. A defect in the tendon is also palpable. Traditionally, Achilles tendon ruptures have been operated on in the majority of cases. A number of studies were published where the surgical methods were described, etiology investigated and the operated persons were evaluated by clinical follow-up. Following studies in the s showing good results with immobilization in a cast without operation, this treatment has also been used in many cases. However, in a recent prospective randomized multicenter study [], non-operative treatment with weeks of cast immobilization was compared with surgical treatment with early graded mobilization using brace. Surgical treatment combined with early mobilization produced better results in terms of lower rerupture rate, and the patients reported a high quality of life during the treatment with fewer complications. At surgery, the tendon ends are adapted by sutures anchored in the firm parts of the tendon and the paratenon is closed. The operation can favorably be performed under local anesthesia without the use of a tourniquet in an outpatient clinic. After surgery, the active rehabilitation phase is months. An early return to work and sporting activity has been reported to give better functional results especially in terms of muscle strength and endurance. Early mobilization is advantageous and has not given rise to higher risk of complica-
(a)
(b) Fig. .. Thompson’s test: With the patient lying with the back facing up and the foot placed over the edge of the investigation couch (a), the investigator compresses the calf muscles side to side (b). With an intact Achilles tendon, the foot plantar flexes, whereas nothing happens if the Achilles tendon is ruptured.
tions. Lower leg braces that inhibit dorsal extension can be used. Stirrup casts can also be used, allowing loading and movement in the ankle to a certain level. Normally, the patients function well in their daily activity in terms of walking without limping after – months of rehabilitation. The prognosis with regard to function is good, and most patients have relatively few subjective problems from the Achilles tendon. The majority can return to preinjury activity including sports. Suture of the Achilles tendon can also be performed percutanously. The short-term results are encouraging. Complications after non-surgical treatment are un-
Chapter . satisfactory healing with pain and reduced strength, healing with lengthening of the tendon giving rise to increased dorsal extension, decreased flexibility, inability to walk on tiptoe, problems with balance, and frequent tripping. Rerupture is the most dreaded complication. The frequency of rerupture varies in different studies between % and %, but is lower after surgical treatment. After surgery, the most common complication is superficial infection, requiring antibiotic treatment.
between and per participants per season. It has been estimated that these injuries constitute approximately % of all time loss due to sports injuries to the ankle, especially in sports that involve running and jumping, e.g. soccer, basketball and volleyball. Although many of these injuries are not serious per se, they are very costly to society due to their high incidence. Ligament injuries to the ankle are divided into acute and chronic. In most cases lateral ligament injury
Ankle joint injuries Ankle arthroscopy Ankle arthroscopy is a valuable tool in the diagnosis and treatment of various intra-articular ankle disorders. Visualization of intra-articular pathology without arthrotomy is possible, thus reducing the risk of surgical complications. Indications for ankle arthroscopy are osteochondral fractures, chondral lesions, soft tissue impingement, bony impingement, post-traumatic osteoarthritis and loose bodies. Chronic pain at the anterior aspect of the ankle joint is rather frequent in athletes, e.g. soccer players, and is often referred to as ‘footballer’s ankle’, and is also a frequent indication for arthroscopy []. Patients with recurrent ankle pain, chondral and osteochondral lesions, anterior tibial spurs and soft tissue pathology such as synovitis and ‘meniscoid’ lesion are those who are most often in need of arthroscopic intervention. Although the risk of complications after arthroscopic surgery of the ankle is low, it should be kept in mind that numerous anatomic structures are at risk. The frequency of neurovascular complications in some reports is as high as %. It has been shown that the anteromedial, anterolateral and posterolateral portals give nearly complete access to all parts of the ankle joint.
ATiFL ATFL CFL
Fig. .. Ligaments at the lateral aspect of the ankle and foot. ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; ATiFL, anterior tibiofibular ligament.
Deltoid ligament
Acute ligament injuries A sprained ankle is the most common sport-related injury, mainly in the younger age groups [–]. The injury may occur as an athletic trauma or during activities of daily living. The reported incidence of ankle ligament injuries varies, mainly due to the profile of sporting activities in the population (Figs .. and ..). The incidence in a high-risk sports population is
Fig. .. Ligaments at the medial aspect of the ankle and foot.
Lower Leg, Ankle and Foot occurs with the foot rotating inwards in plantar flexion when the tibia is simultaneously rotating outwards, giving rise to anterolateral rotational movement. The medial malleolus acts as a fulcrum when the ankle moves into increased inversion, losing its stabilizing function and increasing the strain on the lateral side. Ankle ligament injuries are classified as Grade I (mild), Grade II (moderate) and Grade III (severe). Grade I injuries include stretching of the ligaments without macroscopic rupture. There is minor swelling and tenderness and no increase in laxity. The loss of function is minimal and the recovery is usually quick. In Grade II injuries there is a partial macroscopic rupture of the ligaments, with moderate swelling, tenderness and pain. There is a mild to moderate increase of laxity, some loss of motion and moderate functional disability. These lesions have a low frequency (< %). Grade III injuries always include complete rupture of the ligaments and the joint capsule, with severe bruising, swelling and pain. There is a major loss of function, reduction of motion and increased laxity due to the ligament rupture. The injured subject is often unable to bear weight because of pain. Radiographs are often needed to rule out fracture. Over % of all ankle ligament injuries involve the lateral ligaments (Fig. ..). The anterior talofibular ligament (ATFL) is the most vulnerable of the lateral ankle ligaments. Further, rupture of the ATFL occurs as an isolated injury in approximately two-thirds of all ankle ligament injuries. With an increasing force, the calcaneofibular ligament (CFL) is also damaged. A rupture of both the ATFL and the CFL occurs in –%. Isolated rupture of the CFL happens in approximately %, and injury to the posterior talofibular ligament (PTFL) is extremely rare. Individuals with generalized hypermobility of the joints or a previous history of ankle ligament injury are at greater risk of ankle injuries. Isolated ligament injuries of the deltoid ligament are infrequent (Fig. ..). The frequency has been estimated as approximately .% of all ankle ligament injuries. The injury mechanism is an excessive outward rotation of the foot during simultaneous inwards rotation of the tibia. This type of injury usually takes several weeks to heal, and more often gives rise to chronic anteromedial pain rather than recurrent medial instability. Pain and swelling are present for a longer
period of time than for a corresponding injury on the lateral side. Injury of the anterior tibiofibular ligament (anterior syndesmosis ligament) is sometimes seen in soccer players after external rotation of the foot, in dancers after forced dorsiflexion of the foot or in alpine skiers after combined external rotation, axial compression and forced dorsiflexion. When this injury is suspected, a complete radiographic examination of the lower leg should be performed to rule out a fracture of the proximal fibula. This ligament injury is painful, and heals slowly, but residual disability with recurrent instability episodes is not frequent. A supination trauma is associated with a distraction force on the lateral side and compression force on the medial side of the joint. Apart from anterolateral pain and swelling, % of patients experience pain on palpation of the anteromedial ankle joint structures, indicating that damage has happened to the anterior rim of the tibia, to the cartilage or the joint capsule. Depending on the degree of damage, a repair reaction with cartilage proliferation, scar tissue formation and calcification will follow. Additional damage due to recurrent instability or forced ankle movement, especially forced dorsiflexion, will enhance this process. It has been shown that in patients with anteromedial osteophytes % had a history of supination trauma or had participated in soccer. Presence of osteophytes is not always associated with serious complaints. Removal of these spurs is important to create normal movement and prevent recurrence of the impingement. Arthroscopic removal of these osteophytes produces a good or excellent result in over % of cases. Grading the degree of osteoarthritis in patients with an anterior impingement syndrome is important for the prognosis. Although ruptures of the ankle ligaments are very common, treatment remains controversial. In a recent systematic review of the orthopedic literature, it was found that treatment of too short a duration or which did not include sufficient support of the ankle joint tended to result in more residual symptoms. It was concluded that a ‘no treatment’ strategy for ruptures of the lateral ankle ligaments led to more residual symptoms. After a supination trauma it is therefore important to distinguish a simple distorsion from an acute ankle ligament rupture since adequate treatment
Chapter . is associated with a better prognosis. The reliability of physical examination can be enhanced when the investigation is repeated a few days after the trauma. The accuracy of physical examination has been determined in a series of patients, comparing physical examination within h of the injury and days after injury. All patients underwent arthrography. The specificity and sensitivity of delayed physical examination for the presence or absence of a lateral ankle ligament rupture were % and %, respectively. The most important features of physical examination are swelling, hematoma, discoloration, pain on palpation and the anterior drawer test. Physical examination is unreliable in the acute situation, since the anterior drawer test cannot be performed due to pain. A few days after the trauma, the swelling and pain have subsided and it becomes obvious whether the cause of swelling was edema or hematoma. The pain on palpation has become more localized and the anterior drawer test can now be performed. The site of pain on palpation is important. If there is no pain on palpation over the ATFL, there is no acute lateral ligament rupture. Pain on palpation over the ATFL itself cannot distinguish between a rupture or a distorsion. Pain on palpation in combination with hematoma discoloration means, however, a % chance of acute lateral ligament rupture. A positive anterior drawer test has a sensitivity of % and a specificity of %. A positive anterior drawer test in combination with pain on palpation over the ATFL and hematoma discoloration has a sensitivity of % and a specificity of %. Delayed physical examination provides a diagnostic modality with a high sensitivity and specificity. If there is ankle pain after ligament injury, a number of concomitant lesions should be looked for: cartilage damage (especially on the joint surface of the talus); synovitis/impingement (inflammation and entrapment); entrapment of the tibialis posterior nerve (tarsal tunnel syndrome); partial rupture of the short peroneal tendon; bony outgrowths (osteophytes) in the joint; and loose bodies in the joint. Arthroscopy of the ankle is often of great value in establishing the diagnosis.
Treatment of acute ligament injuries All Grade I and Grade II ligament injuries are safely treated non-surgically. Functional treatment with a
very short period of rest, cooling (ice), compression and elevation to reduce the edema (the RICE principle) during the first – days, depending upon the amount of swelling, bruising and pain, should always be recommended. Early weight-bearing without crutches, if possible, is encouraged. Active range of motion training should be started after the acute phase treatment is completed, followed by neuromuscular coordination training using balance boards and peroneal strengthening exercises []. The injured ligaments should be protected from new injuries during the healing phase by using external support (ankle tape or a brace) to control the range of motion and to reduce the symptoms of functional instability. Both ankle tape and ankle braces, e.g. the air-stirrup, are easy to apply, versatile and effective in stimulating the proprioceptive system. The results of functional treatment of Grade I and Grade II ligament injuries are good in the majority of cases, and most athletes are able to return to sporting activities within – weeks. It has been shown that costs are significantly lower and ankle function is significantly better following early functional treatment (supervised rehabilitation program) or air-stirrup brace than immobilization in a plaster cast. On the other hand, there is still some controversy as to whether grade III ligament ruptures should be treated non-surgically by active functional treatment and early mobilization, or by primary surgical repair followed by immobilization using a plaster cast or a brace. Unfortunately, there are only a few prospective, randomized and controlled studies in the literature. These studies have mostly shown that the mediumand long-term results are satisfactory in the majority of these patients regardless of the primary choice of treatment, i.e. surgical repair, cast immobilization alone for – weeks, or functional treatment based on the principle of early mobilization. In a recent prospective, randomized trial comparing early mobilization with plaster cast immobilization, it was shown that these treatment modalities prevented late residual symptoms and persistent ankle instability equally well, but patients treated with early mobilization had significantly less pain at weeks (% vs. %) and were more likely to be back at work after week (% vs. %). Taken together, at least –% of patients with grade III injuries will regain satisfactory func-
Lower Leg, Ankle and Foot tional stability after non-surgical treatment. This is, however, not uncontroversial and a recent metaanalysis has suggested early repair as the best treatment. Functional treatment includes a short period of relative immobilization using an ankle tape, elastic bandage or ankle brace. Absolute immobilization using plaster cast is not advantageous. Training of range of motion, peroneal muscle strength, and coordination is started as soon as pain and swelling have subsided. Weight-bearing should be encouraged as soon as possible. The functional treatment does not increase the risk of residual laxity and complications are less frequent than with surgical repair followed by cast immobilization. It should also be borne in mind that secondary reconstructive procedures usually produce satisfactory results, even several years after the index injury. This makes the argument in favor of early surgical repair weaker. Also, the cost and the length of sick-leave have been shown to be lower after functional treatment. Thus, there are fairly strong arguments that functional treatment is the treatment of choice for all grades of acute ligament injuries to the ankle joint, providing the syndesmosis is stable.
Chronic ankle joint instability Functional instability is the most common residual disability after acute, lateral ligament ruptures and is a description of the subjective symptoms of the patient, e.g. repeated giving way, in some cases combined with pain. Laxity, on the other hand, refers to an objective measurement, e.g. standardized stress radiographs or clinical measurement of anterior drawer sign. Functional instability is a complex syndrome, in which mechanical, neurologic, muscular and constitutional factors interact. The etiologic factors are not exactly known and in several cases there is a combination of factors. Elongation of the ruptured ligaments, i.e. increased laxity, proprioceptive deficit, peroneal muscle weakness and subtalar instability, are all documented etiologic factors of functional instability, either alone or in combination [–]. A correlation between functional instability and isometric peroneal muscle weakness has been shown. Correlation between functional instability and decreased postural control has also been shown using stabilometric measurements, indicating a proprioceptive
deficit after ligament injury. In these studies, however, no correlation has been found between functional instability and increased laxity. The reaction time of the peroneal muscles, measured during sudden inversion using electromyography (EMG), has been shown to be significantly longer in unstable ankles than in stable ones. This difference in the reaction time is due to the time that elapses between the start of the inversion of the ankle and the stimulation of the mechanoreceptors in the ligaments and the joint capsule. Delayed proprioceptive response to sudden angular displacement of the ankle may be one of the most important causes of functional instability of the ankle joint [,]. Taken together, functional instability is caused by increased laxity, inhibition of proprioceptive function, peroneal muscle weakness or a combination of these factors. The specific cause of functional instability in each individual case has to be analyzed separately. Chronic functional ankle joint instability develops in approximately –% of patients after acute ligament rupture. This ligament instability does not always require surgical reconstruction. Non-surgical treatment is always recommended before operative management should be considered. Surgical reconstruction is probably more often needed in athletes with high demands of ankle function. There is no absolute indication for surgical intervention, but relative indication for surgical treatment is recurrent giving way in spite of proprioceptive training. Several different surgical procedures have been described to correct chronic ankle joint instability. These surgical procedures can be classified as either nonanatomic, using some of the tendons around the ankle joint, or anatomic reconstruction, using either direct suture of the torn ligaments, or imbrication and reinsertion to bone, and in some instances reinforcement with local tissue, such as the inferior extensor retinaculum or a local periosteal flap. The clinical evaluation of chronic ankle joint instability is primarily based on the assessment of anterior drawer sign (Fig. ..) and the inversion (supination) test, always in comparison with the contralateral side. Increased anterior translation of the talus in the talocrural joint is due to rupture or elongation of the ATFL. Increased inversion is due to rupture or elongation of the CFL, or a combination of ATFL and
Chapter . CFL insufficiency, which is more common. Increased inversion may also imply increased laxity between talus and calcaneus (subtalar instability). Subtalar instability has been suggested to be one of the factors behind the development of functional instability. However, no definition of subtalar instability exists in the literature. A correlation between chronic functional instability and prolonged peroneal reaction time has been shown, indicating that a proprioceptive deficit can be at least partly responsible for ankle instability. Good knowledge of the laxity of the ankle joint ligaments in both the sagittal and the frontal plane can give valuable information during the diagnostic assessment of chronic functional instability. Radiographic measurements of ankle joint stability are sometimes used before deciding upon the treatment of chronic lateral instability. Standardized stress radiographs can be used in both differential diagnostic evaluation and assessment of therapy. Their main drawback is the limited correlation between functional instability and increased laxity [,]. The two radiographic tests which are used are the lateral instability/laxity test (talar tilt, TT) and the anterior instability/laxity test (anterior talar translation, ATT) (Fig. ..). Increased laxity can be defined either as a single value of ATT > mm or as TT > °. Another way of defining increased laxity is a difference of ATT > mm, i.e. the difference in ATT between the functionally unstable ankle and the contralateral ankle and/or TT > ° in patients with unilateral instability. A good correlation between functional and mechanical instability has been shown in some studies, but this correlation is highly variable, since several factors other than mechanical instability can be responsible for the development of functional instability. Several studies have questioned the reliability of stress radiographs, especially the measurements of TT, and it must be borne in mind that radiographs alone can never be used to establish an indication for surgery (Fig. ..). Ultrasonography (US) and magnetic resonance imaging (MRI) have been used to delineate injuries such as partial or total ruptures of the ankle ligaments. MRI in particular can provide useful information in patients with chronic pain after ligament injury to the ankle. MRI is both sensitive and specific, although it cannot
replace stress radiographs. US can be useful as a screening modality, especially when there is a discrepancy between clinical and radiologic examinations after trauma. US is cheap and non-invasive. However, like MRI, it cannot replace stress radiographs.
Treatment of chronic ankle instability Non-surgical treatment Less than % of all subjects who have sustained acute ligament injuries will need stabilizing surgery. Before deciding upon surgical treatment in a patient with chronic ligament insufficiency, a supervised rehabilitation program based on peroneal muscle strengthening and coordination training should always be carried out. More than half of all these patients will regain satisfactory functional stability after such a program. The goals of the program are to strengthen the peroneal muscles, to regain normal proprioceptive function, and to re-establish normal protective reflexes. It is of major importance to make the rehabilitation program as complete as possible to regain full ankle function, i.e. full range of motion, improved balance and coordination (proprioceptive reflexes), and full strength and endurance of the injured limb. The training of the calf muscles should be both eccentric and concentric. Patients with high-grade mechanical laxity have less favorable prospects in regaining satisfactory function by physiotherapy. In these patients surgical treatment should be considered at an earlier stage. The aim of the rehabilitation program is to normalize the range of motion, balance, coordination, strength and endurance. The estimated rehabilitation time is at least weeks [].
Surgical treatment Several different surgical procedures to stabilize the unstable ankle have been described. Most of these are either tenodeses or anatomic reconstructions. Increased laxity only, without giving way episodes, is not an indication for surgical stabilization of the ankle. It is also questionable whether repeated episodes of giving way predispose to osteoarthrosis of the ankle. Therefore, the indication for surgical intervention must always be based on the functional status of the ankle. Tenodeses have previously been the most widely used
Lower Leg, Ankle and Foot
(a)
(b)
(c) Fig. .. Stress radiographs of the ankle with lateral instability and test for it. (a) Lateral talar tilt (TT) in AP projection (°). (b) Anterior talar translation (ATT), mm. (c) Testing for the anterior drawer sign: while stabilizing the tibia with one hand, the examiner with the other hand posterior to the subject’s heel, applies an anterior draw to the foot.
Chapter . principle of surgical reconstruction. All tenodeses sacrifice normal, and in most cases, well-functioning anatomic structures around the ankle joint, either the peroneus brevis or the peroneus longus tendons. The plantaris tendon, part of the Achilles tendon, or even a free fascia lata graft may also be used. None of the tenodeses in common use can be considered anatomic reconstructions and they nearly always result in altered kinematics, with limitation of joint motion and gradual deterioration of the reconstructed ligament function. This might cause degenerative changes of the ankle in the long run, leading to osteoarthrosis. All of these procedures also restrict the subtalar motion. Biomechanical analysis of non-anatomic reconstructions have shown that normal ankle biomechanics are not restored. The four classic tenodeses — Elmslie, Evans, Watson–Jones and Chrisman–Snook — are all well known, and the short- and long-term results are well reported. The Evans tenodesis is technically the least demanding of these tenodeses (Fig. ..). However, the Evans tenodesis reconstructs neither the ATFL nor the CFL, as the tendon is positioned in a plane between these two ligaments [–]. Several authors have reported good short-term results after this reconstruction and its modifications, but the long-term re-
sults have been less encouraging. Many patients with satisfactory early results have deteriorated after a few years, resulting in unsatisfactory function in the long run. In one study it was shown that less than % of subjects had satisfactory results after a mean follow-up period of years. This reconstruction is therefore not recommended as the primary choice. The Watson–Jones tenodesis reconstructs the ATFL, but not the CFL. Thus, patients with insufficiency of the CFL will not benefit from this procedure. Several good short-term results have been reported, but long-term follow-up studies have shown disappointing functional results in approximately twothirds of the patients. Late deterioration is common, with increased laxity and reduction of ankle function, as well as pain []. The Chrisman–Snook tenodesis restores both the ATFL and the CFL (Fig. ..), and is probably the most widely used non-anatomic reconstruction today []. The peroneus brevis tendon is split longitudinally, and half of the tendon is used to reconstruct both ligaments. Satisfactory long-term results have been reported in % of patients in one study. Stress provocation has also shown less residual laxity after the Chrisman–Snook reconstruction than after the Evans reconstruction. This procedure is technically more
Fig. .. Evans operation for chronic lateral ankle instability.
Fig. .. Chrisman–Snook operation for chronic lateral ankle instability.
Lower Leg, Ankle and Foot demanding than the other tenodeses. The majority of the complications reported after using this procedure are related to the long skin incision needed for harvesting the peroneus brevis tendon. Problems with delayed wound healing and sural nerve injuries have also been described. Nevertheless, this procedure is a sound alternative, at least in patients where anatomic reconstruction cannot be performed or has failed. This procedure should probably also be considered in case a reoperation is needed. The anatomic reconstruction is the second main principle of stabilization of the unstable ankle. The remaining tissues of the injured ligaments are used, thus permitting a reconstruction without sacrificing any normal anatomic structure, such as the peroneal tendons. Broström, who described this procedure in detail, found that direct suture (repair) of the ruptured and elongated ligaments was possible, even several years after the primary injury (Fig. ..). The combination of shortening, imbrication and reinsertion to the bony attachment of the injured ligaments has been successful [,,]. Good or excellent functional results after anatomic reconstruction of the lateral ankle ligaments have been described in many studies. The surgical technique is simple and easily performed. The damaged remnants of the ATFL and CFL are divided, shortened – mm, imbricated and reinserted into bone using sutures tied over bony bridges. Satisfactory functional results have been reported in approximately % of patients, with radiographic evidence of less residual laxity. The results are, however, less satisfactory in patients with generalized hypermobility of the joints, in very longstanding ligamentous insufficiency (over years) and in patients who have undergone previous ankle joint ligament surgery. These patients should probably be treated with tenodesis; the Chrisman–Snook tenodesis has been especially recommended in these cases. Simultaneous reconstruction of both the ATFL and the CFL gives better results than reconstruction of the ATFL alone. After surgery, an air-stirrup ankle brace can be safely employed for early range of motion training without any risk of compromising the reconstructed ankle. Full weight-bearing is allowed. These procedures are technically simple with few complications, producing satisfactory functional results in both the short and long run. Until recently, no
Fig. .. Anatomical reconstruction for chronic lateral ankle instability.
Chapter . long-term results in athletes with very high demands on ankle stability have been found, but recent studies have indicated good functional results in these patients even after a long observation period. Anatomic reconstruction, rather than the more complex tenodeses, should therefore be the primary choice in patients with chronic ankle instability. Normal range of motion is most often regained during the postoperative rehabilitation after anatomic reconstruction. The loss of motion which is common after the tenodeses is a major drawback for the athlete who is in need of full functional range of motion of the ankle and this speaks in favor of anatomic reconstructions. Modifications of anatomic reconstructions have been described, mainly in order to reinforce the local structures when the ligaments are badly damaged or weak []. These modifications include using a periosteal flap from the lateral aspect of the fibula and the inferior extensor retinaculum and reinforcement of the CFL repair with the lateral talocalcaneal ligament. This procedure was primarily designed for correction of combined ankle and subtalar instability. Tensioning of the lateral ligaments and capsular tissue has also been described. The use of fresh frozen allografts in the reconstruction of the lateral ankle ligaments has also been reported to give satisfactory results in one study. Neither immunologic rejections nor complaints of late instability were reported. As no normal tissues are sacrificed, this procedure can be considered as an alternative to anatomic reconstructions if the quality of the ligamentous tissue is poor. All of these modified procedures have produced results in the range of % satisfied patients, without any significant difference between the various procedures.
Prevention Two different methods for preventing ligament injuries of the ankle exist: coordination training and external ankle support. Proprioceptive training improves both postural control and functional stability. Balance board training can reduce the incidence of ankle ligament injuries among athletes with a history of previous injury, as well as in those with previously uninjured ankles. External ankle support theoretically reduces the ligamentous laxity. Both ankle taping and semirigid braces are much used to prevent ankle ligament in-
juries, both during the rehabilitation phase after injury and to prevent the previously injured ankle joint from further injury. The mechanism behind the function of ankle tape is not fully understood. There are three possible theories: (i) reduction of the ligamentous laxity; (ii) limitation of the extremes of ankle motion; and (iii) shortening of the reaction time of the peroneal muscles by affecting the proprioceptive function of the ligaments and joint capsule.
Ligamentous laxity Laxity in both the sagittal plane (ATT) and the frontal plane (TT) has been shown in several studies to be reduced by the use of ankle tape. The frontal plane (TT) laxity is more effectively controlled than sagittal laxity. A significant reduction of TT has been shown after ankle taping. The highest degree of protection is found in ankles with the highest degree of laxity. In contrast to this, some authors have found insignificant reduction of laxity using ankle tape, analyzed as ATT and TT measured with standardized stress radiographs. The reduction of laxity is thus debated.
Limitation of ankle motion Ankle tape significantly affects the pattern of ankle motion. Tape effectively limits the extreme ranges of ankle motion. In spite of the fact that tape becomes looser after exercise, the partial reduction of laxity gained by limiting the extremes of ankle motion is possibly a major factor behind the function of ankle tape.
Functional instability Shortening the reaction time of the peroneus brevis and longus muscles by enhancing the proprioceptive function of the ankle ligaments and joint capsule might explain the mechanism behind the function of ankle tape. Ankle tape has in some studies been found to have a stimulating effect on the peroneus brevis muscle in unstable ankles, measured using EMG. A significantly slower reaction time of both the peroneus longus and peroneus brevis muscles has been found in unstable ankles than in stable ones using a trap-door mechanism and EMG measurements of the reaction time. These changes were, however, only found in ankles with increased laxity as a sign of residual ligament injury. The reaction time of the peroneal muscles in stable ankles is not shortened using ankle tape. This
Lower Leg, Ankle and Foot mechanism is not uniform in all studies and is therefore debated.
Indications and use of ankle tape Prophylactic: prevention of ligament injury in previously uninjured ankles. After injury: prevention of further ligament injury in previously injured ankles. During the rehabilitation phase as a part of the rehabilitation program, to bridge the time gap between acute injury and full recovery. Treatment of chronic ligament instability, either temporarily or permanently instead of surgery. The role of ankle tape in uninjured ankles is not well proven scientifically. The tape loses at least a part of its stabilizing effect after a short period of exercise.
Ankle tape or brace? Ankle tape is not a substitute for normal soft tissue function. Ankle tape must always be used as a part of a rehabilitation program aimed at restoring normal range of motion, muscular strength and neuromuscular coordination. Some studies have shown that ankle tape is effective in the prevention of ankle ligament injuries. The effect of prophylactic ankle taping is roughly equivalent to coordination training of the ankle. A negative factor in the use of ankle taping is the loss of mechanical support after a short period of exercise, leaving the ankle with only partial protection. In one study it was shown that approximately % of the supporting force of the tape was lost after min of exercise. Other researchers have found that after exercise most of the adhesive bandages are loose and the tape is mostly acting as canvas boots. The cost–benefit of tape used as a general prophylaxis can therefore be questioned. Several different methods of ankle taping have been described. Alternative methods include rigid or semirigid ankle braces, some of which give good external support to prevent ankle sprain and to protect ligament reconstruction. An effective and functional alternative to ankle tape is the air-stirrup, a non-rigid prefabricated shell with an inner lining of air bags. It has been shown to provide good protection by reducing the range of ankle motion. The air-stirrup can be recommended, especially during early tissue healing and full functional recovery (– weeks after injury).
Ankle tape and braces are effective in protecting the ankle joint during the rehabilitation phase after acute ligament injuries. These methods can also be used for the prevention of ankle distorsions or as treatment in chronic cases. The best stabilizing effect is generally obtained in ankles with the highest degree of laxity. If an external support is required during physical exercise, a brace of good quality should be chosen, due to lower cost.
Subtalar instability Subtalar instability lacks clinical and scientific definition. In spite of this, ligament insufficiency of the subtalar joints is now recognized as one of the important factors behind the development of chronic functional instability, and it is probably frequently overlooked. The incidence of subtalar instability is unknown, but the estimated prevalence is % in patients with chronic lateral ankle instability, although this is not documented. Using subtalar arthrography, injuries to the subtalar joints have been found in a high proportion of patients who have sustained acute lateral ligament injuries. The clinical diagnosis of subtalar instability is difficult and unreliable. The diagnosis can be supported by using subtalar arthrography, subtalar stress view or stress tomography. The value of MRI, CT and ultrasonography is unknown. In patients with symptomatic chronic instability of subtalar joints not responding to a supervised rehabilitation program anatomic reconstruction or tenodesis may be recommended. The short-term results of these procedures are promising, but further studies are needed to evaluate their long-lasting function. No comparative studies exist, and the optimal treatment is not known.
Deltoid ligament rupture The deltoid ligament is located on the inside of the ankle. This ligament is thick and strong and, in addition, is in both superficial and deep planes. Damage to this ligament is therefore much more uncommon than to the lateral ligaments. The injury arises following outward rotation of the foot. There can be partial or total rupture of the ligament depending on the amount of force and the direction. Ligament injury can occur in isolation, but is more common in association with a fracture of the ankle.
Chapter . There is pain and swelling at the inside of the ankle. The pain is most pronounced at the front of the ligament. A test of stability is difficult to perform, even for an experienced examiner. Definite instability can therefore often not be established. Radiographic examination is often necessary, in order to rule out fracture.
Treatment Acute treatment is according to the RICE principle, with pressure dressing and possibly ice-packs. After the pressure dressing has been removed, a compression bandage is applied. As soon as the pain allows rehabilitation with agility, balance and weight training can be begun. There are no studies which show that immobilization or surgery in the acute phase improve results, in either the short or long term. Healing time is significantly longer and the discomfort greater than with acute ligament damage to the lateral ankle ligaments. Swelling and pain often persist for several weeks or months. It is important to give the injury a chance to heal without forcing treatment, to reduce the risk of prolonged inflammation together with pain and a reduction in function. There is very little need for surgery in the long run.
Syndesmosis rupture Rupture of syndesmosis ligaments is uncommon. The injury generally occurs in association with a fracture, but can in rare cases also arise as an isolated injury. Damage to syndesmosis ligaments occurs upon forced outward rotation of the ankle (Fig. ..). In most cases it is the anterior syndesmosis ligament (anterior tibiofibular ligament) which is damaged. Acute surgery is generally necessary to prevent future reduction of functions. There can be a fracture of the fibula directly below the knee joint. Careful examination with palpation of the whole fibula is therefore necessary, if there is suspected rupture of syndesmosis ligaments. Rupture of syndesmosis ligaments can be difficult to detect. Careful clinical examination is therefore important. There is swelling and pain over the ligament, which is further forward and higher up the lower leg than with a normal acute ligament injury. Severe pain occurs upon provocation of the syndesmosis ligaments during forced outward rotation of the foot in relation to the lower leg. This test can, how-
Fig. .. Rupture of the syndesmosis with widening of the medial joint space.
ever, be difficult to carry out in acute cases. It should therefore be complemented with radiographic examination to rule out a fracture and examination for instability by means of fluoroscopy. The provocation test reveals instability between the tibia and fibula upon maximum outward rotation of the foot if the syndesmosis ligaments are damaged.
Treatment Acute surgery to stabilize the syndesmosis by osteosynthesis and suturing of the ligament is recommended. Early rehabilitation training is possible if surgery achieves good stability. Chronic pain may follow damage of the syndesmosis, which has not been detected in the acute phase. Healing time is approximately – weeks. With early active training, a return to play can take place slightly more quickly.
Dislocation of the peroneal tendons Dislocation of one of the peroneal tendons, in most cases the short peroneal tendon, occurs when the tendon moves or dislocates out of the shallow groove located behind the lateral malleolus. The retinaculum,
Lower Leg, Ankle and Foot which holds the tendon in place, tears. The injury arises during inward rotation and simultaneous inward twisting of the foot. The acute symptoms are almost identical to those of acute ligament damage, i.e. pain and swelling around the lateral malleolus. Clinical diagnosis is generally difficult and the injury is therefore not always detected. With suspected dislocation of the peroneal tendon, the foot is rotated inward at the same time as the peroneal muscles on the outside of the lower leg are activated. Movement of the peroneal tendon over the lateral malleolus can then be seen and felt. If there is recurrent instability, the tendon can dislocate over the lateral malleolus; this causes a perceptible clicking and is clearly visible. The condition is often painful.
diagnosis. The diagnosis can be confirmed if injection of a small amount of local anesthetic around the bone makes the pain during loading of the foot disappear. Further examination, e.g. MRI, is not necessary.
Treatment Initial treatment consists of correction of external training factors, such as changes in the amount of training and training surface. Tape, which reduces movement of the ankle — especially on downward bending, can also be used. If the player has pronounced, persistent pain which prevents training or play, surgical removal of the bone is appropriate. Prognosis following surgery is generally good. Return to full activity after approximately weeks can be expected.
Treatment Initial treatment of acute dislocation of the peroneal tendon is a compression dressing and ice-packs. Immobilization using a plaster cast or a brace is recommended for – weeks and is then followed by active rehabilitation, weight-bearing and balance training. If the acute damage heals spontaneously, sports activity can be started after – weeks. With recurrent instability surgical stabilization of the tendon is necessary. Several different methods can be used. Recent studies have shown that simple reconstruction of the ligament and ligament reinforcement in the rear of the ankle give good results. The prognosis is good in most cases. Results following surgery are generally good. The majority of sports active people regain normal flexibility and strength in the ankle and can return to the same level of activity as before the injury.
Os trigonum One of the accessory bones in the foot which can give rise to problems is the os trigonum, which is located behind the ankle joint, between the talus and the Achilles tendon. Upon plantar flexion of the foot, the bone can become trapped and produce pain. This bone is normally found in approximately % of the population, but only causes problems if the area is subjected to high stress or pinching. The diagnosis is clinical, based on the occurrence of pain in the posterior part of the ankle joint during stress, such as running on uneven ground or stepping on tiptoe. Radiographic examination corroborates the
Footballer’s ankle Footballer’s ankle (‘anterior impingement’) arises relatively often in footballers, especially at the end of their career. The injury occurs after repeated minor injuries to the front of the ankle. In tearing of the joint capsule attachment to the tibia and talus, small bone fragments become detached, initiating outgrowth of bone osteophytes, which gradually build up on the edges of the joint surface (Fig. ..). During examination there is pain upon palpation in the front of the ankle joint and pain upon provocation when the foot is dorsally extended. Further, dorsal extension is often reduced. Footballer’s ankle is not uncommonly combined with chronic ligament instability. Initially the injury can be treated with antiinflammatory drugs and stabilizing ankle support such as tape, to prevent pain. However, surgery is often necessary. During the operation, the anterior osteophytes are removed. The surgery can be performed very well arthroscopically. The damage is benign, but often bothersome and painful. Results following surgery are generally good and the sports active can return to the same level of activity as before, after approximately weeks.
Osteochondritis dissecans The cause of osteochondritis dissecans is unknown. The pathologic condition is in the talus, generally on the posteromedial corner (Fig. ..), but anterolat-
Chapter .
Fig. .. Radiography of footballer’s ankle.
erally related to ligament damage to the lateral aspect of the ankle joint. The condition is most common in young people, but does not often produce symptoms until adulthood. There is either a bony fragment covered by cartilage, or detachment of the bone fragment which moves freely in the joint and can cause catching, locking and pain. Symptoms are either pain during exertion or recurring catching and/or locking, if a loose body has formed in the joint. The first symptoms are often pain on movement and reduced range of motion.
Fig. .. Medial osteochondritis of the talus as seen on MRI.
In order to establish a diagnosis radiographic examination is always necessary. In certain cases, arthroscopic inspection can be of great value in assessment, especially if surgical treatment becomes necessary. Sometimes osteochondritis dissecans is detected on radiographs taken for other reasons. Treatment depends on the findings made during direct examination. If the bony fragment is loose, re-
Lower Leg, Ankle and Foot moval of this is recommended, if possible by arthroscopic surgery. This results in a bony surface which is not covered with cartilage in the joint surface of the talus. If, on the other hand, the surface of the cartilage is intact, an attempt is made to induce healing of the bone fragment by drilling or pinning. Prognosis is best in children and young people, especially if the cartilage joint surface is intact. If a free body has formed in the joint, the prognosis is worse with a risk of cartilage damage from wear, giving rise to osteoarthrosis.
Injuries to the foot The foot is divided into three functional units — the forefoot, the midfoot and the hindfoot. The foot is composed of bones, not including the two sesamoid bones under the first metatarsophalangeal joint. There are additional named accessory bones in the foot. Some of these, such as the os trigonum in the rear of the ankle, can give rise to problems. In all, there are named joints in the foot and over ligaments which keep these joints together. Problems in the foot in connection with sport are either acute injuries or strain injuries. Fractures of the toes or the metatarsal bones are the most common acute injuries. Many of these fractures are not greatly dislocated and can be treated simply by temporary non-weight-bearing and in severe cases immobilization in a cast, and will heal in – weeks. Healing time, before full-scale sports activity can be resumed, is generally roughly twice that. The prognosis for fractures of the toes and bones in the metatarsus is, with a few exceptions, good. Serious injuries involving fractures or dislocations of the foot are rare during sports activity. In rare cases there are for example compound fractures and dislocations in the joint between the forefoot and the midfoot. Diagnosis can be difficult to make. If such an injury is suspected with pain upon provocation, radiographic examination should be carried out. In certain cases, this must be complemented with CT. It is then often revealed that the injury is more serious than was originally estimated.
Haglund’s disease Haglund’s disease is similar to Osgood–Schlatter’s disease in the knee joint as far as symptoms and origin are concerned. This disease occurs particularly in
young people between and , and the problem disappears during late puberty. The Achilles tendon attachment is strained where the tendon attaches to the heel bone, probably after running on a hard surface, when the Achilles tendon attachment is subject to repeated tension. Fragmentation of bone then occurs and can be seen on radiographs. There is pain and a painful protuberance in the back of the heel, as well as soreness on palpation. The pain increases particularly before and after physical activity. It is a clinical diagnosis which can be confirmed by radiographic examination, which shows a fragmentation of the bone. Treatment is focused on symptoms. Footwear adjustment and a soft insole, such as a heel cup, with a slight heel lift, which reduces symptoms, can be appropriate. In certain cases temporary rest combined with alternative exercise can be necessary. It is completely safe to continue sports activities despite the discomfort. Prognosis is practically always good and the condition is self-healing. A large, protruding lump can be left on the calcaneus, which in isolated cases leads to later problems in connection with exercise and sport.
Plantar fasciitis (calcaneal spur) This condition is a stress injury in the tendon aponeurosis (plantar fascia) on the underside of the foot (Fig. ..). Athletes are at particular risk if they are playing on a hard surface, especially if they use shoes with insufficient shock absorption. Partial rupture with inflammation in the plantar fascia attachment to the calcaneus, or tendinosis (degenerative changes) increases the pain. Athletes with a high (pes excavatus) or low (pes planus) foot arch are considered more vulnerable than others. The most common symptom is pain, which correlates to strain, especially during running or jumping, in particular when the heel strikes the ground or upon tension of the plantar fascia. There is generally pain after training and stiffness is pronounced. Radiographs generally show no specific changes, but sometimes a ‘calcaneal spur’ can be seen. It is not the cause of the problem, but rather a result of it. Radiographic examination is recommended most of all to exclude or confirm other diagnoses, such as stress fracture of the calcaneus.
Chapter .
(a)
(b)
Fig. .. The structures of the foot: (a) the plantar aponeurosis (fascia plantaris); (b) flexor muscles deep to the aponeurosis.
Treatment Correction of external factors, such as unsuitable footwear, excessively hard training surface and internal factors, such as malalignment of the foot, is necessary. Activities should be modified; e.g. running on the forefoot/toes should be avoided. Even running which involves mainly starting, stopping and/or changes in direction should be kept to a minimum. Temporary rest, combined with alternative exercise, can be necessary. Stretching of the plantar fascia is recommended, along with an insole to correct high or low foot arch. Anti-inflammatory drugs can produce good results in the acute phase. Corticosteroid injections can also produce good results. Surgery with tenotomy of the plantar fascia at the calcaneus is only indicated in exceptional cases. The healing period is often very long, but the prognosis is good and the condition normally heals on its own, although it can take several months until the athlete is completely free from pain.
Stress fracture A stress fracture can occur in any bone of the foot, but is most common in the second metatarsal (known as a
march fracture). This type of stress fracture generally arises in long-distance runners. Stress fractures also occur with lower incidence in the fifth metatarsal, in the navicular bone, talus and calcaneus. Women are more vulnerable than men. The injury mechanism in a stress fracture is always excessive strain, i.e. the strain is greater than the bone can withstand. External factors, such as inappropriate footwear, too much training or excessively hard ground are often contributing factors. In the initial stage, there is stress-related pain during exertion, such as running on a hard surface, but no pain at rest. The pain increases gradually. Although training is possible in this phase, it eventually becomes too painful. Upon examination there is localized pain when pressure is applied and on provocation. There is rarely any swelling. Radiographs initially reveal no fracture. Radiographic examination should be repeated after – weeks. The fracture is then often visible. In cases where there is strong suspicion of a stress fracture, an isotope scan (scintigraphy) should be carried out. This shows the fracture within a day of the injury. Diagnosis of a stress fracture of the navicular bone, talus and calcaneus can be difficult. The fracture is often invisible on plain radiographs. When there is a high suspicion of fracture of these bones, isotope scans, CT or MRI should be performed. Delayed diagnosis can lead to impaired results of treatment. Treatment varies depending on which bone is injured. Keeping weight off the foot, combined with alternative training, e.g. wet-vest training, until the athlete is free from pain, is important. In certain cases immobilization by means of plaster or a brace can be necessary. The general treatment of a metatarsal stress fracture is keeping weight off the foot for weeks, either with or without a plaster. With other stress fractures, such as the navicular bone, talus or calcaneus, longer immobilization is generally necessary (– weeks). In spite of this, healing complications are not infrequent, but surgery is rarely necessary. A stress fracture in the metatarsal generally heals without persisting problems, but the healing period varies. The healing period for a stress fracture in the navicular, talus and calcaneus is long and rehabilitation can also be very long, often as much as months. How-
Lower Leg, Ankle and Foot
ever, with correct diagnosis, treatment and rehabilitation, the prognosis for healing is generally good.
Jones fracture Jones fracture is a stress fracture to the proximal part of the fifth metatarsal. The fracture has a slightly worse healing prognosis than other stress fractures in the metatarsus. The reason for this is that the peroneal brevis tendon attaches to the proximal part of the bone. This leads to increased risk of delayed healing or formation of a false joint (pseudoarthrosis). There is pain over the proximal part of the fifth metatarsal upon direct pressure and provocation, and there can be slight swelling. If there is suspected fracture, radiographic examination is recommended. If disturbances in healing and a false joint are suspected, CT or MRI can be necessary to confirm the diagnosis.
Treatment The fracture should be treated with immobilization, using plaster cast or a brace, for – weeks. Despite this, the risk of healing complications is relatively large. With delayed healing or development of a false joint, osteosynthesis with an intramedullary screw is recommended. Healing complications are relatively common. Following surgery, however, prognosis is generally good. Return to sports activity is possible in approximately – weeks.
Fracture of the sesamoid bone Under the metatarsal of the big toe there are two sesamoid bones in the flexor tendon. Damage to these bones is relatively common in sports, especially when training on a hard surface. Fracture of the sesamoid bone can occur as a stress injury and a false joint can develop. Persistent problems with pain often arise. The damaged sesamoid bone causes pain upon direct pressure. Radiographs, which are not always necessary, however, show that the bone is in two pieces (false joint). This fracture is treated by keeping weight off the foot, using an insole and reducing the amount of training. Surgery is indicated only in exceptional cases and involves removal of the damaged sesamoid bone. This is especially appropriate when the damage is to the
Fig. .. Hallux rigidus with dorsal, bony impingement.
medial sesamoid bone. Prognosis is good in the majority of cases.
Hallux rigidus Hallux rigidus is caused by degenerative changes (arthrosis) in the metatarsophalangeal joint of the big toe. There is pain and increasing stiffness in the metatarsophalangeal joint of the big toe. Upon examination movement is reduced, especially in dorsal extension. In addition, there is a painful bony outgrowth, which is mainly felt on top of the metatarsophalangeal joint (Fig. ..). Radiographic examination provides the diagnosis. It shows bony spurs at the dorsal aspect of the joint or reduced joint space in the whole joint.
Treatment Taping of the big toe avoids the extremes of motion, in particular dorsal flexion, and relieves symptoms. A relatively stiff insole is often used, although with varying success. Surgery often becomes necessary. Excision of the bony growth on the top of the joint is recommended. Freedom from pain is achieved if movement can be restored. Other operations, such Keller’s operation or fusion, are rarely successful in athletes. The condition can be very painful and lead to protracted problems. Surgery generally only gives temporary success.
Morton’s metatarsalgia (interdigital neuroma) Morton’s neuroma has recently been defined as a nerve entrapment of one of the interdigital nerves in the
Chapter . forefoot, in most cases between the third and fourth metatarsal heads. The older term neuroma is not correct and should accordingly be replaced. The typical complaint is a radiating pain into the toes. The pain is also often associated with numbness. The pain is elicited and increased by narrow-fitting footwear and weight-bearing activities such as running or skiing. Localized tenderness and an audible click during compression of the metatarsal heads is usually present. This click is most often painful. In several cases excessive pronation of the hindfoot is found, leading to metarsal hypermobility and increased risk of interdigital nerve entrapment. Primary treatment is aimed at reduction of acute pain with a metatarsal padding and shoe insole, in order to spread the load of the metatarsals during weight-bearing. Foot muscle strengthening may be indicated to improve balance and foot strength. In chronic cases little improvement is seen with nonsurgical treatment. Corticosteroid injection in the interdigital space can be used and in case of excessive pronation corrective insoles should be used. If all other treatment fails, surgical excision of the entrapped nerve through either a plantar or dorsal excision usually gives good pain relief.
Summary Overuse injuries of the lower leg are most commonly seen in runners and include medial tibial stress syndrome, stress fracture of anterior or posterior tibia and compartment syndromes. The diagnostic considerations and treatments have been discussed. Achilles
tendon problems are common, most often as tendinosis in the tendon or paratendon, and sometimes as acute tendinitis/peritendinitis. The various treatment options, correction of biomechanical dysfunction, hard eccentric muscle training, corticosteroid injections and surgery, are generally not evidence based, but the prognosis is usually good. Dysfunction or rupture of the tibialis posterior tendon can result in collapse of the medial arc of the foot. Ninety per cent of acute ankle ligament injuries are lateral and most often the anterior talofibular ligament is ruptured. Grade I and II injuries are treated nonsurgically with functional rehabilitation. Treatment of Grade III injuries can be surgical or non-surgical. Ten to % suffer from chronic functional ankle instability after an acute injury. The primary treatment is strengthening of peroneal muscles, regain of proprioception and re-establishment of the normal protective reflexes by functional training. With continuous instability surgical stabilization is indicated. Anatomic procedures have better long-term results than tenodeses. Prevention has been discussed. Footballer’s ankle with tibial osteophytes, loose bodies in the ankle joint, ligament tears and cartilage injury can be treated with arthroscopic housecleaning. Stress fractures of the middle foot or metatarsal bones are not unusual in the athletic population. Plantar fasciitis is also common in runners and jumpers, and responds well to correction of mechanical dysfunction.
Case story 6.1 A -year-old-soccer player with a history of ankle problems for more than years initially sustained a serious inversion trauma of the ankle. The ankle was swollen and he was unable to bear weight. Radiographic examination did not reveal any skeletal injuries. The patient was treated with compression bandaging and range of motion exercises. He was allowed to return to sports (soccer) after weeks.
He did not, however, recover fully. His ankle repeatedly gave way, combined with swelling and pain. In spite of this he was able to continue playing soccer using an ankle tape. The problem has increased and he has now been forced to quit playing soccer. Why did he not recover and why did his ankle keep giving way? How should he be evaluated and treated?
Lower Leg, Ankle and Foot
The most important factor at this stage is the almost total lack of rehabilitation. The player was allowed to return to sports without a proper rehabilitation, and furthermore there was a delay in returning to sport of several weeks. With a well-conducted rehabilitation program, most players are able to return to sports such as soccer after approximately week. However, the rehabilitation program should be continued for at least weeks. Therefore, the most probable reason why the player did not recover was the lack of rehabilitation. This is regretfully a rather frequent occurrence. This player is probably suffering from ligamentous insufficiency of the lateral ankle ligaments, a rather common sequela after acute injury. At this stage the patient should be evaluated for ligamentous insufficiency, but also for secondary bony or cartilage changes. It should be remembered that ligament instability alone does usually not lead to repeated swelling and pain. Besides a thorough clinical evaluation, the first investigation should be plain radiographs in order to evaluate the ankle joint for skeletal changes, such as anterior tibia or talus osteophytes, loose bodies or even osteoarthrosis. Secondary changes at the joint line, such as osteophytes, are common, but arthrosis is not. At clinical investigation, the ankle displayed increased laxity, i.e. increased anterior drawer sign and inversion, indicating ligament injury. The ankle was slightly swollen, with distinct tenderness and swelling behind the lateral malleolus. The plain radiographs were negative. At this stage it should be decided whether the patient is to be treated surgically or non-
Multiple choice questions The most important investigation which should be performed within days in case of a suspected stress fracture of the navicular bone of the foot is: a anterior–posterior and lateral radiographs
surgically or even investigated further. The retromalleolar pain and swelling could be investigated using either ultrasonography of the peroneal tendons or MRI. It was decided to treat the patient with a prolonged and well-supervised rehabilitation program. After months, the patient still had problems, with giving way and pain. MRI of the ankle with special emphasis on the peroneal tendons was therefore performed. This imaging study showed a longitudinal rupture of the peroneus brevis tendon behind the lateral malleolus. How should the patient be treated? It was decided to treat the patient with a ligament reconstruction of the ankle joint. Anatomic reconstruction of both the anterior talofibular and the calcaneofibular ligaments was performed. At the same time the injury of the peroneus brevis tendon was repaired after excision of the partial rupture using side-to-side sutures and furthermore the superior peroneal retinaculum was reconstructed using drill holes through the posterior edge of the fibula. The ankle was immobilized in a below-the-knee plaster for weeks and thereafter in an air-cast brace for a further weeks. The rehabilitation was uneventful and the patient recovered well. What we can learn from this is that all patients who sustain an ankle ligament injury should undergo a well-planned and supervised rehabilitation program and further that ankle ligament injuries may be more serious than anticipated. In this case a serious tendon injury was present and needed to be addressed before the patient eventually became free of symptoms.
b c d e
computed tomography (CT) bone mineral content investigation magnetic resonance imaging (MRI) none of the above.
Chapter . The healing time of deltoid ligament injuries of the ankle is: a approximately the same as for lateral ligament injuries b approximately two to three times longer than for lateral ligament injuries c approximately five to ten times longer than for lateral ligament injuries d likely to result in surgery in more than % of cases e none of the above. Stress fractures of the tibia are: a the most common stress fractures of the lower extremity b connected with more healing problems when located in the anterior aspect (cortex) of the tibia than the posterior c connected with more healing problems when located in the posterior aspect (cortex) of the tibia than the anterior d likely to result in surgery in more than % of cases e none of the above. Total (complete) rupture of the Achilles tendon: a is always associated with chronic degeneration of the tendon b is never associated with chronic degeneration of the tendon c will always need surgical treatment d will never need surgical treatment e none of the above. Partial rupture of the Achilles tendon: a is equivalent to Achilles tendinitis b is equivalent to tendinosis of the Achilles tendon c never needs surgical treatment d always needs surgical treatment e none of the above.
References Touliopolous S, Hershman EB. Lower leg pain: diagnosis and treatment of compartment syndromes and other pain syndromes of the lower leg. Sports Med ; : –. Clement DB, Taunton JE, Smart GW, McNicol KL. A survey of overuse running injuries. Physician Sportsmed ; : –. Lysholm J, Wiklander J. Injuries to runners. Am J Sports Med ; : –. James SL, Bates BT, Osternig LR. Injuries to runners. Am J Sports Med ; : –.
Puranen J, Alavaikko A. Intracompartmental pressure increase on exertion in patients with chronic compartment syndrome in the leg. J Bone Joint Surg (Am) ; -A: –. Reneman RS. The anterior and lateral compartment syndrome of the leg due to intensive use of muscles. Clin Orth Rel Res ; : –. Styf J. Diagnosis of exercise-induced pain in the anterior aspect of the lower leg. Am J Sports Med ; : –. Hulkko A. Stress fractures in athletes. Doctoral thesis, University of Oulu, Finland, . Detmer DE. Chronic shin splints: classification and management of medial tibial stress syndrome. Sports Med ; : –. Mubarak SJ, Gould RN, Lee YF, Schmidt DA, Hargens AR. The medial tibial stress syndrome (a cause of medial shin splints). Am J Sports Med ; : –. Michael RH, Holder LE. The soleus syndrome: a cause of medial tibial stress (shin splints). Am J Sports Med ; : –. Davey JR, Rorabeck CH, Fowler PJ. The tibialis posterior muscle compartment: an unrecognized cause of exertional compartment syndrome. Am J Sports Med ; : –. Micheli LJ, Solomon R, Solomon J, Plasschaert VF, Mitchell R. Surgical treatment for chronic lower-leg compartment syndrome in young female athletes. Am J Sports Med ; : –. Rorabeck CH, Fowler PJ, Nott L. The results of fasciotomy in the management of chronic exertional compartment syndrome. Am J Sports Med ; : –. Schepsis AA, Gill SS, Foster TA. Fasciotomy for exertional anterior compartment syndrome: is lateral compartment release necessary? Am J Sports Med ; : –. Schepsis AA, Leach RE. Surgical management of Achilles tendinitis. Am J Sports Med ; : –. Collins PS, McDonald PT, Lim RC. Popliteal artery entrapment: an evolving syndrome. J Vasc Surg ; : –. Brubaker CE, James SL. Injuries to runners. Sports Med ; : –. Matheson G, Clement D, McKenzie D, Taunton J, Lloyd-Smith D, McIntyre J. Stress fractures in athletes. A study of cases. Am J Sports Med ; : –. Johansson C, Ekenman I, Lewander R. Stress fractures of the tibia in athletes: diagnosis and natural course. Scand J Med Sci Sports ; : –. Burrows J. Fatigue infraction of the middle of the tibia in ballet dancers. J Bone Joint Surg (Brit) ; -B: –. Rolf C, Ekenman I, Gad A, Törnqvist H. The anterior stress fracture of the tibia — an atrophic pseudarthrosis? Scand J Med Sci Sports ; : –. Stanitski CL, McMaster JH, Scranton PE. On the nature of stress fractures. Am J Sports Med ; : –. Green N, Rogers R, Libscomb A. Nonunions of stress fractures of the tibia. Am J Sports Med ; : –. Rettig A, Shelbourne D, McCaroll J, Bisesi M, Watts J. The natural history and treatment of delayed union stress
Lower Leg, Ankle and Foot
fractures of the anterior cortex of the tibia. Am J Sports Med ; : –. Rolf C. Overuse injuries in the lower extremity in runners. Scand J Med Sci Sports ; : –. Orava S, Karpakka J, Hulkko A, Vahanen K, Takala T, Kallinen M, Alen M. Diagnosis and treatment of stress fractures located at the mid-tibial shaft in athletes. Int J Sports Med ; : –. Ekenman I, Tsai-Felländer L, Westblad P, Turan I, Rolf C. A study of intrinsic factors in patients with stress fractures of the tibia. Foot Ankle ; : –. Morberg P, Jerre R, Swärd L, Karlsson J. Long-term results after surgical management of partial Achilles tendon ruptures. Scand J Med Sci Sports ; : –. Sandmeier R, Renström PAFH. Diagnosis and treatment of chronic tendon disorders in sports. Scand J Med Sci Sports ; : –. Józsa L, Reffy A, Kannus P, Demel S, Elek E. Pathological alterations in human tendons. Arch Orthop Trauma Surg ; : –. Józsa L, Kannus P. Human Tendons: Anatomy, Physiology and Pathology. Champaign, IL: Human Kinetics, . Järvinen M, Józsa L, Kannus P, Järvinen TLN, Kvist M, Leadbetter W. Histopathological findings in chronic tendon disorders. Scand J Med Sci Sports ; : –. Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of patients. J Bone Joint Surg (Am) ; -A: – . Kannus P, Józsa L, Natri A, Järvinen M. Effects of training, immobilization and remobilization on tendons. Scand J Med Sci Sports ; : –. Kannus P, Natri A. Etiology and pathophysiology of tendon ruptures in sports. Scand J Med Sci Sports ; : – . Kvist M, Józsa L, Järvinen MJ, Kvist H. Chronic Achilles paratenonitis in athletes: a histological and histochemical study. Pathology ; : –. Åström M, Rausing A. Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clin Orth Rel Res ; : –. Leadbetter WB. Cell-matrix response in tendon injury. Clin Sports Med ; : –. Clement DB, Taunton JE, Smart GW. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med ; : –. Alfredsson H, Pietilä T, Lorentzon R. Chronic Achilles tendinitis and calf muscle strength. Am J Sports Med ; : –. Curwin SL, Stanish WD. Tendinitis: Its Etiology and Treatment. Lexington, MA: Collamore Press, DC Heath, . Möller M, Movin T, Granhed H, Lind K, Faxen E, Karlsson J. Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and
nonsurgical treatment. J Bone Joint Surg (Brit) ; : –. Clancy WG Jr, Neidhart D, Brand RL. Achilles tendonitis in runners: a report of five cases. Am J Sports Med ; : –. Ljungqvist R. Subcutaneous partial rupture of the Achilles tendon. Acta Orthop Scand Suppl ; –. Nelen G, Martens M, Burssens A. Surgical treatment of chronic Achilles tendinitis. Am J Sports Med ; : –. Ferkel RD, Karzel RP, Del Pizzo W, Friedman MJ, Fischer SC. Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med ; : –. Balduini FC, Vegso JJ, Torg JS, Torg E. Management and rehabilitation of ligamentous injuries of the ankle. Sports Med ; : –. Broström L. Sprained ankles: a pathologic, arthrographic and clinical study. Dissertation, Karolinska Institute, Stockholm, Sweden, . Kannus P, Renström P. Treatment for acute tears of the lateral ligaments of the ankle. Current concepts review. J Bone Joint Surg (Am) ; -A: –. Karlsson J, Bergsten T, Peterson L, Zachrisson BE. Radiographic evaluation of ankle joint stability. Clin J Sports Med ; : –. Freeman MAR, Dean MRE, Hanham IWF. The etiology and prevention of functional instability of the foot. J Bone Joint Surg (Brit) ; -B: –. Freeman MAR. Instability of the foot after injuries to the lateral ligament of the ankle. J Bone Joint Surg (Brit) ; -B: –. Freeman MAR. Treatment of ruptures of the lateral ligament of the ankle. J Bone Joint Surg (Brit) ; -B: –. Karlsson J, Andreasson GO. The effect of external ankle support in chronic lateral ankle joint instability. An electromyographic study. Am J Sports Med ; : – . Karlsson J, Peterson L, Andreasson GO, Högfors C. The unstable ankle: a combined EMG and biomechanical modeling study. Int J Sports Biomech ; : –. Johansen A. Radiological diagnosis of lateral ligament lesion of the ankle: a comparison between talar tilt and anterior drawer sign. Acta Orthop Scand ; : –. Karlsson J, Lansinger O, Faxen E. Conservative treatment of chronic lateral instability of the ankle. Swedish Med J ; : –. Karlsson J, Lansinger O. Lateral instability of the ankle joint. Clin Orth Rel Res ; : –. Evans DL. Recurrent instability of the ankle: a method of surgical treatment. Proc Roy Soc Med ; : . Karlsson J, Bergsten T, Lansinger O, Peterson L. Lateral instability of the ankle treated by the Evans procedure: a long-term clinical and radiological follow-up. J Bone Joint Surg (Brit) ; -B: –. Karlsson J, Bergsten T, Lansinger O, Peterson L. Recon-
Chapter . struction of the lateral ligaments of the ankle for chronic lateral instability. J Bone Joint Surg (Am) ; -A: –. Rijt AJ, Evans GA. The long-term results of Watson–Jones tenodesis. J Bone Joint Surg (Brit) ; -B: –. Chrisman OD, Snook GA. Reconstruction of lateral ligament tears of the ankle. An experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J Bone Joint Surg (Am) ; -A: –.
Karlsson J, Bergsten T, Lansinger O, Peterson L. Surgical treatment of chronic lateral instability of the ankle joint: a new procedure. Am J Sports Med ; : –. Löfvenberg R, Kärrholm J, Ahlgren O. Ligament reconstruction for ankle instability. A -year prospective RSA follow-up of cases. Acta Orthop Scand ; : –. Sjölin SU, Dons-Jensen H, Simonsen O. Reinforced anatomic reconstruction of the anterior talofibular ligament in chronic anterolateral instability using a periosteal flap. Foot Ankle Int ; : –.
Chapter 6.2 Knee LARS ENGE B RE TSE N, THOMA S MUE LL NE R, ROBERT L APRA DE , FRE D WE NTORF, RANA TARI Q , JA ME S H- C. WA NG, DAVI D STONE & SAVIO L.- Y. WOO
Classical reference Palmer I. Primary repair of ruptures of the anterior cruciate ligament. Acta Chir Scand Suppl ; LIII Vol LXXXI. Even though several authors had published on the injury and repair of the anterior cruciate ligament in the early s, the father of modern treatment of cruciate ligament injuries is thought to be the Swedish professor Ivar Palmer. His publication of the repair technique of the anterior cruciate ligament (ACL; Fig. ..) led to renewed interest in the biology and mechanics of ACL injury as well as to a number of animal and clinical studies on its subsequent repair.
Palmer describes his interest in the knee ligament in the preface of his thesis: ‘My interest in injuries to the ligaments of the knee joint dates back to , when two cases of crucial band injury came under my care practically simultaneously while I was working in a
(b) (a)
Fig. ..
Chapter . country town. During my four years of service at the Sabbatsberg Hospital, Surgical Clinic II, very extensive material has been placed at my disposal. Throughout this period, the chief of the clinic, Med. Dr. K.H. Giertzhas, with his encouragement and confidence and never failing interest, stimulated me in my attempts to solve the problem of the diagnosis of ligament injuries and to evolve new methods for their treatment. It is therefore a pleasant duty to express to him my respectful and profound gratitude.’ ‘No large series of reliably diagnosed, uniformly treated and sufficiently followed up cases of ligamentous injury has been published. The presentation of the therapy of lesions of the bands is therefore mainly based on my own experience. In some respects, the operative procedure may be claimed to be relatively new, for example as regards the treatment of recent and longstanding injuries to the posterior cruciate ligament and of the recent injuries to the tibia collateral ligament. However, the clinical observations are based on too few cases to be considered incontestable, and, in most of the cases, the follow-up period is too short. Therefore, in this paper no claims are made to import any established clinical truths or definitive therapeutic rules, but is rather intended to arouse more interest in this branch of surgery — the surgery of the ligaments. What can chiefly be attained hereby is more general recognition of these lesions and greater uniformity in their diagnosis. In this way, material will gradually be collected which can be used for a conclusive investigation on the value of various therapeutic methods and the prognosis in cases of ligamentous injuries. To achieve this end, large series and long follow-up periods are necessary.’ Since , more than papers regarding the cruciate ligaments have been published. Not all of them have used Ivar Palmer’s careful approach. His words of caution on the interpretation of scientific data are still very much valid!
Introduction: knee problems in sports Knee problems are among the most common sports injuries [–]. The fact that knee ligament injuries are the most common sports injury leading to medical disability compensation from insurance companies shows the seriousness of these injuries. The diagnosis of an
Table .. Differential diagnoses in acute knee injury.
Most common Injury leading to hemarthosis Rupture of the anterior cruciate ligament Peripheral meniscal tear
Less common
Must not be missed
Avulsion of the anterior cruciate ligament in children Osteochondral fracture
Knee dislocation
Cartilage injury
Epiphysealinjury Rupture of the lateral ligament and posterolateral corner
Rupture of the extensor apparatus
Fracture of the tibial plateau Patellar dislocation Injury without hemarthosis Central meniscal tear Rupture of the medial collateral ligament
Rupture of the posterior cruciate ligament
acute knee injury is difficult and necessitates knowledge of anatomy and biomechanics as well as good clinical skills. In addition, a good overview of imaging techniques is necessary. Table .. shows the most common diagnoses in the acute situation. The incidences of these injuries is well known. The incidence of meniscal injuries is /, and of ACL injuries –/ depending on the population at risk []. In Europe, team handball has a much higher incidence (–/ h play/year) of ACL injuries with women – times more at risk than men []. To get an impression of what physicians will be exposed to in a Scandinavian capital, the numbers from the Emergency Department at Oslo University may be representative. Of acute musculoskeletal injuries treated at the main emergency room at Oslo University in , were knee injuries. Of these were classified as serious (Table ..).
Knee Table .. Main diagnosis in cases of serious knee injuries treated at the emergency room at Oslo University Hospital in . Diagnosis
n
%
ACL total tear PCL total tear Medial meniscal tear Lateral meniscal tear Patellar dislocation MCL tear grade III LCL tear grade III
87 6 105 20 39 13 1
32 2 39 7 14 5 0
ACL, anterior cruciate ligament; LCL, lateral collateral ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament.
Following the introduction of magnetic resonance imaging (MRI) as a possible diagnostic tool, the detection of serious knee injuries has become easier. At the Emergency Department in Oslo it led to an increase in the detection rate of serious knee injuries during the first weeks after injury of % (Frihagen, personal communication). In addition to this, clinical skills in detecting posterior and posterolateral knee ligament injuries have improved. This has led to an improved diagnosis. Also, treatment options for knee injuries have changed both for conservative as well as for surgical treatment. In the most recent years we have seen a surge in treatment options for traumatic and degenerative cartilage injuries. Only good clinical science can tell us which methods will become standard in the near future. The present chapter deals with the most common injuries to the knee after an introduction covering recent discoveries in anatomy and biomechanics.
Anatomy and biomechanics Introduction Knee mechanics is the understanding of how the bones, ligaments, muscles and tendons combine to produce knee stability both statically and dynamically. The knee is composed of four different bones, four major ligaments, two menisci and muscles that cross the joint. An understanding of anatomy is therefore required in order to better understand the mechanics.
With this in mind, we will first describe the anatomy of each individual structure and then demonstrate the mechanics and function. The description will be kept simple and will just focus on passive mechanics of the knee.
Bones of the knee The knee joint is composed of four bones: the tibia, femur, patella and fibula. The tibia is a long triangular bone beginning proximally at the tibial plateau and extending distally to articulate at the ankle. The femur is a long cylindrical bone, which begins at the femoral head, which articulates with the acetabulum to form the hip joint, and ends distally at the femoral condyles. The patella is a sesamoid bone that articulates anterior to the femur and tibia. The fibula extends proximally to its fibular styloid and distally to articulate at the ankle. These bones come together to form individual joints that combined form the knee joint. The tibiofemoral joint is the most important individual joint. The tibiofemoral joint dictates the possible range of motion or kinematics of the knee. The articulating surfaces of the femur and the tibia are shaped in such a way as to allow for motion in all six degrees of freedom: flexion–extension, internal–external rotation, varus– valgus angulation, anterior–posterior translation, medial–lateral translation, and joint compression– distraction. The femoral condyles are obviously designed to allow a large range of motion and this is seen in the rotation about the flexion–extension axis, but the knee cannot be thought of having only this motion. This flexion–extension axis changes as the knee is flexed and extended and can be thought of as an axis through the intersection of the ACL and posterior cruciate ligament (PCL). This intersection moves anteriorly with extension and posteriorly with flexion, and so does the flexion–extension axis. The remaining axes are simple and can be thought of as fixed. There are three other joints involved in the knee, the tibofibular, the patellofemoral and the patellotibial. The tibia and fibula come together proximally to form a syndesmosis. There is very little motion at this joint and it thus has little influence on the knee joint’s mechanics as a whole. The patella’s articulation
Chapter . in and out of the trochlear groove comprises the patellofemoral joint. This joint’s mechanics are highly dependent on whether the patella is in or out of the groove and on the level of activation of the quadriceps muscle. The patellotibial joint only comes to mind when trying to understand or calculate the mechanical advantage created by the patella for the quadriceps mechanics. This joint does not have any articulations in the usual meaning. Only the tibiofemoral joint affects the overall static stability of the knee and it will be the focus of the remaining part of the chapter.
The menisci can be thought of as extensions of the tibia. They increase the joint congruency with the femoral condyles. The peripheral of each meniscus is thick and convex, and attaches to the inside of the joint capsule. The medial meniscus is semicircular in shape and is wider posteriorly than anteriorly (Fig. ..). The anterior horn is attached to a tibial plateau near the intercondylar fossa anterior to the ACL. The transverse ligament attaches the medial and lateral menisci. The posterior horn of the meniscus is attached to the posterior intercondylar fossa of the tibia. The lateral meniscus is almost circular and covers more of the tibial plateau than does the medial meniscus. The lateral meniscus is approximately the same width from front to back. The anterior horn attaches to the tibia anterior to the intercondylar eminence, and the posterior horn attaches posterior to the intercondylar eminence. There are also femoral attachments to the posterior horn of the lateral meniscus, the ligament of Humphrey and the ligament of Wrisberg.
Ligament mechanics The most basic definition of a ligament is a structure that attaches bone to bone. From this definition, it can be deduced that the ligament’s mechanical properties will affect the ability for the two attached bones to move with respect to each other. Thus to understand joint kinematics you need to understand ligament mechanics. The effect of a load along the long axis of a ligament will displace the attachment sites in a similar pattern, no matter which ligament or location. The easiest way to understand the ligament’s ability to resist load is by studying the load–elongation curve (Fig. ..).
Fig. .. Anatomy of the menisci.
600 Failure 500
400 Load (N)
Meniscus
Linear region 300
200
100 Toe region 0
2
4
6
8
10
12
14
16
Elongation (mm)
Fig. .. This is an example of a load–elongation curve that was recorded during a tensile failure test of a goat ACL. The regions of interest are: () the non-linear toe region, that corresponds to the aligning of the collagen fibers to the axis of load; () the linear region, this is when all the collagen fibers are aligned and the corresponding slope is the stiffness of the structure being tested; () failure, this corresponds to the breaking of the collagen fibers.
The load–elongation curve is generated during a mechanical tensile failure test. When load is applied along the long axis of the ligament the ligament elongates. The first part of the curve is non-linear and is referred to as the toe of the load–elongation curve. During this portion of the loading the collagen fibers of the ligament are aligned along the axis of load. When all the fibers are aligned along the long axis of the ligament,
Knee the loading curve reaches a portion that is approximately linear. The stiffness of a ligament is quantified from a linear assumption from this portion of the curve. The curve remains the same until the yield point is reached. This yield point is where the ligament loses its ability to transmit load. If loading continues a maximum load will be reached and then a sudden drop in load will signal total failure of the ligament. Several different criteria can affect the properties of the load–elongation curve, such as age, loading orientation and loading rate [,]. Younger ACLs were found to have a maximum load of ± N and a stiffness of ± N/mm, which was a threefold increase from the older ACLs. Orienting the load along the tibial axis for an ACL test will give you a maximum load of N, but applying the load along the ACL axis will produce a maximum load of N. The change of loading rates from a slow .%/s to %/s increases the maximum load by . times. Autografts and allografts have different properties from the structures that they are used to replace. Both grafts are known to have low stiffness and maximum loads soon after implantation, but these increase with time. The autografts on average are expected to reach % of the original ACL maximum load at year post surgery. The properties of allografts vary according to the preparation procedure, but have been shown to be anywhere from to % of the maximum load of the native ACL at year after implantation.
Knee ligaments Anterior cruciate ligament The anterior cruciate ligament is the most researched ligament in the body. It has its proximal attachment in a fossa on the posterior portion of the medial side of the lateral condyle of the femur and terminates distally on the tibial plateau in front of and lateral to the anterior tibial spine. The ACL can be broken down into two bands, the anteromedial and posterolateral. The anteromedial attaches on the proximal aspect of the femoral attachment and inserts on the anteromedial portion of the tibial insertion. The posterolateral band comprises the remaining fibers that attach to the posterolateral portion of the tibial attachment. It is this multiple-bundled make-up that allows the ACL to function throughout all angles of flexion.
The anteromedial bundle is tight in flexion and the fibers of the posterolateral bundle are lax. When the knee goes into extension the reverse happens: the posterolateral bundle tightens and the anteromedial bundle loosens. The posterolateral bundle also prevents hyperextension. The ACL’s primary function is to restrain anterior motion of the tibia with respect to the femur. It was found by Butler et al. that the ACL produced .% and .% of the restraining force for anterior translation at ° and ° of knee flexion, respectively [].
Posterior cruciate ligament The posterior cruciate ligament is made up of two distinct bands, the anterolateral and posteromedial. The anterolateral is the larger of the two bundles and attaches to the lateral side of the medial condyle on the anterior portion of the femoral notch and terminates on the lateral side of the PCL facet on the tibia. The posteromedial bundle attaches posterior to the anterolateral bundle on the medial condyle and ends distally on the medial side of the PCL facet. The ligaments of Humphrey and Wrisberg are meniscofemoral ligaments that are sometimes grouped with the PCL. Both attach to the posterior horn of the lateral meniscus, with the Humphrey ligament running anterior to the PCL and the Wrisberg posterior. Like the ACL, the PCL is composed of several bands, allowing it to function through the whole flexion–extension arc. The different bands of the PCL function independently. The anterolateral band becomes taut in flexion and the posteromedial band tightens with the knee in extension. The primary function of the PCL is to resist posterior translation of the tibia with respect to the femur. Butler et al. found that the PCL provided .% of the restraining force to an applied posterior drawer at ° and .% at ° of knee flexion [].
Medial collateral ligament The medial collateral ligament (MCL) is a combination of several different structures and is sometimes referred to as the medial collateral ligament complex. The largest component is the tibial collateral ligament (TCL) or superficial MCL. This structure attaches proximally at the medial epicondyle of the femur and runs distally to attach to several places on the tibia. The
Chapter . first is cm distal to the joint line anterior to the posteromedial border of the tibia, and then continues distally to attach further down the tibia just past the pes anserine tendon insertions. The next components are thickenings of the medial joint capsule and are also called the deep MCL. The meniscofemoral attaches proximally just distal to the medial epicondyle on the femur and terminates distally in the middle of the medial meniscus. The meniscotibial begins at the bottom of the medial meniscus and runs just – mm past the proximal edge of the tibia to terminate. The posterior oblique ligament attaches to the posterior edge of the previously mentioned meniscofemoral portions, the medial capsule and adductor tubercle. The primary function of the MCL complex is to restrain valgus rotation of the tibia with respect to the femur and secondarily to restrain anterior translation in an ACL-deficient knee. Grood et al. [a] measured the percentage of valgus restraining moment contributed by the different portions of the MCL. It was found that at ∞ of knee flexion the TCL was .% and the deep MCL was .% of the valgus restraining moment. At ° the TCL contributed .% and the deep MCL only .%. The remaining percentage of restraining moment was found to be contributed by the ACL and PCL.
Fibular collateral ligament The fibular collateral ligament (FCL) and the popliteus complex are commonly grouped together and referred to as the posterolateral complex (Fig. ..). The FCL attaches posteriorly and proximally to the lateral epicondyle on the femur and travels distally to attach to the fibular head. The popliteus complex consists of the popliteus tendon, popliteofibular ligament and popliteomeniscal fascicles. The popliteus tendon begins at the termination of the popliteus muscle body and runs deep to the FCL and attaches to the anterior and superior portions of the popliteal sulcus. The popliteofibular ligament begins at the musculotendinous junction of the popliteus and attaches to the fibular styloid [–]. The posterolateral complex resists varus opening and external rotation. Grood et al. [a] also studied the effect of structures to restrain varus opening. The FCL was found to add .% resistance at ° and .% at °. The popliteus complex contributed
Fig. .. The popliteofibular complex.
.% at ° and .% at °. Again the ACL and PCL contributed the remaining resistance. A study by Gollehon et al. [] demonstrated that sectioning of the FCL and the popliteus complex increased external rotation at °, °, ° and °. In recent studies it has been found that the absence or deficiency of the posterolateral structures can significantly increase the force on ACL and PCL reconstruction grafts []. LaPrade et al. found that after sectioning the FCL, popliteus tendon and popliteofibular ligament, the ACL graft force increased over % at ° and over % at ° of knee flexion with an applied varus moment. Simply tensioning the ACL graft was found to externally rotate the tibia up to ° with respect to the tibia (Wentorf et al., personal communication). In an unpublished study by LaPrade, it was found that the PCL graft force increases with posterolateral deficiency. Varus loading was found to increase the PCL graft force significantly with the posterolateral structures sectioned at °, ° and ° of knee flexion, with the highest being a % increase at °.
The anatomy of the patellofemoral joint The patellofemoral joint is difficult to examine because it functions as a dynamic joint and static loading thus provides limited information. However, a thorough knowledge of the anatomy and the different dynamic interactions that occurs in this joint, is necessary to understand its complexity. The patellofemoral joint has a rather unique anatomy because it relies on a combination of both
Knee static and dynamic stabilizers to have normal function. Imbalances in any of these can lead to patellofemoral dysfunction and pain. This can include the lack of dynamic stability due to muscle weakness or hamstring tightness or a lack of static stabilizers due to injury or to intrinsic anatomic bony abnormalities. It is important to understand the anatomy of both the dynamic and the static portions of the patellofemoral joint in order to understand both its function and how to treat its dysfunction. The patella is a sesamoid bone which sits within the confines of the quadriceps and patellar tendon and articulates in the trochlear groove of the femur. Normally, the patella sits within the confines of the trochlear groove at approximately ° of knee flexion. In most knees, the confines of the trochlear groove provide significant inherent stability to the knee past ° of knee flexion. In those patients who have dysplastic trochleas, there is a loss of this normal inherent bony stability. The two main facets of the patella are the medial and lateral facets. The Wiberg classification notes three types of these facets, with type having equal sized medial and lateral facets, type having a slightly larger lateral facet than the medial facet, and type having essentially a minimal medial facet with the majority of the patellar articular surface being the lateral facet. Dynamic stability of the patellofemoral joint is provided by the quadriceps muscles consisting of the vastus medialis obliquus, vastus medialis, rectus femoris, rectus intermedius, vastus lateralis, genu articularis and vastus lateralis obliquus. Forty to % of the total thigh muscular volume is provided by the vastus lateralis muscle []. It is important to recognize this so that one does not release this muscle when performing a lateral release. A significant release of this portion of the quadriceps musculature can result in permanent thigh atrophy. Static stability of the patellofemoral joint is provided by several thickenings of the joint capsule and extra-articular expansions around the patellofemoral joint. The medial patellofemoral ligament, which runs from the medial border of the patella to the adductor tubercle, is thought to provide the most stability to the patellofemoral joint in preventing lateral translation. This structure is the most commonly torn structure in acute lateral patellar dislocations (Fig. ..).
Fig. .. Axial MR scan of a patella after dislocation with tearing of the medial patellofemoral ligament.
In addition, the medial patellotibial and patellomeniscal ligaments provide stability to lateral translation of the patella. The function of these two ligaments is not well understood. On the lateral side of the knee, the lateral patellofemoral ligament runs from the lateral border of the patella down to the iliotibial band and lateral intramuscular septum at its attachment on the femur. The lateral patellotibial ligament runs from the distal lateral border of the patella down to Gerdy’s tubercle. This ligament is the distal edge of the distal margin of the iliopatellar ligament. This ligament is found to be extremely important in preventing medial patellar subluxation. However, a patellomeniscal ligament also exists on the lateral aspect of the knee. The patellar tendon runs from the inferior pole of the patella to the tibial tubercle. It is trapezoid shaped, with the average width approximately being mm and the average width distally being mm. At its more proximal aspect, it is intimately attached to the retropatellar fat pad, while distally the deep infrapatellar bursa is present between the patella tendon and the proximal anterior tibia prior to its insertion on the tibial tubercle. The medial suprapatellar plica is a fold of synovial tissue which is separate from the medial retinaculum in the knee. It extends from the genu articularis muscle in the suprapatella pouch down to the retropatellar fat pad along the anterior medial aspect of the medial meniscus. This structure has been found to have many pain fibers and can become fibrotic in some instances. In addition, in some patients, this fibrotic band can
Chapter . impinge and erode on the articular cartilage of the medial femoral condyle. While not actually part of the patellofemoral joint, the hamstring muscles are included in the assessment of the patellofemoral joint, due to their interactions with it. On the medial side of the knee, the direct arm of the semimembranosus is known to attach on the proximal aspect of the posterior medial tibia. There is a large semicircular bursa just proximal to this attachment site. The sartorius, gracilis and semitendinosis tendons attach at the anterior medial aspect of the tibia approximately two finger breadths medial to the tibial tubercle. Just proximal and medial to this attachment site, there is a bursa between the tendons and the proximal tibia. On the lateral aspect of the knee, the short and long heads of the biceps femoris attach to the posterior lateral aspect of the fibular styloid. In addition to this attachment site, the anterior arm of the long head of the biceps femoris continues laterally to the fibular head where a bursa is formed when it crosses the fibular collateral ligament []. This bursa, which has an average length of mm, is also commonly found to be irritated in patients with tight hamstrings and patellofemoral dysfunction. Knowledge of the anatomy of all these particular structures of the patellofemoral joint will greatly assist the clinician in helping to make a diagnosis and arrive at the proper treatment protocol for these patients. It is important to understand how all of these structures interact in order to formulate the proper treatment protocols.
History and physical examination A thorough and detailed physical examination of the knee is more useful than any other diagnostic test to aid the examining physician in determining the etiology of a patient’s presenting complaints. The presenting complaints for the majority of knee injuries are fairly specific in the majority of cases and a clinician should have a general idea of what to expect on physical examination after reviewing a thorough history on a patient. The initial part of the history should start with the etiology of the patient’s initial presentation. It is important to determine whether it was a traumatic or a non-traumatic event that caused the onset of symp-
toms. In addition, it is useful to have the patient describe what type of problems they have with their knee. It is also helpful to have them point to the area where their knee hurts. This helps to determine whether pain is located in their patellofemoral joint or in their tibiofemoral joint. Patellofemoral joint symptoms are most commonly located over the anterior aspect of the knee, while tibiofemoral joint problems are usually associated with pain localized to the joint line or feelings of instability.
Mechanism of injury It is extremely helpful to review the mechanism of injury with the patient to assist in understanding their knee pathology. Injuries to the patellofemoral joint are usually caused by direct trauma or a contact valgus injury. In this instance, a direct blow to the patella, retinaculum or fat pad could result in a contusion, hemorrhage and effusion. In addition, a sudden twist or pivot could result in a lateral patellar subluxation or dislocation event. Injuries to the tibiofemoral joint can be either contact or non-contact. Non-contact injuries are usually associated with a sudden twist, turn or pivot, with the athlete feeling a pop inside the knee. The most common finding in this type of presentation, especially when there is a large knee effusion that develops rapidly, is an anterior cruciate ligament tear. Other things to suspect are a meniscal tear or a bone bruise. In the evaluation of contact injuries to the knee, it is important to recognize that the structures most commonly injured occur on the side opposite to the contact to the knee. When a patient has a valgus contact injury, then generally the most common finding will be an MCL complex injury, followed by medial meniscal pathology, patellar subluxations or dislocations, ACL tears, and lateral compartment bone bruises. Varus contact injuries usually cause an injury to the posterolateral corner of the knee and may injure the common peroneal nerve as part of this mechanism. Pure hyperextension contact injuries are rare, with the usual blow being anteromedial or anterolateral. Either cruciate ligament may be injured in this type of mechanism, with a high suspicion of a posterolateral corner injury with an anteromedial blow to an extended knee and a
Knee medial collateral ligament complex injury with an anterolateral blow to an extended knee. Which structures are injured with a direct blow to a flexed knee usually depends upon the ankle position. In the case of a dorsiflexed ankle, a direct blow to a flexed knee may cause an injury to the patellofemoral joint. Likewise, in a plantar flexed ankle, a blow to the anterior aspect of a flexed knee may result in an injury to the PCL, because the force is transmitted to the intra-articular structures via the tibial tubercle (rather than by the patella).
Physical examination of the patellofemoral joint The examination of the patello-femoral joint [] starts with an overview of the mechanical axis of the extremity compared with the non-affected side. The q-angle (the intersection of the center line of the patellar tendon and the line from the center of the patella to the anterior superior iliac spine) is measured. The normal q-angle is reported to range between and ° with the knee in full extension. An increase in the q-angle may cause an increase in the peak patellofemoral pressure and may be associated with unpredictable patterns of cartilage loading. In the examination of the patellofemoral joint, it is helpful to be thorough in evaluating all potential sources of pain and the examiner should strive to examine the structure which the patient states hurts the most last to eliminate any potential guarding by the examiner. An overall assessment of the quadriceps tone is helpful to determine the patient’s overall strength. This is of course difficult to assess clinically, and is therefore usually done with isokinetic devices such as Cybex, Biodex, Kinkom, etc. In addition, measurement of the thigh circumference may help to assess whether there is any underlying thigh atrophy. It is recommended that the thigh circumference be measured at a point cm proximal to the superior pole of the patella. Thigh atrophy of greater than cm on the affected side compared to the contralateral side is generally considered significant. A number of functional tests have been developed to assess the functional strength of the patient, such as one-leg jump and triple jump tests []. The next assessment performed is to evaluate the amount of hamstring tightness. Hamstring tightness can be evaluated by measuring the
hamstring–popliteal angle and comparing it to the contralateral side. In general, males tend to have tighter hamstrings than females. Next, palpation of the hamstring tendon attachments on the tibia and fibular head is performed to determine whether there is any irritation at these attachment sites which may indicate an amount of underlying bursitis. The pes anserine, semimembranosus and the FCL–biceps bursae are palpated to assess them for any underlying bursal irritation. In addition, we palpate the quadriceps attachment on the superior pole of the patella and the patellar tendon attachment on the distal pole of the patella to determine whether there is any quadriceps insertional tendinopathy or patellar tendinitis, respectively. We also palpate the patellar tendon just proximal to its attachment on the tibial tubercle and distal to its insertion on the patella to determine whether there are any symptoms of Osgood–Schlatter’s or Sinding–Larsen–Johansson’s irritation or irritation of the deep infrapatella bursa. The next evaluation of the patellofemoral joint is to determine whether there is any plical irritation (medial retinacular synovium). The examiner can roll the fingers over the medial suprapatellar plica about two finger breadths medial to the medial border of the patella to see if there is any plical irritation in this location. The plica can be felt as a band of tissue in the area. If there is any pain present with palpation, it is important to ask the patient if this duplicates their symptoms, because some patients may have some normal irritation to palpation of their plica. The plica on the lateral side can also be assessed for any associated pain to palpation. Concurrent with this evaluation, the patellomeniscal and patellotibial ligaments and the retropatellar fat pad should be palpated to determine whether there is any associated pain, which may be indicative of scarring or injury to these structures. Next, we evaluate any potential subluxation or dislocation of the patellofemoral joint. Medial patellar subluxation is assessed in the initial –° of knee flexion. A gentle medial push to the lateral aspect of the patella is applied when the knee is in full extension and then the knee is slowly flexed. If the patella subluxes medially, there is usually a catch which is felt upon reduction when it enters the bony confines of the trochlear groove at approximately –°. Medial patellar subluxation rarely occurs due to trauma and
Chapter .
Fig. .. Lateral patellar apprehension test.
Fig. .. The Lachman test for anterior knee instability.
usually is due to iatrogenic causes such as an overzealous lateral release. It is important to compare the symptomatic side to the contralateral normal side to determine whether there is any increase in subluxation on the symptomatic knee. Lateral patellar subluxation is assessed by the lateral patellar apprehension test. This test is usually performed with the knee flexed to ° and over the side of the examination table (Fig. ..). It is important in this test to make sure that the patient is totally relaxed. The examiner then applies a gentle lateral force on the patella to assess for any increase in translation. It is important in performing the test for the examiner not to apply the lateral force through an irritated medial plica. During the course of this test, the examiner can also get an assessment of any underlying crepitation in the patellofemoral joint which can be felt with the fingers, which may be indication of chondromalacia of the patella or trochlear articular surfaces. If a patient expresses pain or apprehension with a lateral force, the test is considered positive.
Examination of anterior translational abnormalities
Physical examination of the tibiofemoral joint When considering examination of the tibiofemoral joint, the examiner should think in terms of both intraarticular pathology and potential ligamentous instability. Examination of any potential intra-articular pathology can be easily assessed during the evaluation of any joint line instability and we prefer to measure it in this manner.
The primary structure that resists anterior translational abnormalities of the knee is the ACL. Since the ACL is most isolated in terms of its contribution to resisting anterior translation of the knee at approximately ° of knee flexion Lachman’s test is an extremely useful tool to assess for the integrity of the ACL. Lachman’s test is performed with the knee flexed to approximately –°. In this test, the examiner uses one hand around the distal thigh, which attempts to stabilize the distal thigh against resisting motion. The other hand of the examiner is utilized to apply a gentle anterior translation force anteriorly in neutral rotation (Fig. ..). It is essential that the examiner gets the patient to totally relax while performing Lachman’s test. With an intact ACL present, the examiner should feel a good solid endpoint when performing this test. However, when the ACL is torn, either no endpoint or a soft endpoint will be felt at the end of the examiner’s translation of the tibia on the distal femur. It is also important to make sure that pure anterior translation is being measured because a posterolateral corner injury can give the false impression of increased anterior translation in some instances. In this circ*mstance, the increase in motion should be felt as due to posterolateral rotation and there should be a good endpoint to Lachman’s test. Instrumented mechanical testing has also been successful in determining the integrity of the ACL.
Knee The KT-, KT-, Rolimeter and Stryker mechanical devices have all proved useful in determining the integrity of the native ACL and have been used as an assessment of the success of an ACL reconstruction in restoring normal anterior translation stability to the knee. With all of these devices, it is felt that the difference in anterior stability between the tested knee and the contralateral normal knee should be £ mm. Increased translation stability of greater than this amount would indicate either a torn native ACL or an ACL reconstruction graft which is slightly lax or potentially non-functional. The limitations of these mechanical devices are such that they are still user specific and it is most ideal to have a limited number of personnel using these devices on patients to eliminate the potential variability among examiners. The pivot-shift tests produce anterior subluxation and internal axial rotation in early flexion in ACLdeficient knees. The posterior pull of the iliotibial tract then reduces the tibia subluxation at –° flexion. The tests (McIntosh, Slocum or flexion rotation drawer test) are consistently positive in the relaxed patient with a chronic ACL deficiency and in the acutely injured anesthesized patient with an ACL tear.
Fig. .. Test for medial knee instability.
Examination of medial-sided knee injuries The tibial collateral ligament and associated medial collateral ligament complex is the primary stabilizer to valgus instability of the knee [,]. Since it is primarily isolated when the knee is flexed to °, this is the best position to perform stability testing for MCL complex injuries. In performing the valgus stress test at ° of knee flexion, the patient is placed on the examination table such that one hand of the examiner is placed with the fingers over the medial joint line to measure the amount of medial compartment joint line opening, while the other hand is used to apply a valgus force through the leg. We recommend that the hand applying the valgus force be placed on the foot, and not the tibial shaft, to apply this force so that the true amount of valgus and coupled valgus rotational instability can be assessed (Fig. ..). Concurrent with measuring the amount of medial compartment opening, the examiner’s fingers assess for any underlying joint line crepitation. This may indicate any associated meniscal
or chondral pathology in the medial compartment of the knee. If a large ‘clunk’ is felt, we have found it to be consistent with a detached peripheral medial meniscal tear. Assessment of medial joint line opening can also be performed with the knee in full extension. When there is increased medial joint line opening to a valgus stress with the knee in full extension, it is usually due to a significant injury involving the entire MCL complex as well as both cruciate ligaments. In this instance, the examiner needs to be cognizant of the fact that there may have been a tibiofemoral dislocation. The one thing to be careful of in assessing this situation is in a patient with open physes. In any patient who has open physes, consideration should be given to obtaining valgus stress AP radiographs when there is apparent MCL complex instability. This is because there is a potential for an underlying physeal fracture which could appear to be a MCL complex injury on clinical examination.
Chapter . Assessment of posterior instability of the knee The posterior cruciate ligament (PCL) is the main structure responsible for preventing posterior translation of the knee [,,,]. The PCL has two main portions, the anterolateral and posteromedial bundles. The anterolateral bundle is the strongest and is the primary stabilizer against posterior translation of the knee when the knee is at ° of knee flexion. In this position, it is in its most isolated state. For this reason, the majority of assessment tests for posterior instability of the knee are performed at ° knee flexion. The posteromedial bundle protects against posterior tibial displacement near full knee extension. The posterior sag sign should be one of the first tests performed to assess for the integrity of the PCL. In this test, both knees are flexed to °. In the PCLdeficient knee, a posterior sag of the proximal tibia on the distal femur will occur such that there is a visible difference in the posterior step-off of the affected knee (Fig. ..). Concurrent with assessment of the posterior step-off, the quadriceps active test is next performed. In this test, the patient’s knee is flexed to ° and the examiner uses one of his hands to hold down the ankle of the patient. The patient is then asked to try to extend or straighten out their leg. In the process of doing this, the quadriceps muscle contracts and by pulling through the patella and patellar tendon on the tibial tubercle, the posteriorly translated proximal tibia is pulled back into a more reduced position (Fig. ..). This is something that can be seen graphically by the examiner. We have found the quadriceps active test to be very effective for helping to determine whether the patient has an ACL tear, an ACL tear with a partial PCL tear, or a partial PCL tear when it is not possible to be certain as to the amount of anterior to posterior translation in a knee during the physical examination. After the quadriceps active test, the posterior drawer test is next performed. It is important to make sure that this test is performed with the knee in neutral rotation. In this test, the knee is flexed to ° and we recommend that the examiner sits on the foot, or stabilizes the foot by other means, such that the foot is in neutral rotation. It is important to obtain complete relaxation of the patient’s hamstrings to be able to best perform this test. A gentle to and from force is then applied to
(a)
(b) Fig. .. The posterior sag sign test (a) and the quadriceps active test (b) for posterior ligament instability. The tibia excursion is reduced when the patient tries to extend the knee (b).
the knee by pushing gently on the proximal tibia with the examiner’s hands to determine the amount of anterior to posterior translation that is present. The grading of the posterior drawer is usually done in relation to the amount of step-off that occurs in relation to the proximal tibia and the distal femur. A I+ posterior drawer test is present when there is some increase in posterior translation, but the proximal tibia remains anterior to a line drawn parallel to the femoral condyles and the anterior aspect of the tibia. A II+ posterior drawer test occurs when there is increased posterior translation and the line drawn parallel with the femoral condyles is in line with the anterior aspect of the tibial plateau. A III+ posterior drawer test occurs when the posterior tibia falls posterior to this parallel line and the
Knee
anterior tibial plateau is posterior to the anterior aspect of the femoral condyles.
Assessment of posterolateral instability of the knee The main function of the many structures of the posterolateral aspect of the knee is to prevent excessive recurvatum, varus opening of the knee, and posterolateral rotation of the knee [,,,,,– ]. Assessment of potential injury to the posterolateral structures of the knee primarily requires an assessment of abnormalities in motion testing for these motion and translation tests. The external rotation recurvatum test is one of the first tests that should be performed when examining a knee. In this test, the examiner lifts the patient’s great toe to determine whether there is any increase in relative varus and recurvatum of the knee (Fig. ..) [,]. It is important to compare this finding to the patient’s normal contralateral knee to see if there is any increase in instability present. Any increase in recurvatum is considered abnormal and may be indicative of a significant knee injury involving one or both cruciate ligaments. Measurement of heel height differences off the examination table is a potential means of quantifying this examination. The varus stress test at ° knee flexion is performed in the same way as a valgus stress test at ° knee flexion. In this test, one of the examiner’s hands is placed with the fingers in the lateral compartment to assess the amount of joint space opening which occurs with application of a varus stress. The varus stress is applied to the leg by the other hand, which holds the foot and applies a varus stress. It is especially important to compare the amount of lateral-sided joint line opening to the contralateral normal knee as there is a wide variation of varus opening among individuals. This has been quantified to vary between and mm among asymptomatic patients in the general population []. The dial test assesses the amount of external rotation, which occurs in the tibia compared to the femur. In laboratory studies, it has been shown to be one of the most accurate methods of assessing the integrity of the posterolateral corner structures of the knee []. While this test has been described primarily as being performed with the patient prone, we prefer to have it
Fig. .. The external rotation recurvatum test, and the dial test for rotational instability of the knee.
performed with the patient supine. The dial test is performed at both and ° knee flexion. One of the examiner’s hands is used to stabilize the distal thigh while the other hand is placed around the patient’s foot and an external rotation force is performed (Fig. ..). The amount of rotation of the tibial tubercle is then compared to the normal contralateral knee. At °
Chapter . knee flexion, any increase in external rotation is indicative of any injury to the posterolateral corner structures with a greater than ° rotational difference considered a severe injury. After testing at ° knee flexion, the test is then repeated at ° knee flexion. In the knee with an isolated posterolateral corner injury, there should be a slight decrease in external rotation of the tibia on the femur at ° knee flexion compared to ° knee flexion. However, if there is a concurrent PCL injury in the knee, there will be an increase in external rotation at ° compared to ° knee flexion. The posterolateral drawer test assesses the amount of coupled posterior translation and external rotation due to a posterolateral corner injury of the knee. In this test, the knee is flexed to ° knee flexion and the foot is externally rotated to about °. We choose to sit on the foot to make sure that we know how much external rotation is actually present. It is very important to make sure that the examiner understands the difference in this test compared to the posterior drawer test. With the patient’s knee totally relaxed, we then apply a gentle posterior force to the knee with a coupled external rotation torque (Fig. ..). It is important to compare the amount of posterolateral rotation that occurs in the injured knee to the contralateral uninjured knee to determine the amount of pathologic increase in motion that may be present. An increase in posterolateral rotation of the knee compared to the normal
knee is indicative of an injury to the posterolateral structures of the knee. The reverse pivot-shift test derives its name from the fact that it is almost the reverse of the normal pivotshift test which assesses anterolateral rotation of the knee. This test starts out with the knee flexed, with the foot externally rotated, and a valgus force applied. In this position, the lateral tibial plateau may be subluxated posterolaterally under the lateral femoral condyle. The knee is then extended and the examiner looks for any signs of a reduction of the subluxed joint between and ° knee flexion when the iliotibial band goes from a flexor to an extender of the knee (Fig. ..). If this subluxation reduction occurs, the reverse pivot-shift test is considered positive. This reduction in the posterolateral subluxation is very similar to what is seen with a reduction of an anterolat-
Fig. .. The posterolateral drawer test for posterolateral instability.
Fig. .. The reverse pivot-shift test for posterior rotational instability of the knee.
Knee
Table .. A number of clinical tests for knee examination, and the diagnostic possibilities in relation to the results of the tests. Test
Diagnosis
Be aware of
Varus/valgus stress at 30° flexion (Fig. 6.2.6)
MCL or LCL injury (grade I < 5 mm side difference, grade II 5–10 mm side difference, grade III > 10 mm side difference)
Physeal injury in children may mimic the collateral ligament injury laxity
Anterior cruciate ligament injury
Describes the lateral tibial plateau subluxation on the femur Feeling of the endpoint Often partial injury
Lachman’s test 30° flexion (Fig. 6.2.7) Pivot-shift test
Posterior drawer at 90° flexion Sag test (Fig. 6.2.9) Posterolateral Lachman at 30° (Fig. 6.2.11)
Recurvatum test (Fig. 6.2.10) McMurray meniscal test
Posterior cruciate ligament injury Posterior cruciate ligament injury Posterolateral injury often to LCL, popliteal tendon, popliteofibular tendon Posterolateral injury often in combination with ACL or PCL injury Medial or lateral meniscal injury
eral subluxed knee during the pivot-shift test. The reverse pivot-shift test has the most variability among all motion tests. Up to % of normal subjects may have a reverse pivot-shift test when tested under general anesthesia. The majority of these patients were also noted to have some degree of recurvatum in their knee. There are a number of meniscal tests described in the literature. Usually, three relatively simple tests are sufficient. In the McMurray test for the medial meniscus, the tibia is externally rotated on the femur, a small valgus stress is put on the knee, and the knee joint is flexed and extended during the test. The examiner has the pulp of the long finger in the medial joint space. When testing the lateral meniscus, a varus stress is carried out and the tibia is internally rotated. In doing this, the meniscus is rotated toward the finger of the examiner and the patient with a meniscal tear may express pain. In the original McMurray test a click should be felt when the meniscus is torn — this is, however, unusual. Apply’s test is carried out with the patient in the prone position. The knee is flexed to °. The tibia is distracted from the femur and rotated. The test is then repeated, this time with compression and rotation of the tibia on the femur. Pain on compression suggests meniscal tear, pain on distraction suggests ligament pathology. The final test done by the authors is the
Be aware of side difference Pain in the joint space and often a small click against your fingertip
hyperextension test where the knee is simply hyperextended thereby compressing the meniscus which will elicit pain if the meniscus is not stable. In Table .., the most common tests and their possible results are listed.
Imaging of the knee Diagnostic imaging of sports-related injuries of the knee (Table ..) is an area that is currently undergoing rapid evolution. Specifically, the imaging techniques of cartilage injuries as well as dynamic techniques of ligament injuries are developing. This short section gives the reader an overview of current techniques available and follows this with a proposed use of the techniques in the most common diagnosis of the knee. It is important for the examiner to order scans or radiographs that should either result in significant decision-making in patient management or prognosis alteration, or give information not available from the history, physical examination or routine X-rays. Understanding the basis of the imaging modalities available for diagnosis of many commonly encountered disorders of the bones and joints is of utmost importance. It may help determine the most effective radiologic technique, minimizing the cost of examination as well as the exposure of patients to radiation. It is
Chapter . important to choose the modality appropriate for specific types of orthopedic abnormalities and, when using routine X-ray techniques, to be familiar with the views and the techniques that best demonstrate the abnormality. Routine radiography remains the most effective means of demonstrating a bone and joint abnormality. Use of imaging techniques differs in evaluating the presence, type and extent of various bone, joint and soft tissue abnormalities. Therefore, both the radiologist and orthopedic surgeon must know the indications for use of each technique, the limitations of a particular modality, and the appropriate imaging approaches for abnormalities at specific sites (Table ..). The choice of techniques for imaging bone and soft tissue abnormalities is dictated not only by clinical presentation, but also by equipment availability, expertise and cost. No matter what ancillary technique is used, conventional radiography should be available for comparison. Most of the time, the choice of imaging technique is dictated by the type of suspected abnormality. For instance, if osteonecrosis is suspected after obtaining routine X-ray, the next examination should be MRI, which detects necrotic changes in bone long before plain films, tomography, CT or scintigraphy become positive. In evaluation of internal derangement of the knee, conventional films should be obtained first, and if the abnormality is not obvious, should again be followed by MRI, since this modality provides exquisite contrast resolution of the bone marrow, articular cartilage, ligaments, menisci and soft tissue.
Radiographs (routine X-ray) Routine X-ray remains the mainstay for diagnostic evaluation of orthopedic problems, and often it is sufficient for evaluating many traumatic conditions of the knee joint. AP (anteroposterior) and lateral radiographs fulfil the minimum requirement for the knee following trauma. In addition, tunnel views are routinely obtained. Evaluation of condyles requires both oblique projections []. For adequate evaluation of the patellofemoral joint axial views beside the lateral view is necessary []. An anteroposterior radiograph of the knee is obtained with the beam directed –° toward the head, and a lateral radiograph is obtained with the knee flexed –°. A ° oblique view is
usually necessary in a patient who has knee trauma. An angulated posteroanterior projection with the knee flexed –°, the tunnel view, is used to visualize the intercondylar notch. In such a patient, a cross-table lateral projection should also be added to the examination, allowing demonstration of fat–fluid levels, indicative of fractures with release of medullar fat into the articular cavity. Upright standing views are required to accurately access the femurotibial joint. Several techniques can be used in patients who are able to bear weight for this procedure. Typically a ¥ inch cassette is positioned posterior to the knee so that the lower femur and upper tibia and fibulas are included on the film. The tube is parallel to the floor or angled slightly (tibia plateau ∞ caudal posteriorly) toward the feet. A ∞ weight-bearing view has been described by Rosenberg et al. []. The knees are flexed ∞ and the tube angled ∞ off the horizontal. The tube is positioned cm from the cassette. This method was more accurate than conventional extension weightbearing views in evaluating cartilage lesions.
Conventional tomography Conventional tomography is a useful adjunct to plain film radiography, may compare with CT in the evaluation of certain musculoskeletal problems, and should be used when standard and specialized views fail to provide needed information for correct diagnosis and treatment. Tomography has been recommended to evaluate the amount of articular surface depression or displacement, the site of the fracture, and extent of comminution. Tomography is especially useful in differentiating split-depression fractures from fractures in which depression of the articular surface alone is present. Tomography, through its ability to demonstrate the integrity of the anterior cortex, is also helpful in planning a surgical treatment of tibial plateau fractures. This technique is now being replaced by reconstructed CT scans (spiral T) and magnetic resonance.
Arthrography This technique uses injection of radiopaque contrast material into the knee to outline articular cartilage, menisci and cruciates with multiple X-rays recorded to visualize structures. MRI has now predominantly replaced the technique. The advantage is its relatively
Knee low cost, but its disadvantage is the fact that it is invasive and visualizes structures with far less accuracy than MRI or other techniques. The sensitivity and specificity for meniscal tears, for example, in an arthrogram is only approximately %.
Scintigraphy (radionuclide bone scan) Scintigraphy is a modality that detects the distribution in the body of a radioactive agent injected into the vascular system. Following an intravenous injection of radiopharmaceutical agent, the patient is placed under a scintillation camera, which detects the distribution of radioactivity in the body by measuring the interaction of g rays emitted from the body with sodium iodide crystals in the head of the camera. The photoscans are obtained in multiple projections and may include either the entire body or selected parts. One major advantage of skeletal scintigraphy over all other imaging techniques is its ability to image the entire skeleton at once. As in most procedures in nuclear medicine, the bone scan is an extremely sensitive but relatively nonspecific method. Any process that disturbs the normal balance of bone production and resorption can produce an abnormality on the bone scan. These abnormalities may be manifested as regions of increased or decreased activity. The great majority of lesions appear as focal areas of increased activity. The amount of radiopharmaceutical agent accumulated in any region of bone depends on two major factors, the rate of bone turnover and the integrity of the blood supply. Of these two factors, the intactness of the vascular supply appears to have a more important influence on the bone scan; when blood perfusion is absent, a photondeficient or ‘cold’ region is evident on the scan. Although there are many indications for the use of bone scanning in clinical practice, the most common use is in oncology for detection and follow-up of metastatic bone disease primarily from prostate, breast and lung cancer or primary bone tumors. The orthopedic uses of bone scanning primarily include diagnosis of trauma and infection, determination of vascularity, compartmental evaluation of degenerative arthritis of the joints, and evaluation of patients with painful prostheses []. Secondary uses include evaluation of elevated alkaline phosphates and diagnosis of patients who present with bone pain of undetermined etiology [].
The bone scan may be helpful in imaging either fatigue or insufficiency fractures, especially when radiography is unrevealing. This technique is also useful in the diagnosis of shin splint syndrome. On bone scan shin splint pain is associated with periosteal deposition of the radiopharmaceutical, with the appearance of a ‘double stripe’ sign, similar to that reported in hypertrophic osteoarthropathy. The role of the radionuclide study in the evaluation of infection includes early detection, differentiation of osteomyelitis from cellulitis and identification of renewed activity in cases of chronic osteomyelitis. The differentiation between osteomyelitis and cellulitis may be a difficult clinical problem. The threephase or four-phase bone scan is widely used for these purposes. In chronic osteomyelitis, comparison of Tc-m phosphate bone imaging and Ga- citrate imaging suggests greater accuracy of the gallium scan in detecting the response or lack of response of the infection to therapy []. Despite the recent emphases on the role of MR imaging in the assessment of osteonecrosis, bone scintigraphy remains an effective diagnostic technique. Initially, on the bone scan, if a substantial interruption of blood supply has occurred, the radiopharmaceutical cannot reach the involved area and decreased activity may be evident on the scan. As the bone reacts to the insult with revascularization and reossification, scintigraphy may show increased activity in the involved area.
Computed tomography In this technique computer-generated X-ray images are used in surgical, coronal and axial planes providing exceptional detail as to bone location, comminution and displacement. Currently -D constructions are being used which are very helpful in certain fracture circ*mstances. The indications are tibial plateau fractures, osteochondritis dissecans, bone tumors and occasionally, in the patella, femoral tracking. Computed tomography (CT) is often able to define soft tissue and bone alterations that are undetectable with conventional radiography because of its cross-sectional display, excellent contrast resolution, and ability to measure specific attenuation values. CT has matured into a reliable and prominent tool for study of the
Chapter . musculoskeletal system. Like conventional tomography, CT is planar, but CT images are transaxial and unobscured by overlying tissue. This technique has superior contrast resolution with a capacity to provide quantitative measures of the skeleton. In a dramatic departure from film methods, the CT images are produced in a computer that allows manipulation of the display. CT can be used to evaluate many anatomic regions of the body and a variety of musculoskeletal disorders. The specific musculoskeletal disorders are trauma, infection and neoplasm. The role of CT in evaluation of tibial plateau has been well established; CT provides optimal visualization of the plateau depression, defects and split fragments. It has also proved more accurate than conventional tomography in assessing depressed and split fractures when they involve the anterior and posterior border of the plateau, and in demonstrating the extent of fracture comminution. The degree of fracture depressions and separation as measured by the computerized technique is often more accurate than measurements obtained from conventional tomograms. Particularly useful are reformatted images in various planes and three-dimensional reformation []. Kode and coworkers [] have suggested that MRI was equivalent or superior to twodimensional CT reformation for depiction of tibial plateau fracture configuration. The multiplanar capabilities of MRI may facilitate three-dimensional perception, and in addition, this technique permits assessment of the associated injuries to the ligaments and menisci that are not visible on CT scans. The early diagnosis of osteomyelitis is best left to scintigraphy or MR imaging, but defining the intraosseous extent of disease can be accomplished with CT, owing to a change in attenuation values as normal marrowfat is replaced. In cases of chronic osteomyelitis, CT may be used to identify sequestra, bone abscess and soft tissue abscesses as well as sinus tracts. The role of CT in the evaluation of musculoskeletal neoplasm is best described by considering separately the neoplasms arising in bone and those originating in soft tissue. CT has not replaced conventional radiography in the diagnosis of primary and secondary bone tumors; however, it is better able to delineate the osseous and soft tissue extent of the process. Intraosseous extension of the neoplasm leads to the
conversion of fatty marrow, with its negative CT numbers, to marrow containing tumorous tissue, with higher CT numbers. The ability of CT to delineate the soft tissue extent of the bone neoplasm is a consequence of its excellent contrast resolution.
Ultrasound The term ultrasound refers to mechanical vibrations whose frequencies are above the limit of human audible perception. Medical ultrasonography utilizes frequencies in the range of – MHz. A central component of any ultrasound instrument is the transducer, which contains a small piezoelectric crystal. It serves as both the transmitter of sound waves into the body and the receiver of the returning echoes. When a brief alternating current is applied to the crystal, it vibrates at a characteristic frequency. By applying this vibrating transducer to the skin surface (through an acoustic coupling medium such as mineral oil or gel), the mechanical energy is transmitted into the body as a brief pulse of high-frequency sound waves. The advancing wave front interacts with tissues in various poorly understood ways and generates small reflected waves that return to the transducer. These cause the crystal to vibrate again, thereby generating an electrical signal that is conducted back to the machine where it is processed and displayed. Perhaps the most severe limitation of diagnostic ultrasound imaging is due to the inability of sound waves to penetrate gas and bone. The applications of this modality to orthopedics are generally limited to the soft tissues []. Ultasonography is non-invasive and painless to the patient. Furthermore, it is less expensive, safer, and performed more rapidly than most alternative imaging methods. Because it allows localization of lesions in three dimensions, sonography is a useful technique for guiding percutaneous aspiration or biopsy and for mapping radiation portals. The use of ultrasound for evaluating various swellings in the popliteal space gained acceptance early. Because the fluid–solid distinction was accomplished easily even by early instruments and because popliteal cysts and popliteal artery aneurysms constitute the majority of masses in this area, sonography has been used frequently in diagnosing these lesions [].
Knee Ultrasound has been recommended as a screening procedure for patients with rheumatoid arthritis who have painful or asymptomatic swelling of the popliteal space. Moreover, ultrasound is a particularly attractive means of performing serial non-invasive studies to monitor response to various forms of therapy []. MR imaging has diminished the role of ultrasound in the evaluation of the knee. However, sonography has been shown to be capable of measuring the thickness of articular cartilage and of assessing its surface characteristics []. Real-time ultrasound can show the posterior horn of the medial and lateral menisci. The normal meniscus appears as a triangular hyperechoic structure. Meniscal cysts are also easily identified sonographically as fluid-containing spaces superficial to the menisci and ligaments. Ultrasound is also useful in diagnosing tendinitis and bursitis around the knee [–]. At the knee, tendinitis is frequently observed in the quadricipital, patellar, bicipital and per anserinus tendon. Tendinitis is seen as a swelling and hypo-echoic appearance of the tendon. Calcifications are rare, but are pathognomonic of a chronic stage. Ultrasound is the only method that can show tendon fibers. In contrast to MRI, ultrasound is able to show microruptures, due to its high resolution. In MRI, a hyperintense signal is seen in tendinitis, as well as in partial rupture.
Magnetic resonance imaging The phenomenon of nuclear magnetic resonance (NMR) was first investigated nearly years ago []; since then it has become a standard tool in chemistry and in the last two decades it has served as the basis for a remarkably powerful and flexible medical imaging technique []. The intense enthusiasm for and the rapid introduction of MRI into the clinical environment stem from the abundance of diagnostic information present in MR images. Although the image format is similar to CT, the fundamental principles are quite different; in fact, an entirely different part of the atom is responsible for the image formation. In MRI, it is the nucleus that provides the signal used in generating an image. We note that this differs from conventional diagnostic radiology in which the electrons are responsible for the imaging signal. Furthermore, it is not only the nucleus of the atom but also its structural
and biochemical environment that influence the signal. The musculoskeletal system is ideally suited for evaluation by MRI since different tissues display different signal intensities on T1- and T2-weighted images. The images displayed may have low signal intensity, intermediate signal intensity or high signal intensity. Low signal intensity may be subdivided into: (i) signal void (black); and (ii) signal lower than that of normal muscle (dark). Intermediate signal intensity may be subdivided into: (i) signal equal to that of normal muscle; and (ii) signal higher than muscle but lower than subcutaneous fat (bright). High signal intensity may be subdivided into: (i) signal equal to normal subcutaneous fat (bright); and (ii) signal higher than subcutaneous fat (extremely bright). High signal intensity of fat planes and differences in signal intensity of various structures allow separation of the different tissue components including muscles, tendons, ligaments, vessels, nerves, hyaline cartilage, fibrocartilage, cortical bone and trabecular bone. For instance, fat and yellow (fatty) bone marrow display high signal intensity on T1- and intermediate signal on T2-weighted images; hematoma displays relatively high signal intensity on both T1 and T2 sequences. Cortical bone, air, ligaments, tendons and fibrocartilage display low signal intensity on T1- and T2weighted images; muscle, nerves and hyaline cartilage display intermediate signal intensity on T1- and T2weighted images. Red (hematopoietic) marrow displays low signal on T1- and low-to-intermediate signal on T2-weighted images. Fluid displays intermediate signal on T1- and high signal on T2-weighting. Most tumors display low-to-intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Lipomas display high signal intensity on T1- and intermediate signal on T2weighted images. Traumatic conditions of the bones and tissues are particularly well suited to diagnosis and evaluation by MRI. Some abnormalities, such as bone contusion or trabecular microfractures not seen on radiography and CT, are well demonstrated by this technique. Occult fractures, which can be missed on conventional X-ray films, become obvious on MR imaging. The value of MRI for the imaging of musculoskele-
Chapter . nuclear scintigraphy in the characterization of osteonecrosis and, furthermore, can be used to assess the integrity of the overlying articular cartilage surfaces. MR imaging is unique in its ability to evaluate the internal structure as well as the surface of the meniscus. With conventional arthrography, intra-articular injection of contrast media permits visualization of surface anatomy but does not allow delineation of fibrocartilage structure or subchondral bone.
MR arthrography
Fig. .. MRI of an injured popliteofibular ligament.
tal conditions such as tumors and osteonecrosis became apparent almost immediately after the introduction of this modality in the early s. Many advances have been made in MRI of the knee since its initial application, in , for evaluation of the meniscus, and MR examination is now routinely used to assess a wide spectrum of internal knee derangement and articular disorders (Fig. ..) []. A noninvasive modality, MR has replaced conventional arthrography in the evaluation of the menisci and the cruciate ligaments and has decreased both the morbidity and the cost associated with arthroscopic examinations that yield negative results [,]. The decrease in the cost of MR knee studies has also contributed to their acceptance by the orthopedic community as a non-invasive replacement for arthrography and nontherapeutic arthroscopy. With MR imaging, the anatomic and pathologic definition of soft tissue, ligaments, fibrocartilage and articular cartilage is superior to that seen with CT. Fast spin echo imaging, used in conjunction with fat suppression MR techniques, has extended the sensitivity and specificity of MR for the detection of articular cartilage injuries. Additional advantages of MR imaging are multiplanar and thinsection capability and the ability to evaluate subchondral bone and marrow. As a result, MR imaging is recommended instead of CT for the evaluation of bone contusion and occult knee fractures, including tibial plateau fractures of the knee. MR has supplanted
Despite the challenge presented by arthroscopy and newer imaging techniques such as CT and MR imaging, the role of arthrography is most established for abnormalities of the knee []. Single-contrast examination using air and oxygen or radiopaque substances [] has been replaced, in large part, by double-contrast examination using air and radiopaque contrast material []. In recent years computed arthrotomography (or CT alone) has been introduced in the evaluation of chondromalacia of the patella, cruciate ligament injuries and even meniscal abnormalities. The postoperative evaluation of partial meniscectomies and primary repair offers unique challenges for MR imaging. Correlation of MR findings with preoperative MR studies or details of the arthroscopic surgery is useful in increasing the accuracy of MR diagnosis of a retear, persistent tear or a normal healing response in the meniscal fibrocartilage. It may be difficult to identify tears in the meniscal remnants after a partial meniscectomy. Even in the absence of a retear, the meniscal remnant may demonstrate a residual grade signal intensity. Long TE or T2-weighted spin echo images or T2* gradient echo images can be used to identify fluid directly extending into the cleavage plane of a tear in a meniscal remnant. This finding is more specific than the presence of grade signal intensity on short TE or T1-weighted images. Applegate and colleagues [] have reported an % accuracy for the diagnosis of recurrent tears in the postoperative meniscus with MR arthrography compared with an overall accuracy of % when conventional MR imaging was used. MR arthrography was particularly useful in characterizing small meniscal remnants. MR arthrography has become popular in recent
Knee
Table .. Imaging of acute knee injuries. Test
Interpretation
Be aware of
Plain radiograph AP and lateral MRI
Will diagnose a fracture Will diagnose ACL, PCL, MCL, LCL and posterolateral ligament injuries, meniscal tears, bone bruise and extensor apparatus tears May diagnose tears of the extensor apparatus Reconstruction CTs are useful in tibial plateau fractures
Stress radiograph if epiphyseal injury is suspected The newer extremity MRI machines do not usually image the entire extensor apparatus — a tear may be missed
Ultrasonography CT scan
Operator dependent
ACL, anterior cruciate ligament;AP, anteroposterior; LCL, lateral collateral ligament; MCL, medial collateral ligament; PCL, posterior cruciate ligament.
years. The diagnostic accuracy of this technique may exceed that of conventional MRI because the intraarticular structures are better demonstrated if they are separated by means of capsular distension. Such distension can be achieved with intra-articular injection of contrast material such as diluted gadolinium or saline. The generated images are very similar to those obtained of the joint with pre-existing joint effusion. In clinical practice MR arthrography is predominantly used in the evaluation of shoulder abnormalities. An indication in the knee joint is the imaging of postoperative menisci. There are many studies that indicate the difficulty encountered in the MR imaging analysis of the repaired or partially resected meniscus. The diagnostic value of standard arthrography in this clinical setting is based primarily on the intrameniscal extension of fluid after an iatrogenic effusion produced by the injection of contrast material into the joint. MR arthrography using gadolinium compound or saline solution shares many of the advantages of standard arthrography in the diagnosis (or exclusion) of a retorn meniscus. With MR arthrography, the most definite sign of a retorn meniscus is the presence of contrast material within the meniscus. The absence of such contrast material is consistent with (but not diagnostic of) the absence of a new tear [–].
Fractures and chondral injuries Fractures of the femoral or tibial part of the knee are relatively common in sports. The usual fractures are located on the proximal part of the tibia, primarily as
tibial plateau fractures, often in conjunction with cruciate ligament injuries. It is beyond the scope of this book to review the typical intra-articular fractures. Cartilage injuries have become quite frequent in the athletic population. In a Norwegian study, % of patients in consecutive arthroscopies had cartilage damage suitable for treatment []. Cartilage injuries can be acute or chronic. The so-called bone bruise which occurs with rotational injuries and may lead to secondary cartilage damage occurs in as many as % of rotational injuries to the knee [,]. Recent studies, both basic science and clinical, suggest that bruising of the subchondral bone changes the environment for the cartilage in the area. Follow-up MRI studies of patients with bone bruise suggest that this may lead to degeneration of the cartilage and early arthritis [,]. In addition it has been shown that isolated cartilage injuries may lead to degeneration of the adjacent cartilage []. These changes may be caused by the abnormally high stresses acting on the rim of the defect []. The cartilage surface opposing an isolated cartilage injury often shows fibrillation caused by mechanical irritation []. Thus there is evidence that rotational injury to the knee with bone bruise and additional cartilage changes may develop into degenerative arthritis. Twyman et al. [] prospectively followed knees in which osteochondritis dissecans (OCD) had been diagnosed before skeletal maturity. At an average of years, % had radiographic evidence of moderate or severe osteoarthritis. Only % had a good or excellent functional result.
Chapter . In the prospective study of consecutive arthroscopies, three main cartilage injury patterns were detected [,]: cartilage injuries in conjunction with bone bruise as mentioned above; osteochondral fractures caused by a traumatic incident; and osteochondroses representing the typical osteochondritis dissecans or the subtler avascular necrosis. After an acute traumatic event, an osteochondral injury will lead to hemarthrosis and pain. Some patients will even experience locking. The injury will not usually be picked up on a plain radiograph, but will be detected on a MRI arthrogram. Symptoms from OCD are usually pain and swelling with occasional locking. The majority of patients will be adolescents. Even though the cause of an OCD is presently unknown, the symptoms often occur after a sports event. Consequently the patient feels that the injury has occurred during sport. It is well established that damaged articular cartilage has a very limited potential for healing. The literature suggests that defects larger than – mm in diameter in particular rarely heal. Articular cartilage in adults possesses neither a blood supply nor lymphatic drainage. Although the cells continue to produce new extracellular matrix throughout life, they are ineffective in responding to injury []. Not until the subchondral bone is penetrated is the usual inflammatory wound healing response observed. Cells recruited from the bone marrow then attempt to fill the defect with new tissue. To date, no one has been able to fill the defects with normal hyaline cartilage regardless of methodology. According to O’Driscoll the options for operative treatment of damaged cartilage can be grouped according to four concepts [,]. The articular cartilage can be restored, replaced, relieved or resected. In the following an overview of the current status in this field is presented.
Osteochondritis dissecans Review of the literature of ostechondritis dissecans (OCD) is quite confusing. There is little agreement among investigators concerning the etiology of OCD. The most widely accepted theories include trauma, ischemia, abnormal ossification within the epiphyses, or a combination of these. Regardless of cause, the
symptoms and signs are identical, with pain, stiffness and swelling the most common. The diagnosis is confirmed with a plain radiograph, preferably a tunnel view. A more dynamic approach is through a scintigraphic or MRI arthrographic evaluation. Currently, MRI arthrogram seems to give the best information on the degree of ingrowth of the OCD in the surrounding bone. After the diagnosis is confirmed, treatment in the child and adolescent will involve non-weight-bearing with motion for – weeks if the piece is still in its bed. In most patients below the age of , this leads to ingrowth of the OCD with good long-term results. If the patient continues to have pain after a period of non-weight-bearing, an arthroscopic examination is recommended. If the bone piece is still in place, but loose, it should if at all possible be fixed. This can be done as an arthroscopic procedure with either a metal screw or synthetic screws or pegs. Many authors have also published good results using an open procedure with bony pegs. If the bone piece is either impossible to retain or in many small pieces, it should be removed. During the same procedure a microfracture technique to obtain the so-called ‘super clot’ may be carried out. This procedure followed by continuous passive motion daily for weeks has been shown to produce hyaline-like cartilage in rabbits and good clinical results in humans [–]. If this procedure fails and the lesion is on the weight-bearing surface of the femoral condyle, a number of procedures are available currently. These will be described briefly in the next paragraph.
Osteochondral or chondral fractures These fractures occur during a traumatic event, often in combination with major ligament injuries or bony fractures. The patient will complain of stiffness and pain and the examiner will often note swelling. The diagnosis is confirmed through either a MRI arthrogram or an arthroscopic examination. The natural history of these injuries is not well documented. The literature shows that ACL tears with additional cartilage or meniscal injuries do worse than the isolated ACL tear. In addition there is indirect evidence through animal studies that isolated cartilage injuries in the knee leads to development of degenerative arthritis. Because the natural history in humans is not well documented, a
Knee
number of treatment options exist. Currently, there seems to be consensus on the fact that defects less than cm2 can be treated conservatively even when they are located on weight-bearing surfaces. This is based on retrospective studies showing these patients to do reasonably well short term. This concept has been accepted, although no science exists regarding this problem. In patients with defects larger than cm2 on weight-bearing surface of femur, a large number of well-proven and new techniques are currently undergoing tests.
Subchondral drilling or microfracture These techniques have in common the goal of recruiting pluripotential stem cells from the marrow by penetrating the subchondral bone. According to Steadman [,], the penetration must be done with specific awls to avoid the heating that occurs with drilling. The Steadman technique has been shown to produce hyalin-like cartilage in small defects in rabbits and in larger defects in horses. Human studies have not as yet had a control group, but several publications have suggested good efficacy in reducing pain. The method is currently being used as a first choice in patients with untreated cartilage defects. Salter introduced and investigated the biologic concept of continuous passive motion (CPM) of joint for the postoperative treatment of articular cartilage injuries []. His group found a good effect of CPM in rabbits with small cartilage defects, with much smaller effect on larger defects. CPM has subsequently been used by Steadman in his microfracture technique with good success. The present use of CPM in several of the new cartilage repair techniques is controversial. To date, no controlled, randomized studies have been published on the microfracture technique.
Periosteal transplant Periosteum has been used alone for biologic resurfacing arthroplasty in humans for more than a decade. In Scandinavia, the Swedish Umeå group has published long-term results of their technique for resurfacing patellar cartilage defects (Fig. ..). Their clinical use of periosteum is built on animal data predominantly from rabbits where short-term results are encouraging, showing a majority of hyalin-like cartilage. O’-
Fig. .. Periosteal transplantation for a patellar cartilage defect.
Driscoll [] has published extensively on the animal side and has reported encouraging clinical results. As he and the Umeå group point out, the technique is demanding and relies on meticulous surgical procedure.
Transplantation of autogenous chondrocytes Many investigators have chosen to use chondrocytes for cell transplantation for the regeneration of cartilage [–]. Other possibilities include undifferentiated stem cells or even allogene cells. Bone marrow as well as periosteum can be used as sources for such cells. The fully differentiated chondrocytes have the capacity to produce cartilage matrix and may be suitable for chondral defects only. Most defects, however, involve a bony part as well, and chondrocytes cannot produce bone. Periosteal and bone marrow cells do have the capacity to regenerate both the cartilage and the subchondral bone. In many instances the osteochondral defects are several mm deep and an isolated chondrocyte transplant will not be able to fill the gap. Many clinicians have therefore now moved to a combination of bone graft followed by chondrocyte transplantation, or use periosteal transplantation alone. Another trend is to use a carrier, that is, a scaffold or matrix upon which the cells are grown. The ideal material has not been identified, and to date biodegradable matrices seem to have the most promise. Carriers have already been marketed and development will continue also with regard to growth factor stimulation attached to the scaffolds.
Chapter .
Fig. .. Autogenous chondrocyte transplantation for a cartilage defect of the medial femoral condyle.
So far animal results of chondrocytes transplants have varied from excellent in rabbit studies [,] to mediocre in dog studies []. A remaining problem is the incomplete incorporation of the healing tissue into the cartilage defect. On the experimental side much research remains to be done to confirm the scientific validity of transplantation of chondrocytes using the currently advocated technique. Several clinical studies have reported promising results with chondrocyte transplantation in femoral cartilage defects [,,] (Fig ..). The procedure involves the patient having to undergo harvesting through an arthroscopic procedure, followed – weeks later by an arthrotomy where the cells are injected under a cover of periosteum. Clinical results from femoral defects have ranged from to % excellent and good in different studies. So far no controlled studies are available. At the moment the procedure is reserved for patients with large defects on the weightbearing surface of the femur. The defects should not be deeper than approximately mm without being bone grafted. Currently, the procedure is generally carried out on the femur. Chondral transplantation onto the tibia and patella is being done in centers for research purposes only for the time being. So far no randomized, controlled studies have been published on this technique.
Mosaicplasty and osteochondral autogenous grafts An alternative to biologic regeneration of a defect is to replace it with a substitute. This can be done either partly using special equipment where available, or
Fig. .. A -year-old patient treated with mosaicplasty because of a major cartilage injury during skiing.
completely with a matched osteochondral transplant (Fig. ..). Several orthopedic companies have produced coring drills, which will harvest plug from areas that are relatively less weight-bearing such as the intercondylar notch or the most lateral part of the femoral condyle (Fig. ..). The plugs are then placed in the defect in predrilled cylinders. Studies have shown that no part of the femoral condyle is non-weight-bearing and the long-term results of the harvesting procedure are not known. So far there is limited animal data on the procedure. The first clinical data were published by Hangody and Bobic [–] and match those of chondrocyte transplantation by Brittberg et al. [,]. As for chondrocyte transplantation, no controlled studies exist. The procedure is much cheaper than cell transplantation and can be used in defects that are deeper without bone grafting. The use is limited only by the size of the defect due to the necessity of harvesting from relatively less weight-bearing areas.
Osteochondral allografts Because large, symptomatic cartilage defects are difficult to fill with autologous osteochondral plugs, allografts have been used. So far, the use of osteochondral allografts has primarily been after fracture sequela of the femur or tibial plateau or large OCD lesions []. The viability of chondrocytes has been demonstrated both after refrigerated allografts and in retrieved specimens after as long as years. There seems to be
Knee a larger immune response to fresh vs. frozen allografts, but the bottom line is that the technique seems to work well. The use of the technique is currently only limited by allograft availability.
Osteotomy None of the techniques mentioned so far will be successful if the knee is malaligned. Consequently, one must consider an osteotomy if the knee is valgus or varus compared to the normal knee. The most common is a varus knee in conjunction with injuries to the ACL and/or PCL and posterolateral structures. Some of these patients will have a so-called ‘varus thrust’ gait and are candidates for an opening wedge osteotomy. Patients with normal ligament function, but with a knee in varus malalignment, may need a closing wedge osteotomy to decrease the load on the medial part of the joint [].
Conclusion Cartilage lesions or injuries are common in sports. There are indications that the damaged articular cartilage can be restored through cell or periosteal transplantation, microfracturing be replaced through an osteochondral auto- or allografts, and/or relieved through an osteotomy that unloads the injured joint compartment and decreases the stress. Currently, efforts to induce healing and regeneration of cartilage are being directed toward enhancing the natural healing potential of cartilage or replacing the damaged cartilage with tissues or cells that can grow cartilage. These procedures have shown promise but are not yet at a stage where they should be used indiscriminately. So far, no controlled, randomized studies have been published in this field. It remains to be seen which, if any, of these procedures will survive after good, controlled studies have been carried out.
Meniscal injuries Injuries to the menisci are common in sports, with an incidence between and / per year []. They are frequently the culprits for keeping athletes out of activity and for creating early osteoarthritis. The menisci are known to serve a crucial role in the complex biomechanics of knee joint function. The fact that meniscal injury and meniscectomy may result in early osteoarthritis of the knee serves as an impetus to
advance our knowledge of this structure with regard to basic biomechanics, kinematics and reparative qualities. There has been great development in meniscal repair devices over the last few years. Efforts are also being made to substitute the meniscus with allografts or prosthetic replacements. Two aspects of the treatment of lesions of the meniscus are currently the subject of much discussion and research: repair of the tears in the ‘avascular zone’ and meniscal transplant. Histologic examination of adult cadaveric specimens has suggested that the inner –% of the meniscus is avascular. Tears in the so-called ‘white zone’ have been thought to have little or no potential for healing and consequently have led to resection of large parts of the injured meniscus. The avascular part of the meniscus may be given access to a blood supply by making vascular access channels and placing a fibrin clot between the edges of a meniscal tear. Other investigators have covered the meniscus with synovial flaps to encourage vascularization. Both these techniques have expanded the indications for meniscal repair, which now can be carried out with a number of different devices.
Diagnosis A knee sprain followed by immediate swelling usually points toward a cruciate ligament injury. However, an acute tear of the red–red or red–white zone of the meniscus will lead to intra-articular bleeding and pain. If the patient is unable to extend the knee, further suspicion of a meniscal tear results. Acute swelling of the knee, however, caused by bleeding will lead to decreased range of motion. It is often difficult to discern between a meniscal, osteocartilage or ligament injury. The usual meniscal tests may be difficult to carry out due to pain. In a more chronic case, the diagnosis can usually be made based on the clinical examination using the McMurray test and hyperextension test. Most patients will also have pain on palpation in the joint line close to the meniscal tear. If the clinical diagnosis is difficult, the final diagnosis may be made through MRI which has high sensitivity and specificity for meniscal tears.
Treatment Meniscal injuries leading to symptoms should be arthroscopically examined and treated. A small radial
Chapter . tear can easily be removed by basket forceps, whereas a peripheral injury may be suitable for a repair. Today these are carried out with the use of the arthroscope and additional devices. The repair is carried out either in the inside-out fashion with transmeniscal sutures tied through an incision outside the knee, or with an all-inside approach using meniscal arrows or tacs which are absorbable. The best results of a meniscal repair are achieved when the repair is done in conjunction with an ACL reconstruction within weeks after the injury, and the injury is located close to the periphery. Repairs in a stable knee approach % good results, whereas repairs in an unstable knee are associated with a –% rate of retear. The choice between bioabsorbable tacs or arrows and suture repair is not easy. The tacs are easy to use and have shown good results, although there have been reports of the tacs creating temporary synovitis in the joint and not being resorbed for a long time resulting in migration to the skin. The authors prefer inside-out suture repair in large tears. In small tears in the posterior part of the lateral meniscus, arrows or tacs may be the technique of choice. No randomized controlled studies are available to date on the different techniques. In patients with total or subtotal menisectomies and chronic pain, osteoarthritis is often found in one compartment. The joint angle is usually changed from neutral to varus or valgus based on radiographs. These are the patients who have been operated on with a combination of osteotomies and meniscal allografts. A few studies have been published on the long-term effectiveness of meniscal allografts, and the results have varied considerably []. For the treatment of partial menisectomies and osteoarthritis, collagen-based templates have been sutured to the meniscal remnants in a limited number of patients. No controlled studies are available on any of these techniques.
Meniscal cysts Meniscal cysts are uncommon lesions usually found in the lateral meniscus. They are usually associated with a degenerative tear. The patient commonly has lateral joint line pain and % will have a palpable mass. Other patients have pain, but the cyst can only be detected on MRI or by ultrasound. The cysts will usually not disappear once the meniscus injury is established and will usually need surgical removal. This should
always be preceded by an arthroscopy examination since these patients always have a meniscal tear with connection to the cyst. The tear can be debrided arthroscopically and the cyst emptied. However, the cyst itself will often need removal through a separate skin incision.
Ligament injuries Isolated ligament injuries of the knee Medial collateral ligament The medial collateral ligament complex of the knee is the main stabilizer to a valgus force applied to the knee. Isolated MCL complex injuries are usually secondary to a valgus contact injury [,]. In addition to diagnosing the severity of the MCL complex injury by performing the valgus stress test at ° knee flexion, the medial epicondyle, the meniscofemoral portion of the complex, the joint line, the meniscotibial portion of the complex and the MCL complex attachment sites on the proximal tibia are palpated to determine the potential location of injury. While this may not be as important for incomplete MCL injuries, it is very important for complete tears of the MCL complex. This is because it is believed that tears of the meniscofemoral portion of the MCL complex are inherently more stable and have a lesser likelihood of needing surgical intervention and repair than meniscotibial lesions, because of the inherent bony stability of the medial side of the knee. The convex surface of the medial femoral condyle articulates well on the concave surface of the medial tibial plateau. Complete tears of the meniscofemoral portion of the MCL complex do not usually result in any significant instability to this. However, tears of the meniscotibial portion of the complex tend to give more rotational laxity, which may not heal completely over time. Grade I or II MCL complex injuries [] (incomplete) are primarily diagnosed by the physical examination. Acute injuries will have pain over a portion of the MCL complex with an endpoint present on the valgus stress test at ° knee flexion. If there is joint line opening > cm, it is considered that the MCL complex is completely torn. If the physical examination does not suggest any evidence of other ligament injury, meniscal pathology or lateral-sided joint line pain
Knee (which could be due to either a bone bruise or a meniscal tear), the patient is started on a program of physical therapy to address their pathology and to return them back to function as soon as possible [,]. After the initial swelling and pain has been addressed in these injuries, these patients start a functional program of rehabilitation soon after injury. Patients are allowed to weight bear as tolerated and may come off crutches when they can walk without a limp. They start to perform quadriceps setting exercises and straight-leg raises immediately. Once range of motion allows, they are started on an exercise biking program and progressed in both time and level of effort based upon their symptomatology. Utilizing this program, athletes are usually back to full participation within – weeks for a grade I MCL tear, and – weeks for a grade II MCL tear. In the evaluation of isolated grade III (complete) MCL complex tears, it is especially important to make sure that there is no associated concurrent injury present. In this regard, it is important to check the patellofemoral joint for evidence of any lateral patellar dislocation and to check for the integrity of the anterior cruciate ligament to make sure that it is not torn. While performing the valgus stress test, the examiner can also assess for any significant meniscal pathology, which is usually felt as a clunk or crepitation by one’s fingers over the joint line of the medial compartment. Grade III MCL tears require closer follow-up and more individualized treatment than grade I or II tears do. We do not use a brace for meniscofemoral-based tears, but will use a hinged knee brace for weeks for meniscotibial-based lesions to make sure that there is no significant abnormal motion of the tibia as the patient progresses in rehabilitation. After pain and swelling have subsided, the patient is enrolled in a program of rehabilitation. First, the patient is allowed to weight bear as tolerated with the use of crutches. Crutches are used for – weeks with these tears to ensure that the athlete does not significantly stress the knee. They are allowed to come off the crutches at this point if the physical examination indicates that the MCL complex is healing well and they are making good progress in their rehabilitation program. Patients will begin a program of quadriceps sets and straight-leg raises immediately. Once their range of
motion allows, they are also started on an exercise bike. The goal is to have them working on increasing amounts of time and levels of intensity with the exercise bike based on the symptomatology of their knee. The patients are followed closely at approximately –-week intervals to ensure that their MCL complex is healing and no residual laxity is present. For those patients who do show good evidence of healing, our goal is to increase their functional activities as tolerated at approximately – weeks after injury with a goal of return to full activities by – weeks after injury. This clinical program is based on the animal studies of Frank and Woo [] who noted that early motion improved the overall strength of a ruptured MCL. This may be true in the human clinical situation and athletes are encouraged to use an exercise bike as much as possible both to build up their overall strength and to put some beneficial stress on the healing MCL complex. In those rare instances where there is still no evidence of healing of the MCL complex at approximately – weeks after injury, consideration is given to performing a primary repair or surgical augmentation of the torn structures.
Anterior cruciate ligament tears As mentioned previously, the ACL is the primary stabilizer to anterior translation of the knee. Functional limitations caused by ACL tears include difficulty with cutting, pivoting and twisting due to anterolateral subluxation of the lateral tibial plateau on the lateral femoral condyle. Lack of an ACL does not usually hinder function with level jogging in a straight line, ice skating or in-line skating. Partial ACL tears are not common. When they do occur, they are usually due to a tear of either the posterolateral or anteromedial bundles of the ACL rather than a partial intrasubstance stretch of the ligament. When these partial ACL tears do occur, the basic principles are to decrease the effusion in the knee, minimize quadriceps atrophy, and regain full range of motion as soon as possible. It is also important to make sure that there are no concurrent intra-articular injuries present, such as an osteochondral fracture or a meniscus tear, which could hinder subsequent rehabilitation. Patients with perceived partial ACL tears are entered into a rehabilitation program as soon
Chapter . as their pain and effusion will permit. Patients are instructed to work on range of motion of their affected knee several times daily. In addition, they are instructed in quadriceps sets, straight-leg raises, and other closed-chain kinetic exercises. This would include the use of an exercise bike, leg presses and minisquats, or the use of a squat rack as tolerated. The amount of weight used initially is approximately one-quarter body weight (if tolerated). Progressive strengthening is then performed, based upon the patient’s symptomatology. The patient is also instructed to initiate a walking program, with progression to jogging at approximately – weeks after injury, as tolerated. Once the patient is able to perform sports-specific functional activities without limitations, he or she is allowed to participate in sports. Many centers are using isokinetic muscle testing or specific functional tests as guidelines for return to sport [,,]. It is believed that patients who have a partial ACL tear may in some instances have an unrecognized complete ACL tear or they may be at higher risk for a resultant complete ACL tear with minimal trauma. For this reason, these patients should be counselled to look for signs of instability with function and to seek treatment if this should occur. Complete tears of the ACL may be diagnosed either by physical examination or by other diagnostic methods. Evidence of functional limitations in the patient with activity, a positive Lachman’s test and a positive pivot-shift test is evidence enough of a complete ACL tear and further diagnostic testing, such as an MRI scan, is probably unnecessary. We recommend that obtaining an MRI scan for purposes of diagnosing an ACL tear be reserved for those patients in which the diagnosis is in doubt based on the clinical picture. This would include those patients who present acutely with a knee effusion and who have evidence of a potential mechanical block or a substantial decrease in the range of motion of their knee (especially with an inability to extend their knee). In these instances, the examiner needs to be cognizant of the fact that the patient could potentially have a displaced bucket-handle tear of their meniscus, which could be amenable to repair. The use of an MRI scan for diagnosis in this instance would be considered good use of health care resources. It would also be considered useful to perform an MRI scan in either acute or chronic cases in which it is difficult to
determine whether the increased translation that is seen is due to an isolated ACL tear or whether there is a component of other ligamentous instability present which makes the physical examination somewhat inconclusive.
Complete isolated anterior cruciate ligament tears After diagnosis has been made of a complete tear of the ACL in a patient, it is important to consider the patient’s age, activity level and expectations. An important decision needs to be made in terms of whether to proceed with non-operative or operative treatment. In those patients who are relatively young with open physes or in patients whose activity levels may not justify an ACL reconstruction, a trial of rehabilitation and activity modification, possibly supplemented with the use of an ACL functional brace, may be indicated. Due to the fact that most patients who have an acute ACL tear have a significant intra-articular hemarthrosis, it is important for the patient to resolve the pain, swelling and decrease in range of motion that is normally seen with an acute ACL tear prior to working on an aggressive rehabilitation program. Once the effusion has diminished and the patient has achieved full range of motion, they may initiate a rehabilitation or exercise program which does not cause any significant irritation or symptomatology in their affected knee. This would primarily consist of a closed-chain kinetic exercise program for the quadriceps and hamstrings with an emphasis on low-impact activities, such as the use of an exercise bike, leg presses and squats. The usual time for a patient to return to full activities after an acute ACL tear is – weeks. In those patients who wish to return to sports, they should be counselled as to the fact that they are at increased risk for meniscal tears and chondral injuries with subsequent subluxation episodes. The overall functional benefits from the use of an ACL brace are still unknown. While some braces have been shown to be effective at reducing anterolateral subluxation of the tibia on the distal femur at low applied loads in in vitro testing in the lab, this has not been demonstrated for the higher loads that a patient’s knee would see functionally []. However, it is recognized that many patients do obtain some benefit from wearing these braces. It still remains to be seen whether
Knee this benefit is due to actual prevention of subluxation episodes or the potential improved proprioception that a patient may have while using the brace. For those patients who choose to return to cutting, pivoting and contact sports, we currently recommend that they strongly consider an ACL reconstruction to prevent resubluxation events in the future. While there are many choices with varying arguments for the type of graft utilized for an ACL reconstruction, it is currently accepted that anatomically placed reconstruction tunnels of the ACL have the best functional results []. One way to visualize and understand where to place these tunnels correctly is to look at an MRI scan of a normal ACL on the sagittal view (Fig. ..). It becomes especially obvious that the normal femoral attachment for the ACL is at the very far posterior aspect of the intercondylar notch. The authors’ current recommended tunnel positions for an ACL reconstruction on the tibia are at a point approximately – mm anterior to the ligament of Humphrey/PCL, at the bottom of the medial tibial spine, and in line with the anterior horn of the lateral meniscus. Due to distortion from the ° arthroscope, the anatomic landmark of the anterior horn of the lateral meniscus is not very useful in arthroscopic reconstructions. However, it is especially useful in open reconstructions,
Fig. .. MRI of a normal anterior cruciate ligament.
especially in knee dislocations where there is a combined ACL and PCL tear with loss of the normal ACL reference off the PCL. In this anatomic reconstruction point on the tibia, there should be either no or only minimal impingement of the ACL graft on the intercondylar roof. Anterior tibial tunnel placement usually results in an extension deficit to the knee unless an aggressive roofplasty of the intercondylar notch is performed. Knee extension deficits are not well tolerated by patients and usually lead to functional limitations. It can also lead to a cyclops lesion (Fig. ..) as the fibers of the ACL graft become sloughed with the formation of an anterior nodule on the graft. Malplacement of the femoral tunnel is still believed to be one of the most common causes of a failed ACL reconstruction. Anterior tunnel placement of the femoral tunnel results in the knee being overconstrained in flexion. Invariably, either these patients have a loss of full knee flexion, or over time they gradually stretch out their ACL reconstruction grafts when they do achieve full flexion. The current recommended tunnel position is to put the ACL graft as far
Fig. .. Cyclops nodule of fibrous tissue (arrowed) anterior to an ACL reconstruction, blocking full extension of the knee.
Chapter . posterior on the intercondylar notch as possible. This usually means that only a -mm back wall is present after the femoral tunnel has been drilled. In addition, the normal ACL is located at approximately : on the right knee and : on the left knee so this is where the tunnels are recommended to be placed rather than centrally in the intercondylar notch. Because of this, it is important to make sure that the tibial entry site is positioned properly during a one-incision ACL reconstruction so that the graft is not malpositioned and placed centrally rather than in the correct position. Two-incision ACL reconstructions also need to follow these tunnel placement positions. The surgical technique of ACL reconstruction using an autogenous central third patellar tendon graft or four-bundle hamstrings is considered the best technique for ACL reconstruction [,].
Posterior cruciate ligament tears In the discussion of the treatment of PCL tears, it is important to know whether it is an isolated tear or one with a combined concurrent ligament injury. This is because it is felt that the natural history of isolated PCL tears is very different from that of combined ligament injuries. Parolie and Bergfeld [] have reported that about % of American collegiate senior football players at a National Football League predraft examination were found to have chronic PCL-deficient knees. Fowler and Messieh [] reported that athletes, with arthroscopically diagnosed isolated PCL tears who were followed for an average of . years were able to return to their previous activities without limitation. More recently a prospective study of athletes with isolated PCL tears treated nonoperatively for the mean follow-up of . years has been reported. In this group of patients, regardless of the amount of residual laxity they had from their PCL tear, half the patients were able to resume sports at the same or higher level. In light of this information, which demonstrates that the natural history of isolated PCL tears in many instances may result in little functional loss to the patient in the short term, a course of non-operative treatment of acute PCL tears may be indicated. Some centers splint an acute isolated PCL tear with the knee in full extension. In this position, posterior translation of the knee is minimized and there is little tension on
the anterolateral bundle of a PCL. Splinting from anywhere from to weeks may allow the PCL tear to heal and result in little instability over the long term. Once the period of initial splinting has been followed, the patient is then placed in a rehabilitative program to work on regaining their range of motion and rehabilitating their quadriceps mechanism. The importance of the quadriceps mechanism is especially important in PCL-deficient knees. This is because of its protective role in preventing posterior tibial translation. A strong quadriceps muscle group pulls through the quadriceps tendon, patella and patellar tendon anteriorly on the tibial tubercle to reduce the posteriorly subluxed tibial plateau to a normal position. Patients who undergo this form of rehabilitation program can usually return to activity by months. In patients who continue to have functional limitations at months after injury, PCL reconstruction is considered. In addition, it is important to investigate whether there are any other associated ligamentous injuries, which are initially not recognized, in this patient group. Avulsion fractures We believe that acute intervention may be indicated when there is a displaced avulsion fracture of the PCL. These avulsion fractures are usually from the PCL facet on the posterior proximal tibia. In those cases where there is a large bony avulsion fragment, we first perform a diagnostic arthroscopy of the knee to determine whether there is any concurrent structural damage (such as a meniscal tear or chondral injury). The avulsion is then fixed with a screw through a posterior, curved incision. Postoperative care for this type of treatment usually involves placing a patient into an immobilizer for – weeks and then starting a program of range of motion. The aggressiveness of this technique will depend upon the intra-articular appearance of the PCL. If there is a stretch component of the PCL in addition to the ligament avulsion fracture, or if intrasubstance necrosis has started because of the time from injury to surgical treatment (we prefer to treat these within the first – weeks after injuries), then the length of time in the immobilizer may be increased to nearer weeks rather than weeks. Once the avulsion fracture has healed, we will initiate the patient on a program of rehabilitation similar to the treatment of an isolated PCL tear.
Knee
Posterior cruciate ligament reconstructions The authors’ preferred technique is to use a singlebundle reconstruction of the anterolateral bundle of the PCL. Our preferred graft source is an Achilles tendon allograft, although a quadruple-bundle hamstring allograft may be indicated in those places where an Achilles allograft may not be available. Posterior cruciate ligament onlay technique The tibial onlay technique for a PCL reconstruction relies on the principle that passing a tendon graft over the posterior aspect of the knee and through a PCL tibial tunnel can result in fraying of the graft and possible loosening over time. In attempts to avoid this ‘killer turn’ of the PCL reconstruction graft, some authors have advocated a direct onlay on the posterior tibia with a bone block to achieve fixation of the graft. We have found this technique to have some use in patients in revision PCL cases where there may be osteolysis of the tibial tunnel and attempting a primary revision reconstruction, as opposed to a two-stage reconstruction with bone grafting of the tibial tunnel performed, would be difficult. One of the limitations that we have found with this technique is in using patellar tendon allografts. In some of our cases, we found that there was a second ‘killer turn’ created by using this technique. While we were able to obtain excellent placement of the PCL tibial bone plug, when the patellar tendon graft was passed intra-articularly and out through the femur, there was frequently graft tunnel mismatch and the entire bone plug on the femoral side exited the femoral tunnel (Fig. ..). We have utilized bone staples to fix the graft under the vastus medialis obliquus (VMO) and obtain fixation. In all of our cases, patients have had irritation of their vastus medialis obliquus from utilization of this technique. For this reason, we have reserved this reconstructive technique using patellar tendon grafts for revision PCL reconstructions with previous tibial tunnel osteolysis present. Double-bundle posterior cruciate ligament reconstructive technique A newer technique for reconstructing both the anterolateral and the posteromedial bundle of the PCL has been advocated by some centers [,]. The rationale behind this is to totally anatomically reconstruct the PCL. While the anterolateral bundle of the PCL is
Fig. .. Graft tunnel mismatch in reconstruction of the PCL.
important in preventing posterior translation of the tibia on the femur at ° knee flexion, the posteromedial bundle helps to provide stability against posterior translation close to extension. The importance of recreating the posteromedial bundle is probably of greater significance when there is a concurrent posterolateral corner injury present. In performing the double-bundle PCL reconstructive technique, the methods of preparing the PCL tibial tunnel are the same. Either a tunnel is drilled or an onlay technique with a bone plug is utilized. The difference lies in that instead of one large graft which recreates the anterolateral bundle of the PCL, smaller bundles are utilized which recreate both anterolateral and posteromedial bundles of the PCL. The femoral tunnels are placed at the normal anatomic positions of the anterolateral and posteromedial bundles of the PCL, respectively. Usually with this technique, the femoral tunnel position is the same as in the single-bundle PCL reconstruction. The difference is that instead of the usual -mm PCL femoral tunnel, a - or -mm tunnel is drilled. Once this is in place, a second femoral tunnel is then drilled slightly distal and posterior to this, which has an entry point slightly proximal and parallel to the anterolateral bundle’s femoral tunnel. The size of this tunnel is usually – mm in diameter.
Chapter . The usual graft used to reconstruct these twobundle PCLs is either hamstring tendons or Achilles allografts. The usual method of fixation on the femur is either with soft tissue interference screw or bone staples. The same technique in positioning of the knee for fixation of the anterolateral bundle is followed. However, there is some disagreement among different centers about how the posteromedial bundle should be fixed. The general consensus is to fix this bundle with the knee in full extension. Rehabilitation principles for posterior cruciate ligament reconstructions The general concepts behind a PCL reconstruction are that these reconstructions must be rehabilitated differently from ACL reconstructions. The grafts are generally larger and probably take longer to revascularize, and are considered to stretch out if an overly aggressive initial rehabilitation program is performed. With these general concepts in mind, it is still recognized that no prospective studies have demonstrated that this occurs with a more aggressive rehabilitation program. In many centers, a less aggressive rehabilitation program for the PCLs is utilized. For the initial weeks after surgery, we splint the patient’s knee in full extension for isolated PCL reconstructions for weeks. At weeks, the patient’s surgical subcuticular stitches are removed and a program of range of motion is initiated. In the initial -week interval, attention is turned towards obtaining pain control and attempting to minimize the postoperative effusion. Cold compression devices are utilized routinely to attempt to achieve this. In addition, patients are allowed to perform quadriceps sets and straight-leg raises in their immobilizer. This is performed because the quadriceps mechanism is protective to a PCL reconstruction. Aggressive hamstring exercises should be avoided for months after a PCL reconstruction to avoid putting any potential significant increased stress on the healing graft. At weeks –, the patient is initiated on a program of range of motion. Immobilizers are still worn for protection whenever the patient is up and out of bed. We continue to work on active and active assisted range of motion to ° during this time period. The patient works on performing straight-leg raises (done in the immobilizer), quadriceps sets, hip extension and hip
abduction exercises. After weeks, the patient works on weaning themselves off crutches and achieving a normal gait pattern. By months postoperatively, the patient should have achieved ° flexion. The use of a stationary bicycle is initiated once ° knee flexion is achieved. At months postoperatively, the patient may initiate a walking program as well as the use of a stairmaster. Patients may progress functionally in activities with attempts to avoid patellofemoral irritation by months postoperatively. They may progress to a jogging program between months and based on their overall quadriceps strength. Pivoting sports are avoided for months, with no contact sports allowed for months.
Posterolateral knee injuries Treatment of isolated posterolateral knee injuries The recommended treatment protocol for partial posterolateral knee injuries, which includes grade I and grade II instabilities, is primarily non-surgical. The program of immobilization of the knee in full extension and either an immobilizer or a plaster of Paris cast for weeks may be followed by a progressive functional rehabilitation program similar to that which would be performed for an MCL complex injury. Those patients who have functional limitations after this treatment program should be carefully evaluated to determine whether they have residual varus instability or rotational abnormalities, which are contributing to their lack of function. In this instance, surgical repair of the torn structures may be indicated []. The treatment of grade III posterolateral knee complex injuries is almost uniformly surgical. Patients who do have grade III posterolateral knee corner injuries treated non-surgically, or with a cast, have been shown to do poorly []. Surgical repair is recommended as soon as possible after injuries to enhance the identification of the torn structures, prior to the onset of scar tissue planes. This handling also provides good structures to hold the sutures. After the initial weeks, scar tissue planes develop which make it more difficult to identify the normal anatomy. In addition, identification of the peroneal nerve would be greatly complicated by these scar tissue planes which could add
Knee time to the surgical repair. It is helpful to break down the zone of injury for posterolateral knee injuries in attempts to determine where to perform the repair. Avulsions of either the popliteus tendon or the fibular collateral ligament off the femur are best repaired with a recess procedure. The popliteal recess procedure may be more useful than attempted direct suturing to bone or suture anchors, as these repairs tend to get more lax over time. In the recess procedure, a small tunnel is drilled at the anatomic location of the attachment site of the injured structure with an eyelet pin threaded out which exits on the medial aspect of the femur, proximal to the adductor tubercle region. A whipstitch-type repair is then placed into the avulsed structure, the sutures are then placed into the eyelet and the guide pin is then pulled out medially on the femur. The sutures can then be tied medially on the femur with the use of a surgical button. It is important to aim proximally when drilling this guide pin to exit on the anteromedial aspect of the distal femur such that the guide pin does not enter through the intercondylar notch. Tears of the mid-third lateral capsular ligament or the lateral gastrocnemius tendon off the femur can be repaired with suture anchors. Tears of the meniscotibial portion of the mid-third lateral capsular ligament or the anterior arm of the short head of the biceps femoris, or the components of the iliotibial band off the lateral aspect of the tibia, can easily be repaired either directly to bone or with suture anchors in this location. It is important to attempt to put these structures back into their anatomic position prior to repair. We have found the bone to be relatively soft in this area and often the needle can be placed directly through the bone for purposes of repair such that suture anchors are not necessary. The other type of common anatomic injury is avulsion of structures off the fibular head and styloid. This would include the popliteofibular ligament, direct arms of the long and short head of the biceps femoris, and the fibular collateral ligament. Due to the hard cortical bone of the fibula in this location, we have found that suture anchors allow for anatomic replacement of the structures and good secure repair. In those cases where the fibular styloid has an avulsion fracture (arcuate avulsion), it can be repaired by either an open reduction and internal fixation or a cerclage nonabsorbable suture or wire.
The repair of the structures should be sufficient to ensure that early range of motion (ROM) can be initiated without compromise of the postoperative stability. Occasionally, a period of cast immobilization is necessary in those patients in whom the structures that have been sutured have tenuous fixation. In those patients who need cast immobilization, we recommend that casting be performed at ° knee flexion with the tibia internally rotated. In other words, in order to make sure that there is no external rotation of the tibia on the femur in the cast during this period of immobilization, we place a dowel rod at the foot of the cast, which is positioned to prevent external rotation. Weight-bearing is not allowed for the first weeks after surgical repair and work with these patients primarily involves a program of ROM. In addition, they are allowed to perform straight-leg raises in the knee immobilizer during this period. Their progressive strengthening exercises are slowly progressed after the tissues have healed at weeks if the clinical examination seems to indicate that repair has healed. In addition, the use of the hamstrings is minimized for the first months after surgery due to the perceived deleterious effect of hamstring firing on posterolateral corner repairs. The treatment of chronic isolated grade III posterolateral corner injuries requires a more thorough workup than the acute situation. First, it is recognized that patients who have underlying genu varus alignment with grade III chronic posterolateral rotatory terrain instability need a full-length standing radiograph of the affected extremity to make sure that there is no varus malalignment. If there is, we recommend that a proximal tibial opening wedge osteotomy be performed to restore the mechanical access to the downslope of the lateral tibial spine. It is well recognized that the failure of the clinician to recognize the genu varus and to perform an osteotomy in these cases often results in a failure of the repair or reconstruction because the resultant varus thrust gait will cause the tissues to stretch over time. Although chronic injuries to the posterolateral corner structures can occasionally have an anatomic repair, it has been recognized that there is frequently a return of instability in joint laxity in many of these patients over time. Therefore, reconstructions of these posterolateral knee complex injuries have been devised
Chapter . to attempt to restore stability for these injured anatomic structures. A primary repair cannot be performed in the chronic situation if the posterolateral structures are deficient. In such cases a biceps tenodesis or an allograft reconstruction have been utilized in attempt to reproduce the normal function of the fibular collateral ligament in the popliteus–popliteofibular ligament complex. Most of the current procedures used attempt to create a soft tissue sling to inhibit varus opening and/or external rotation. However, it must be recognized that this is an extremely difficult knee instability problem with a large learning curve for the individual surgeon. Therefore, there is no clear-cut answer as to which technique would work best in the individual patient. The biceps tenodesis procedure [] attempts to reconstruct a portion of the fibular collateral ligament by taking all or a portion of the common biceps tendon and transferring it just proximally and anterior to the lateral epicondyle. The biceps tenodesis procedure has been shown to overconstrain the knee somewhat in external rotation and then there is some concern as to its long-term effect on the knee. In addition, it has been recommended that this procedure only be performed in those cases in which the capsular arm and the capsulosseous confluence layers of the short head of the biceps femoris have not been injured. Since this occurs in less than % of cases other options for surgical reconstruction should be thought out in advance. Some authors have advocated an osteotomy of the femoral attachments of the lateral head, gastrocnemius, fibular collateral ligament, mid-third lateral capsular ligament and popliteus tendon origin in attempt to perform an advancement of these structures and restore normal tension of these structures on the posterolateral aspect of the knee. In this technique, a square or rectangular-shaped piece of bone is osteotomized off the distal lateral femur with the above-noted attachments and advanced proximally and anteriorly and then held in place with some type of internal fixation (usually a four-pronged bone staple). Allograft reconstruction of chronic posterolateral corner knee injuries is often necessary to reconstruct the deficient native injured anatomic structures. There are a large variety of these techniques which attempt to duplicate the normal function of the popliteus ten-
don complex and/or the fibular collateral ligament (R. F. LaPrade, personal communication). One or both of these structures may be reconstructed depending upon whether the patient’s primary instability problem is varus and/or external rotation. The main goal behind all of these reconstructions is to provide an increased tissue mass of appropriate strength to make up for the poor quality of the injured native structures.
Treatment of combined grade III posterolateral knee injuries and other ligament ruptures of the knee In the acute injury situation, it is recommended that a primary repair of the injured grade III posterolateral corner structures be performed at the same time as a repair or reconstruction of the other ligamentous structures within the first – weeks after injury. All structures should be either repaired or reconstructed in one sitting rather than using a staged surgical technique. While a period of immobilization may be necessary in some instances because of the poor quality of tissues repaired with sutures, in the majority of cases an early ROM program is instituted to prevent the onset of arthrofibrosis which can commonly occur in multiligament knee injuries. This is especially important when there are concurrent medial collateral ligament complex injuries present. The majority of chronic posterolateral corner injuries occur in combination with an ACL or PCL tear. Once it has been determined that these patients do not have underlying varus alignment, the decision must be made to proceed with either a repair or reconstruction of the injured posterolateral corner structures at the same time as the cruciate ligament reconstruction procedures. It has been demonstrated that a failure to repair the posterolateral corner structures at the time of the cruciate ligament reconstruction results in a significant increase in a force on the cruciate ligament graft which could potentially lead to its failure [,]. In addition, an examination under anesthesia must be performed prior to the fixation of the cruciate ligament grafts. The grafts will overconstrain the knee and hide any potential residual posterolateral instability if the knees are examined immediately after cruciate ligament fixation. In these instances, the examiner may be misled into believing that the posterolateral reconstruction
Knee may not need to be performed. The type of primary repair or surgical reconstruction is similar to that described in the previous section. The rehabilitation principles that are followed with combined posterolateral and other ligament repairs of the knee depend on the overall quality of the tissue repair. It is desirable to start a program of early ROM in these knees. Commonly, the knee is put through a full ROM prior to skin closure to determine the point at which there may be increasing tension on the posterolateral corner repair. If the patient cannot achieve a full ROM, or is limited in deep flexion, the patient will then be placed into a hinged knee brace which would be locked within the limits of the patient’s ROM. In addition, a program may be instituted using a continuous passive motion (CPM) machine for these patients. In these instances, the patient is placed into a hinged knee brace such that the CPM does not stretch out the repair when we feel that the repair may be stretched out past a certain range of motion. If the motion needs to be limited, the CPM is commonly utilized for weeks in attempt to increase the program of ROM such that full motion is achieved by weeks after surgery. The patients are kept non-weight-bearing for the first – weeks after surgery to allow time for the posterolateral corner structures to heal. Patients are initiated in a program of quadriceps sets and straight-leg raises in their knee immobilizer (only) for the first weeks. An exercise bike program may be initiated at weeks – if their ROM allows it. Commonly a patient will be instructed to start by simply cycling and not trying to put any resistance on the exercise bike. Patients are allowed to initiate gentle leg presses at months after surgery. Active hamstring exercises are avoided for the first months postoperatively because of the potential deleterious effects of the hamstring muscles firing on the posterolateral corner repairs or reconstructions. At approximately months after surgery, patients are allowed to progress to the rehabilitation protocol according to the principles of the other combined ligament reconstructions in the knee.
Overuse injuries Introduction Tendon overuse injury, often called tendinitis, is a common problem in both sports and industry. Data
from the Bureau of Labor Statistics () indicate that tendon overuse injuries account for % of reported occupational illness. Also, in a large European sports clinic, a quarter of all athletes treated for knee disorders were diagnosed with tendon overuse injury []. Clinically, the treatment of tendon disease has been largely empirical. Typical treatment protocols include combination of relative rest, therapeutic exercise, modalities such as electrical stimulation and ultrasound and non-steroidal anti-inflammatory drugs (NSAIDs). Guidelines have been published in an attempt to direct treatment, but with little scientific data to support them []. In this section, current understanding of the etiology and pathology of tendon overuse injury will be reviewed with a focus on the patellar tendon. This will be followed by a discussion of non-invasive imaging techniques for diagnosis of tendon overuse injuries. Then, both the in vivo and in vitro studies that have attempted to elucidate cellular mechanism of tendon overuse injury will be presented. Finally, future directions of research on tendon overuse injury will be suggested.
Etiology of tendon overuse injury In spite of the high incidence of tendon overuse injury, the etiology of this disease is unclear. The incidence of patellar tendon overuse injury also varies within the tendon. In the order of frequency, the incidence has by some authors been found to be % in the infrapatellar insertion, % in the tuberosity and % in the quadriceps patellar insertion site []. It has been generally believed that tendon overuse injury is related to cumulative trauma on tendons by repetitive mechanical loading. In addition, the effect of mechanical loading on tendons can be adversely impacted by intrinsic factors, including malalignment, inflexibility and muscle weakness or imbalance. The combination of these factors can cause a large magnitude of load, a high frequency of load, or both, on tendons during normal activities. Other etiologic factors include age-related degeneration of the tendon and decreased vascular supply to the tendon []. In patients with chronic tendon problems, histologic examination reveals degenerative tendons without apparent inflammatory changes within the tendons. Nevertheless, it is possible that the tendons may have undergone inflammation when they are first injured. This is because most biopsy speci-
Chapter . mens were obtained only after the tendon failed to heal after a prolonged non-surgical treatment; the phase of the tendon inflammation may have already passed. Therefore, it seems that the etiology in chronic tendon injuries is multifactorial. However, these factors may not play an equal role in different individuals. For example, in young athletes with healthy tendons, repetitive mechanical loading of the patellar tendon may be the major factor for tendon overuse injury, whereas in aging patients a sedentary lifestyle combined with pre-existing tendon degeneration may contribute to the tendon becoming symptomatic. On the other hand, all explosive start–stop or jump sports, such as basketball, volleyball and soccer, predispose the participants to tendon overuse injury in the knee. Deceleration and jumping entail eccentric muscle contraction, which results in tension that would be much greater than with concentric muscle contraction. As a result, if the large contraction is repeated, tendon microstructure damages are likely to occur.
Pathologies of tendon overuse injury Many researchers have tried to distinguish the pathology between the acute traumatic inflammatory response and the more insidious process of chronic tendon degeneration. Consistent findings include mucoid degeneration and fibrinoid necrosis within the tendon. Microtearing and areas of repair with proliferation of the tendon fibroblasts and thin-walled vessels can also be observed []. Leadbetter [] reported the following features of specimens from many types of tendons including the patellar tendon: (i) hyperplasia of tendon fibroblasts; (ii) morphologic change of the tendon fibroblasts from the linelike to blastlike; (iii) small vessel ingrowth with accompanying mesenchymal cells; (iv) perivascular collections of macrophage-like cells; (v) endothelial hyperplasia and microvascular thrombosis; (vi) collagen fiber disorganization with mixed reparation and degenerative change; and (vii) collagen fiber microtear and separation. In addition, there are other changes. For example, quadriceps atrophy occurs as a secondary effect of the tendon overuse injury [].
Diagnosis of tendon overuse injuries with imaging techniques Magnetic resonance imaging (MRI), ultrasonography and computerized tomography (CT) are non-invasive techniques able to visualize tendon structures. Therefore, it is possible to use these tools to identify the location of tendon overuse injury. MRI offers clear soft tissue contrast and direct sagittal imaging []. Hence, patellar tendon structures can also be clearly imaged with MRI. Ultrasonography is one of the most efficient and effective ways of imaging the tendons. It provides an accurate anatomic picture that allows for greater specificity in treating patellar tendon overuse injury []. Hence, this technique makes it possible for clinicians to determine where tendinosis, a degenerative change in extracellular matrix of a tendon, or partial tears are present in persistently symptomatic tendons not responding to non-surgical intervention.
NSAIDs for treatment of tendon overuse injury An early study showed that NSAIDs were able to inhibit the production of prostaglandins []. It is now thought that the mechanism of action by NSAIDs is through inhibiting cyclooxygenase (COX), which is the key enzyme for the formation of prostaglandins from arachidonic acid. Recently, two COX isoforms have been discovered. These are COX- and COX-, which are variably expressed in different tissues. COX- is expressed constitutively in most tissues throughout the body, including the gastrointestinal mucosa [], whereas COX- is induced mainly at inflammation sites. Furthermore, unlike COX-, COX- can be up-regulated at inflammatory sites by cytokines and bacterial products such as lipopolysaccharides []. There are three types of NSAIDs: (i) COX- selective; (ii) COX- selective; and (iii) non-selective. Clinically, there is an enormous interest in using COX- selective NSAIDs to treat inflammatory conditions, particularly because COX- selective and non-selective NSAIDs often result in gastric and intestinal ulcers. Studies have shown that NS-, rofecoxib and celecoxib, which are recently developed COX- selective NSAIDs, can achieve an anti-inflammatory effect on gastric biopsies [], and an analgesic effect on postdental surgery pain [] and on pain from
Knee
Table .. Overview of common overuse problems of the knee. Most common Anterior knee pain including PFSS Cartilage lesions including degenerative arthritis Jumper’s knee Quadriceps tendinitis Biceps tendinitis Meniscal tears Bursitis Plica syndrome Mb. Osgood–Schlatter–Johansson Mb. Sinding–Larsen Popliteal artery entrapment Saphenous nerve entrapment
Less common
Do not miss
Fat pad syndrome Osteochondritis dissecans Popliteus tendinitis
Malignant tumors
Runner’s knee/iliotibial band friction syndrome
PFSS, patellofemoral pain syndrome; Mb, morbus.
osteoarthritis []. However, the efficacy of these drugs for the treatment of tendon overuse injuries is yet to be determined.
Table .. Classification of jumper’s knee according to symptoms as outlined by Roels et al. [] and current classification system.
Differential diagnoses
Roels et al.
An overview of the usual diagnoses is seen in Table ... Most common are meniscal injuries, jumper’s knee and patellofemoral arthralgia. Meniscal injuries and patellofemoral pain syndrome (PFPS) are covered in other parts of this chapter.
Grade I Pain at the infrapatellar or suprapatellar region after practice or after an event
Patellar tendinitis (jumper’s knee) Jumper’s knee, as an adult form of the Sinding– Larsen-Johansson disease, may occur due to an acute partial tear or overuse, but usually a good medical history will detect one specific event leading to later pain. The syndrome is characterized by tenderness at the inferior pole of the patella. This problem usually occurs in sports characterized by a high number of maximal jumps and sprints. Out of elite division volleyball players, players fulfilled the diagnostic criteria of jumper’s knee []. The histopathologic changes described include tearing of tendon fibers, myxomatous degeneration and capillary proliferation [,,]. Clinically, jumper’s knee can be classified into four grades, originally described by Roels et al. [] and modified by Lian et al. [] (Table ..). According to Ferretti [], the insertional tendinopathy affects, in order of frequency, the insertion of the patellar tendon into the patella in % of cases, the at-
Grade II Pain at the beginning of the activity, disappearing after warm-up and reappearing after completion of activity Grade III Pain remains during and after activity and the patient is unable to participate in sports
Grade IV Complete rupture of the tendon
Current classification
Same
Same
IIIa: Pain during and after activity, but the patient is able to participate in sports at the same level IIIb: Pain during and after activity and the patient is unable to participate in sports at the same level Same
Chapter . tachment of the quadriceps tendon into the patella in %, and the insertion into the tibial tubercle in %. Symptoms and signs The athlete often has a small, but significant acute trauma in the history. An epidemiologic study of volleyball players showed that half the players had had symptoms of the syndrome. The study also suggested that the players with the highest jumps were the ones most susceptible to the problem. Typical symptoms are pain when reducing speed or trying to make a quick stop, landing after a jump and walking downstairs, and ultimately it becomes difficult to run and play. Most patients do well in biking and swimming. The history can be classified according to Lian et al. [] (Table ..). Diagnosis The diagnosis is based on the history and clinical findings. During physical examination, marked tenderness is detected at the insertion site of the patellar tendon on the patella. This finding is furthermore reinforced if the patella is pushed in the distal direction with the finger of the examiner palpating the insertion site of the tendon on the distal pole of the patella. Ultrasonography and MRI strengthen the diagnosis. As recently shown, however, the correlation between ultrasonography and clinical findings is not good [,]. Treatment options Treatment is conservative, including eccentric exercises for at least months. If a well-supervised conservative treatment program fails, surgical excision of the necrotic part of the patellar tendon is indicated. However, only –% [] of competitive athletes return to their original sporting level. Both arthroscopic and open patellar tenotomy provide symptomatic pain relief in most patients with end-stage patellar tendinopathy. After open patellar tenotomy, MRI and ultrasound findings remain abnormal despite clinical recovery. Thus, clinicians should base postoperative management of patients undergoing patellar tenotomy on clinical grounds rather than imaging findings (Fig. ..). No consensus exists on the treatment of jumper’s knee. The consensus at the moment seems to be that a
Fig. .. Intraoperative appearance of the necrotic patellar tendon in an -year-old handball player who had had jumper’s knee for years and in whom conservative treatment had failed. Appearance of the granuloma on MRI inserted.
small tear in collagen fibers is followed by a short inflammatory phase. Theoretically, NSAIDs should be effective in the acute phase, but there are no clinical studies confirming this. The inflammatory phase is followed by a degenerative phase where there are very few inflammatory cells in the injured area. In this phase the goal is to rebuild the tendon, and recent literature suggest that eccentric training over a period of weeks or more may be efficient. So far, good studies comparing a rehabilitation program with eccentric exercises to surgery have not been published. The prognosis for returning to sport is not favorable, as mentioned above. However, patellar tendinitis does not lead to major arthritis or disability. On the other hand, it may lead to the retirement of the player from sports involving jumping and fast running.
Quadriceps tendinitis Tendinitis at the quadriceps tendon insertion into the proximal pole of the patella might seem to be a situation similar to that of patellar tendinitis, although much less frequent. This author has seen this primarily in volleyball players, hockey goalies, cyclists and weight lifters. In each case, the player has developed a major eccentric force leading to a partial tear at the insertion site of the tendon. This leads to an inflammatory reaction followed by a repair phase.
Knee Diagnosis Tenderness to direct palpation is the only clinical finding. This finding can be substantiated by ultrasonography or MRI which often needs contrast to reveal a small tendon tear. Treatment options Treatment should follow the same protocol as jumper’s knee. In the acute phase NSAIDs and RICE (Rest, Ice, Compression, Elevation) should reduce the inflammation. In the chronic phase the goal is to rebuild collagen fibers. This seems to be successfully achieved with an eccentric training protocol in the majority of cases. If the pain is still there after – weeks, surgical excision of the degenerative area may be chosen. There is only one study available (four patients) on the results after surgical treatment [] and no conclusions can be drawn based on this. The general feeling is that recovery is faster than after surgery for patellar tendinitis and probably more successful.
Popliteal tendinitis The muscle and tendon of the popliteal complex is both an active structure involved in tibia inward and forward rotation and a passive restraint preventing posterolateral instability. The tendon is most often irritated and injured in athletes involved in downhill running such as marathoners or cross-country racers. Diagnosis This is a clinical diagnosis, although increased signals due to inflammation may be picked up on MRI. Pain is usually localized to the insertion site of the tendon on the popliteal groove on the femur, which is easiest to palpate in the figure-of-four position. It occurs mainly during weight-bearing with the knee flexed between and ° or during the early part of the swing phase of gait. The onset is usually insidious with no history of acute injury. Typically, the distance runner will report pain after – km preventing him or her from continuing the run. The main diagnostic task is to differentiate popliteal tendinitis from biceps tendinitis, iliotibial friction syndrome, lateral meniscal tears or lateral cartilage tears.
Treatment options No studies have shown structural damage to the popliteal tendon with tendinitis. Consequently antiinflammatory medication should theoretically be effective, as should a corticosteroid injection. The main treatment modality is, however, training modification. In first few – weeks the athlete should use alternative training methods on the bike or in the pool; he or she should make training changes such as running uphill or changing the side of the road or the direction run on a track.
Runner’s knee — iliotibial band syndrome Iliotibial band (ITB) syndrome is an overuse injury caused by excessive friction between the ITB and the lateral femoral epicondyle as the knee is flexed and extended. In extension the ITB lies anterior to the lateral epicondyle of the femur. As the knee flexes, the tendon passes over the condyle. Due to the excessive friction here, a bursa is often developed which secondarily gets inflamed. The ITB is often described as tight in affected athletes. Many of these athletes also have increased pronation, genu varum and increased tibial torsion. The clinical findings are pain on palpation, and often crepitation and aggravation on running downhill or downstairs. A diagnostic anesthesia blockade will help in pinpointing the area of maximum tenderness. A radiograph should be obtained to rule out other causes of pain. Treatment consists of advice on alternative training and stretching. Orthoses are usually prescribed based on the form of the foot. A cortisone injection is often carried out and is documented to achieve good results in this diagnosis. If no improvement occurs after months of conservative treatment, surgery is sometimes resorted to []. The procedure is simple and consists of decreasing the friction between the tendon and the condyle by making a ‘window’ in the tendon and removing the inflamed bursa. The reported results have been encouraging.
Bursitis A bursa is a sac with a synovial-like lining that functions to reduce friction and protect structures from pressure. These sacs may be inflamed, infected or traumatized, with a hematoma as a frequent result.
Chapter . The most frequent bursitis is that of the prepatellar bursa located anterior to the distal half of the patella. This is seen frequently in wrestlers and team handball players when the fronts of their knees hit the floor during matches. The other frequent bursitis around the knee is pes anserinus bursitis. The bursa is located between the aponeurosis of the threehamstring tendon insertion and the medial collateral ligament, approximately cm below the joint line. Treatment consists of training guidance, antiinflammatory medication including corticosteroid injections, and occasionally surgical removal of the inflamed bursa.
structure and function, and provide a scientific basis for evaluation of the efficacy of NSAIDs in the treatment of tendon overuse injuries. Once the mechanisms of the tendon overuse injury are better understood, the creation of animal models of tendon overuse injury would become more useful and realistic. In the final analysis, the treatment protocol for tendon overuse injuries can be developed and optimized on a scientific basis.
The patellofemoral joint Patellofemoral pain syndrome (PFPS) — anterior knee pain
Future directions To help understand the biologic mechanisms of tendon overuse injury, several lines of future research are suggested. With the advent of gene-chip technologies [], the differential expression of multiple genes in the tendon fibroblasts when subjected to repetitive mechanical loading could be examined. This approach has the potential to identify specific genes, and their products (proteins) that are involved in the onset and progression of tendon overuse injury. With this knowledge, novel targets for intervention of the disease can then be developed. Another approach involves the development of an organ culture system, in which tendons from experimental animals are placed in growth medium and are cyclically stretched. In this way, the biologic responses of the tendons can be studied in a well-controlled environment. The organ culture system can also potentially be used to evaluate the effects of various NSAIDs and steroids on tendon
Symptoms and signs See Table ...
Diagnosis The diagnosis of PFPS is made if the patient has three of the symptoms listed in Table ... The diagnosis is clinical; a radiograph, CT scan or MRI will not give further information. The diagnosis of chondromalacia during an arthroscopic procedure is inconclusive. Many patients without any symptoms from the patellofemoral joint may have chondromalacia on their patella and patients with major patellofemoral pain may have normal cartilage under arthroscopic examination.
Treatment The patient will be referred to a physical therapist for a program of strength and proprioceptive training.
Table .. Overview of typical history of patients with patellofemoral (PF) pain syndrome. Usual history
Mechanism
Comments
Pain on stair climbing (usually downwards)
Eccentric use of the extensor apparatus results in creation of high forces in the PF joint May be able to go down, but cannot rise without help Increased pressure in the PF joint?
Most painful in patients with established osteoarthritis in the PF joint
Increased forces on the PF joint
Most usual in patients with pathology in the patellar tendon
Pain on squatting Pain when driving a car Pain when sitting at a movie Pain on deceleration
Knee The basic rehabilitation principles for the patellofemoral joint are to restore the normal balance between the quadriceps and hamstring muscle groups. This must be done in balance with how the joint responds to a particular exercise program. One of the first basic principles in addressing rehabilitation for the quadriceps mechanism is to make sure that the patient is on an appropriate hamstring stretching program. The role that tight hamstrings can play in increasing the force on the anterior aspect of the knee, and thus causing anterior knee pain, is often not given appropriate recognition by physicians and therapists alike. When a patient shows signs of hamstring bursal irritation, it is important that they be placed on an appropriate hamstring stretching program. This includes stretching several times daily. In the more severe cases, we often recommend an hourly stretching program. Patients must be taught that they can stretch in almost any environment, as long as they keep their ankle dorsiflexed, their knee straight, and their back straight. Rehabilitation of the quadriceps mechanism primarily involves the use of closed-chain quadriceps exercises. In the majority of cases, even when patients participate in a regular physical therapy exercise program, patients need to engage in a regular exercise program for maintenance at home. Patients should work on quadriceps setting exercises, straight-leg raises, leg presses (preferably with the knees not bent past ° knee flexion), squats and the use of an exercise bike. The patients are recommended to set the seat height of their exercise slightly higher than normal in their initial usage of the bike if they have any patellofemoral discomfort. The preferred seat height is to have the lower leg flexed to approximately ° when the foot is on the pedal. It is recommended to start cycling for min with no resistance on alternating days. If there is no patellofemoral discomfort created with this, patients can proceed to a cycling program on a daily basis. The amount of time on the bike can be increased in -min increments every few days or weeks, depending on the patient’s symptoms. Once the patient is able to tolerate min on the exercise bike, we recommend that they return to min biking and increase the resistance. The amount of time on the bike is then increased up to min again and the cycle is repeated. Patients should strive to achieve a workout
whereby they can use the exercise bike for min at a tolerable resistance several times a week []. Another form of treatment recommended for patients with significant patellofemoral discomfort and atrophy is a hydrotherapy program. While this may not be available to many patients, pool walking is an excellent form of low-impact energy exercising for these patients. Patients can start out by walking pool lengths in waist-high water, and then can progress to deeper lengths as tolerated. In addition, if the patient can wear a personal flotation device, they can work on walking or jogging on the spot at the deep end of the pool as an excellent source of low-impact exercises. Open-chain quadriceps exercises are seldom recommended because of the added pressure that they place on the anterior aspect of the knee. Knee extension exercises can cause significant irritation of the patellofemoral joint. The preference is to avoid them in these patients. These exercises should be reserved for the terminal phases of rehabilitation and elite-level athletes, or for sports participants who have no evidence of any patellofemoral arthritis or other abnormalities. Many of these patients experience major feelings of pain at the start of their rehabilitation program. Often it is difficult for the patient even to step down from a height. The majority of these patients will have developed hip, especially abductor muscle, weakness and rehabilitation on this is needed in addition. These patients are often aided by the use of a special tape that may improve patellar alignment. A special program emphasizing this technique is used by many therapists although the science behind it is limited.
Patellar dislocation Patellar dislocations are usually caused by a traumatic event. Typically, the patella is hit on the medial side by a pole in skiing or by an opponent in contact sports. The patella always dislocates laterally. At the time of dislocation, the patella may hit the lateral femoral epicondyle resulting in a small fracture of most often the medial facet of the patella. The dislocation is painful and frequently requires anesthesia for relocation. Due to extensive tears of the medial ligament stabilizing the patella, a large hemarthrosis is usually seen. Treatment consists of relocating the patella and immobilizing it in a brace for – weeks. If the patient
Chapter . is young (< ), recurrent dislocations may occur. A patellofemoral brace may reduce the number of redislocations, as will proper strength in the extensor apparatus, specifically the vastus medialis obliquus, but only surgery has been shown to prevent redislocations. Today the torn structures are usually repaired. In cases where malalignment of the extensor apparatus is found, a distal–proximal realignment may be the surgery of choice.
Knee pain in adolescents The structures in and around the knee are frequently injured in children in athletics as a result of chronic overuse and the special anatomic and morphologic situations in the growing adolescent. This section will focus on common causes of knee pain in the adolescent, but will also emphasize the importance of tumors and referred pain in the diagnostic approach. Traumatic, acute disorders have been covered in the previous sections. Knee pain in adolescents has many etiologies and the clinician must also rule out rare entities (e.g. tumor, referred pain) to establish a thorough diagnosis. Although meniscal injuries are less common in children than in adults, several recent reports indicate an increasing incidence of meniscal lesions in children and adolescents, especially those in competitive sports. De Inocencio [] investigated the distribution of musculoskeletal pain in children. The knee was the most affected joint (%), followed by other joints (e.g. ankle, wrist, elbow, in %), soft tissue pain (%), heel pain (%), hip pain (%) and back pain (%). Symptoms were caused by trauma in %; overuse syndromes in % (e.g. chondromalacia patellae, mechanical plantar fasciitis, overuse muscle pain); and normal skeletal growth variants (e.g. Osgood–Schlatter syndrome, hypermobility, Sever’s disease) in % of patients. Sources of chronic pain about the knee may include tendinitis, apophysitis, patellofemoral malalignment and maltracking, quadriceps dysfunction, hamstring contracture, neural dysfunction, vascular dysfunction, pathologic plica, cartilage degeneration, meniscal tears, and also benign and malign tumors around the knee. Special consideration must be given to the possibility of referred knee pain, e.g. from slipped capital femoral epiphysis. Compared to adults the long bones in children are
able to absorb more energy before breaking, and the presence of growth plates and apophyses for the attachment of musculotendinous structures leads to a different spectrum of injuries compared with those in adults. Both epiphyses and apophyses have physes that grow and develop by enchondral ossification. Apophyses have physes similar to epiphyses, but in contrast to epiphyses do not participate in longitudinal growth, are usually not perpendicular to the long axis of bone, are not articular, and are subjected to tension forces rather than to compression. The reason for knee pain in children is often difficult to establish and depends on an experienced physician. The history and clinical examination are crucial, as is the correct choice of additional diagnostic investigations. This section discusses the most frequent causes of knee pain in children.
Extensor apparatus Osgood–Schlatter disease According to Sponseller and Beaty, Paget described in the clinical symptoms which later became known as Osgood–Schlatter disease (OS). In , Osgood [] and Schlatter published separate papers on the avulsion phenomena of the tibial tubercle. OS is thought to result from submaximal, repetitive, tensile stresses acting on the immature junction of the patellar tendon, tibial tubercle and tibia, causing mild avulsion injuries followed by attempts of osseous repair. The symptoms usually start during a rapid growth phase. In girls, the condition tends to appear at an earlier age — – years — than in boys who usually present – years later []. Boys are more commonly affected than girls, but the prevalence in girls is increasing because of their increased participation in sports activity. In a group of athletic adolescents, Kujala et al. [] found a % prevalence of OS, while in a group of non-athletes the prevalence was only .%. Usually one side is more symptomatic and the tibial tubercle may become prominent. In –% of patients both sides are symptomatic. Swelling and prominence of the tibial tubercle can be found on clinical examination, accompanied by exquisite local tenderness. The pain is usually made worse by climbing stairs, running and jumping. Radiographs are essential to rule out a bone tumor or other rare disorders. Approximately
Knee % show a discrete, separate ossicle at the tibial tubercle []. This fragment is cartilaginous initially and may ossify later. Krause et al. [] described patients who presented with fragmentation of or an abnormally shaped apophysis, and had abnormal tibial tubercles on follow-up examination after an average of years. These patients were much more likely to have chronic symptoms. Treatment should be based on the symptoms. Immature athletes with open physes should be treated with guided activity limitations and in a few cases with partial immobilization (no casting) for a period of weeks or until the tubercle apophysis is no longer tender. Be aware that this group may have a physeal injury in the area — a so-called Ogden lysis [,]. In these acute traumatic avulsions of the tibial tuberosity, pain and swelling occur immediately and standing or walking is impossible. However, open reduction and internal fixation may be necessary, depending on the displacement and type of avulsion fracture (Fig. ..). For the skeletally mature patient with OS disease a treatment regimen consisting of rest, training modification, ice and oral anti-inflammatory drugs will be helpful. Tenderness is a sign of inflammation, and with pain relief strengthening and flexibility exercises are started. Surgery may be indicated for the adult patient with chronic OS disease, multiple ossicles and failed conservative treatment, when excision of symptomatic ossicles may lead to pain relief. This ossi-
Fig. .. Traumatic avulsions of the tibial tuberosity. In type I the avulsion fracture involves the secondary ossification center, in type II the proximal tibial epiphysis, and in type III the fracture passes proximally and posteriorly accross the epiphyseal plate and proximal articular surface of the tibia. (From Roberts JM. Fractures and dislocations of the knee. In: Rockwood CA Jr, Wilkins KE, King RE (eds). Fractures in Children. Philadelphia: J.B. Lippincott Co., , used with permission.)
cle resection can also be performed endoscopically []. Sinding–Larsen–Johansson disease Sinding–Larsen-Johansson disease is usually seen in an active preteen boy with activity-related pain. Persistent traction on the cartilaginous junction of the patella and the patella tendon is thought to be the cause of this condition. Sometimes similar symptoms can be found at the insertion site of the quadriceps tendon into the patella. The main symptom is usually tenderness at the involved site. Radiographs may show varying amounts and shapes of calcification or ossification near the patellar apex. Medlar and Lyne [] identified four radiographic stages of the disease process. Differential diagnosis includes a stress fracture of the patella, a sleeve fracture and a type I bipartite patella. In the older adolescent, an adult type of jumper’s knee must be considered []. The symptoms usually resolve with progressive skeletal maturation. As in OS disease, adult patients who do not respond to conservative treatment may benefit from surgical debridement of the necrotic intratendinous tissue. Patellofemoral pain syndrome — patellar overload syndrome Many of the most difficult management problems in the adult knee are a result of ill-advised surgical interventions during youth []. Inappropriate surgery in patients diagnosed with patellofemoral malalignment is often the first episode in a series of surgical disasters. Fairbank et al. [] found no correlation of an abnormality of q-angle, patellar height and patellar tilt in adolescents with and without knee pain. They concluded that chronic overloading, rather than faulty mechanics, is the dominant factor in the genesis of anterior knee pain in adolescent patients. Patellofemoral crepitus does not indicate knee pathology in adolescents. Abernethy et al. [] found asymptomatic patellofemoral crepitus in more than %, only four (%) having true chronic anterior knee discomfort. However, the treatment of ‘patellofemoral dysfunction’ requires patience. More than % of patients can be spared a surgical procedure by using conservative treatment, and % of patients will have no limitations and % only minimal limitations by months to years []. A directed isometric progressive re-
Chapter . sistance quadriceps program with iliotibial band and hamstring stretching exercises improved patients consistently in a study of O’Neill et al. []. The patellofemoral pain syndrome can also be caused by a deficiency in motor control. The vastus medialis muscle has been implicated because it is often underdeveloped in patients suffering anterior knee pain. Further support for a neural component derives from the observation that the deficit in torque production is seen only during eccentric exercises, and that training relieves pain []. Extensor apparatus overload is perhaps the most common cause of anterior knee pain. Pain is aggravated by activity and accompanied by mild swelling. The pain is more troubling because of its chronicity than because of its severity. Activities requiring increased hamstring contractions cause the characteristic anterior knee pain. Synovial thickening may be detected which was described by Eilert [] as the ‘silk’ sign of synovitis. Growth is a common factor in anterior knee pain, because rapid increase of the extremity length is not always a balanced pattern. There are no correlations between mechanical disturbances and knee pain in children. In % the adolescent will recover within a year and should be encouraged to live a normal life. If the patient has developed strength deficit in the knee and hip, a rehabilitation program similar to the one outlined for adults should be instigated. Bipartite patella The frequency rate of bipartite patella has been reported to be as low as .% to as high as .%. Anatomically, bipartite patella is indistinguishable from a pseudarthrosis, with a cartilaginous bridge uniting the two fragments. In many respects it is similar to a synchondrosis. According to Saupe, three types of bipartite patella can be distinguished: in type I the second part is located at the inferior pole (%), in type II at the lateral patellar margin (%), and in type III at the superolateral pole (%) []. Acute or chronic stress may make the junction site symptomatic. When the diagnosis of an acute fracture, a stress fracture and a dorsal patellar defect has been ruled out, the treatment depends on the severity of the symptoms. When symptoms persist despite conservative treatment, the entire fragment may be excised to eliminate the painful
pseudoarticulation [,,]. Before such excision arthroscopic examination of the joint is appropriate. If the articular cartilage is normal, the fragment may be fixed.
Intra-articular disease Osteochondritis dissecans (OD) The disease was given its present name by König in in the belief that an inflammatory reaction to an injury is the underlying pathologic process. However, Paget called this disease ‘quiet necrosis’ and reported on it in . Four main theoretical explanations of OD exist: (i) ischemia; (ii) endogenous trauma; (iii) exogenous trauma; and (iv) the constitutional theory. OD is a process whereby a segment of hyaline cartilage, together with subchondral bone, separates from the articular surface, and is most common in the knee. It occurs specifically in athletic boys between the ages of and . The medial femoral condyle is affected in %, and the ‘classic site’ (i.e. lateroposterior position of the medial femoral condyle) in %. The patella is involved in approximately % [] (Fig. ..). The early presentation is often inconclusive with knee pain, joint effusion and thigh atrophy. Giving way, catching or locking suggest separation of the fragment. OD can be diagnosed on routine radiographs, but MRI can detect whether the lesion is loose. A diagnostic test described by Wilson [] produces pain when the knee is extended from ° of flexion and thereby internally rotated. The reaction is explained by abutment of the ACL from its tibial attachment with the lesion on the medial femoral condyle. The goal of treatment should be to prevent partial or complete detachment of the lesion. Important factors in the natural history of OD include among others the patient’s age and the status of physis. The natural history of OD is different in children and adults, and different in the medial and lateral femoral condyles []. Based on these variables patients with OD may be placed into three groups. Linden [] found no complications of OD that could be related to the original condition in patients who had the condition in childhood, and were re-examined an average of years later. A more recent study of another knees diagnosed before skeletal maturity was not quite so positive; the follow-up was
Knee
ment, in all cases of OD pain had disappeared and that in of the the OD was not detectable on a follow-up radiograph. Therefore they recommend no treatment for an osteochondritis dissecans in children.
(a)
(b) Fig. .. Osteochondritis dissecans of the medial femoral condyle in an -year-old patient whose main problems were pain, catching and locking. (a) Plain radiographs (AP, lateral and tunnel view). (b) Arthroscopic appearance of a loose osteochondritis fragment.
years, and % showed moderate or severe arthritis []. The results were less favourable if the lesion was large and/or involved the lateral femoral condyle. Lesions in the classic area of the non-weight-bearing portion of the medial femoral condyle did well with simple excision. However, there is no published evidence at present to warrant an aggressive surgical or arthroscopic approach to OD in children, with the exception of large lesions involving the lateral femoral condyle. The OD of the patella is less likely to heal than in other locations, and fixation has to be considered before total separation occurs. Separation of the fragment yields a poorer prognosis []. These lesions are described to be more common in males and in patients with open epiphysis and in the lateral patellofemoral compartment []. In approximately % the trochlea is involved, while in the other % the OD is located on the patella. At the follow-up examination % out of patients achieved fair or poor results []. In children with a mean age of . years, de Ganzy et al. reported [] that, without any treat-
Plica The plicae are normal synovial folds whose function is probably to assist in lubrication of the femoral condyle, in the same way that an eyelid spreads tears over the eyeball. The symptomatic plica usually presents with a snapping or catching sensation and localized tenderness at the involved site. Synovial plicae of the knee have been suggested to be a cause of anterior pain in children and adolescents []. Flexion of the knee to ° brings the plica into prominence. Inflammation and fibrosis, either from a single major incident or from repetitive microtrauma, causes thickening of the plica. According to Tindel et al. the plica syndrome is an uncommon pathologic entity diagnosed far too often in the setting of concomitant pathology []. Dorchak et al. [] found of nearly patients (%) who underwent diagnostic arthroscopies to have thickened and/or fibrotic plicae. The diagnosis of the plica as the cause of knee pain is difficult and often one of exclusion. Conservative measures are very effective and must be emphasized before operative treatment. When arthroscopy is indicated, a thorough examination of the entire knee joint is necessary. When a pathologic plica is found, reports are available on success after their removal [], but again no controlled studies exist. Synovitis Persistent swelling of the knee and generalized tenderness are signs of inflammatory synovitis. In the majority of cases, the cause of the synovitis is unknown and it is therefore characterized as reactive, often after a traumatic event. In pigmented villonodular synovitis and other types of synovitis, arthroscopic synovectomy has proved to be superior to open synovectomy in adolescents because of its lower incidence of postoperative stiffness. However, pigmented villonodular synovitis which is characterized by pain, swelling and hemarthrosis, recurs in approximately %. The test for rheumatoid factor is notoriously negative in children even with confirmed juvenile rheumatoid
Chapter . arthritis. There is no specific laboratory test diagnostic for rheumatoid arthritis. Positive antinuclear antibodies are found in % of children with juvenile rheumatoid arthritis, and rheumatoid factor is detected in less than %. Slit lamp examination of the eye for iridocycl*tis is indicated if monarticular rheumatoid arthritis is suspected, as iridocycl*tis is treatable and potentially very damaging. Iridocycl*tis, the most severe extra-articular manifestation of juvenile rheumatoid arthritis, occurs in –% of patients. A popliteal cyst (Baker’s cyst) may also be an early manifestation of juvenile rheumatoid arthritis. Meniscal injuries—discoid meniscus Meniscus injuries occur in children at a much reduced rate compared to adults. The menisci assume their adult semilunar form by the th fetal week. During the remainder of growth, the menisci change in size but not in shape. Especially in the peripheral, the child’s meniscus is more vascular, and blood vessels have been demonstrated to penetrate the inner zones even at the age of years. Most reports on the meniscus in the adolescent deal with the discoid lateral meniscus [–]. When a congenital discoid lateral meniscus becomes symptomatic during childhood, the symptoms are variable and inconsistent. The classification of Watanabe in describing the discoid meniscus is widely accepted. There are three classes: an incomplete discoid meniscus, a complete discoid meniscus and the Wrisberg type. In a Wrisberg type of discoid meniscus total excision is indicated []. If a peripheral attachment is present, then a peripheral rim may be left. Hayashi et al. recommend a residual rim of – mm. A torn discoid meniscus may be excised and the meniscus reshaped to ‘normal’ anatomy. Meniscal injuries may also occur in children and adolescents (Fig. ..). Out of arthroscopies % of the patients had a meniscal injury, while cartilage lesions were found in most patients []. In knee arthroscopies, Maffulli et al. [] found meniscal tears in children with a mean age of . years. There is only a % chance of making a correct diagnosis on clinical grounds, which contrasts with an accuracy in excess of % of MRI and % with arthroscopy []. The treatment of meniscal tears in adolescents is similar to adults, with a tendency for increased frequency of
Fig. .. Medial meniscus tear.
Fig. .. Referred pain of the knee: slipped capital femoral epiphysis in a -year-old boy.
repair. The potential for osteoarthritis after meniscectomy in children is discussed in Chapter ..
Referred pain Slipped capital femoral epiphysis is a relatively common disorder in late childhood and adolescence (Fig. ..). It is more common in blacks and males and there seems to be a relationship to geographical location. If the slippage is slow and more chronic, clinical findings may be minimal and subtle. Referred pain to the medial knee via the obturator nerve is a common reason for delayed diagnosis. As many as % of patients diagnosed with a slipped capital femoral epiphysis have onset of symptoms for week to months before diagnosis. Left untreated the slip will often progress and stabilize when the physis closes. Thus severe slips will result in severe deformity and significant early arthritis. Also an avascular necrosis of the femoral head — Legg–Calvé–Perthes disease —
Knee 30
50
25
40
20
30
20
15
10 10
0 Malignant
5 Osteosarcoma
Ewing's sarcoma
Parosteal osteosarcoma
Benign Osteochondroma Osteoid osteoma
Non-ossifying fibroma
Chondroblastoma
Fig. .. Benign bone tumors around the knee in children [].
can be the reason for knee pain and is diagnosed through decreased rotation of the hip as well as radiographically [].
Fig. .. Malignant bone tumors around the knee in children [].
plastic problem. Most young patients seeking treatment for knee pain will have a traumatic, infectious or developmental cause for the symptom []. Differential diagnoses are seen in Figs .. and ... Unilateral knee pain exceeding weeks should lead to a radiograph to prevent doctor’s delay in this patient group.
Tumor The incidence of most musculoskeletal neoplasms is highest around the knee. Nevertheless Dickinson et al. report that a majority of patients with knee tumors had symptoms for around months prior to initial radiographs. It is fortunate that tumors make up a small fraction of the many causes of pain and mass around the knee, but suspicion must be maintained in order to avoid making an error in diagnosis that could lead to loss of a limb or even life []. Malignant bone tumors and soft tissue sarcomas are the sixth and seventh most common causes of childhood cancer, respectively. Gebhardt et al. reported on patients, of whom had bone lesions and soft tissue lesions (Figs .. & ..) []. The knee is the most frequent site for osteosarcoma, probably related to the rapid growth at this location. Approximately % of osteosarcomas are located in the knee region (%: distal femur; %: proximal tibia) []. As a cause for recurrent hemarthrosis, an intra-articular hemangioma may be found and mechanical instrumentation during arthroscopy may result in significant bleeding. Evaluation of a child with a suspected bone neoplasm is a complex process, but initially the most important thing is to recognize that one is dealing with a neo-
Conclusion The vast majority of the sources of knee pain in adolescents are benign and treatable. Keep in mind those chronic cases in which the pain may sometimes be due ‘only’ to a physical expression of unhappiness. But the pain of adolescence must not be underestimated, since serious diseases such as tumors could be the reason. An error in diagnosis could lead to loss of limb or even life. One should remember that the incidence of most musculoskeletal neoplasms is highest around the knee. It has been reported that the majority of patients had symptoms for around months prior to the initial radiograph, irrespective of age or the grade of malignancy. The evaluation of history and the clinical examination are crucial in the establishment of the diagnosis and should always be performed. Radiographic imaging is the most appropriate supplemental test to be done after examination and should be done in the majority of patients with longstanding pain. The standard views of the knee (anteroposterior, lateral, tunnel and tangential) usually provide sufficient information. To finalize the diagnosis additional tests and investigations such as MRI, CT or bone scan may be necessary and should be performed when they
Chapter . are appropriate and needed to establish the correct diagnosis.
Rehabilitation of knee injuries Goals of rehabilitation Phase Normal and pain-free range of motion. Phase Normal strength in quadriceps and hamstrings compared to normal side. Phase Normal proprioceptive function. The rehabilitation program after knee injuries will differ according to the injury the patient has. However, injuries to cartilage, menisci and ligaments may benefit from a general database of exercises provided the therapist takes into consideration special aspects of each injury. This differentiation is especially important when it comes to starting time for the different exercise activities, frequency, intensity and speed of the exercises. The most important steering variables for the therapist are pain and function. If the patient reacts with pain and/or swelling and thereby decreased function, the program must be adjusted accordingly until the knee has settled down. The therapist then should return to exercises tolerated by the patient previously. A good tip is to only change one exercise at a time to judge the effect of each individual exercise. In the general program it is important to emphasize proprioceptive training as well as motion and strength exercises. Knee injuries reduce the proprioceptive sense and it takes time to return to normal. Consequently, one must encourage the patient to train daily to re-establish proprioceptive function as early as possible.
Return to sport After surgery, patients are usually given an approximate time for return to sport. After ACL surgery, the patient may return after – months depending on the sport and additional injuries. After meniscal surgery this varies considerably. While a repair may require – months, a simple resection may enable the player to return after weeks. Collateral ligament injuries usually require a rehabilitation period of at least weeks — if surgery is needed, longer. There are tests available to aid the physician in predicting return to sports. A strength test in an isokinetic testing device may be of help. The usual goal before
training is % strength compared to the normal side and % for full return. Functional tests such as oneleg-jump and triple jumps have been shown to correlate well with isokinetic strength testing and may be more functional [,,]. The most important aspect in judging when to return to sports is for the physician and therapist to create sports-specific testing programs, preferably with a control population consisting of baseline data of players including the injured player. One key issue in rehabilitation of knee injuries is the prevention of re-injuries. Unfortunately, there is little evidence that current braces or orthoses are able to unload meniscus, cartilage or ligaments under healing, and consequently few athletes use braces to prevent re-injuries. After ACL injuries and surgery, patients are usually hospitalized for a day or two. Prior to discharge from the hospital or outpatient clinic, the physical therapist (PT) must instruct the patient in activities needed to restore range of motion. After ACL surgery, the motion is usually normalized after weeks. The patient is then usually equipped with devices for cryotherapy to prevent swelling and given an appointment with a PT after – days. The first few days will emphasize circulatory exercises with many repetitions and little resistance (typical are series of ¥ – repetitions). After approximately a week, more active quadriceps and hamstring exercises will start and full weightbearing may be commenced. Controversy still exists on the issue of closed- vs. open-chain exercises. Most PTs recommend closed-chain exercise to reduce loading of the healing ligament or tendon. However, recent studies have challenged this view and feel that exercises emphasizing open-chain exercises are more effective without compromising the healing of the ligaments. In patients with meniscal repairs, the rehabilitation program is affected only if the repair is done without a concomitant ACL reconstruction. A repair in conjunction with an ACL reconstruction will give priority to the important rehabilitation protocol for the ACL with the exception of preventing hyperflexion for weeks. In isolated repairs, the patient will usually have restrictions on weight-bearing and flexion based on the perceived motion of the meniscus when the knee is flexed beyond °. Patients with cartilage surgery will usually be al-
Knee lowed full range of motion and in fact be on a CPM machine for h times a day for a week or more. However, their weight-bearing will be restricted to approximately kg for – weeks. For ACL rehabilitation a few randomized controlled studies exist on early ‘aggressive’ rehabilitation compared to a more restricted protocol. No differences have been detected on later laxity of the ACL after an early and aggressive protocol has been followed. There are no randomized controlled trials (RCTs) on different protocols for meniscus or cartilage rehabilitation.
Summary Knee injuries are among the most common traumas in athletes. The history and mechanism of injury is helpful to establish the correct diagnosis. Clinical tests for instability, meniscus lesions and patellofemoral disorders are described in this chapter. Their individual indications are discussed as well as the use of imaging techniques. The use of MRI and ultrasound has increased the diagnostic accuracy.
The natural course of osteochondral lesions of the knee is not known. The best treatment of these lesions in athletes with persistent symptoms has not been established, despite the development of several different techniques: drilling, microfracture, periosteal transplantation, mosaicplasty and autogene chondrocyte implantation. Lesions of the medial collateral ligament are treated non-operatively with active rehabilitation. Ligament reconstruction is often necessary in active athletes after anterior or posterior cruciate ligament lesions to prevent subluxation and giving way. Complete (grade III) posterolateral lesions, either isolated or combined with other ligament lesions, should be repaired subacutely to assure optimal function. Overuse problems with degenerative changes of the tendon structure are most common in the inferior patellar ligament and are primarily treated conservatively with eccentric training. Surgery is rarely indicated. Anterior knee pain is treated with rehabilitation of the extensor mechanism.
Case story 6.2.1 A -year-old-team handball player injures her knee when performing a two-step fake. She immediately falls to the ground in great pain. Within the next h she develops a large swelling and decreased range of motion. Which are the four most typical differential diagnoses? Answer: Swelling within h in a young female handball player must mean hemarthrosis which narrows the diagnoses down to ACL injury, peripheral meniscal tear, patellar dislocation and intra-articular fracture. The patient is seen again by you after days. The swelling is receding, but she still has an extension deficit with a solid stop when you are approaching full extension. What is your thinking? Answer: The extension stop is probably caused by either a meniscal or cartilage tear. How will you improve your diagnostic accuracy?
Answer: An MRI will detect a meniscal buckethandle tear. Only an MRI arthrogram will be able to find a possible large cartilage tear. A bucket-handle tear is detected; furthermore the patient is found to have an ACL tear as well as extensive bone bruise in the lateral femoral epicondyle and tibia. What are your treatment options? Answer: The bucket handle tear in the meniscus may be repairable and as such should have surgery within the next weeks. Some surgeons will do this alone and wait to perform the ACL surgery, whereas others will do everything at the same time. The healing ability for the meniscal repair is improved when the knee is stabilized and the repair is done at the same time as the ligament reconstruction. Although the bone bruise is extensive, no controlled studies exist on whether reduced weight-bearing on the extremity will be beneficial.
Chapter . Knee pain in adolescents is most often a problem of overload in bone (Osgood–Schlatter), tendons or cartilage (osteochondritis) and is generally treated with decrease of load and active rehabilitation. Referred pain from the hip or pain from tumors must always be kept in mind. Rehabilitation of the knee has been discussed.
Multiple choice questions Which of the following is the most accurate clinical test to assess for an anterior cruciate ligament tear? a Reverse pivot-shift test. b Varus stress test at ° of knee flexion. c Anterior drawer test at ° of knee flexion. d Lachman’s test. e Quadriceps active test. In the evaluation of a chronic grade III posterolateral corner injury, the most appropriate initial diagnostic test to order would be which of the following? a Anteroposterior standing radiograph of the knee. b KT- testing. c Varus thrust standing radiographs. d Full-length standing (hip to ankle) anteroposterior radiographs. e Ultrasound of the knee. The main structure injured in a traumatic lateral patellar dislocation is which of the following? a Chondral fracture of the lateral trochlea. b Tear of the lateral patellotibial ligament. c Tear of the medial patellofemoral ligament. d Medial patellomeniscal ligament tear. e Vastus medialis obliquus tendon tear off patella. A positive dial test at ° of knee flexion is indicative of a tear of which structure/complex? a Anterior cruciate ligament. b Posterior cruciate ligament. c Ligament of Wrinsberg. d Tibiocollateral ligament. e Posterolateral knee structure. A team handball player makes a sudden stop and twisting valgus maneuver with the knee near extension, where she notices her knee buckle and she hears a pop inside her knee. Within the next – h, a large knee effusion develops. The most likely diagnosis for the injury sustained to the athlete is: a medial meniscal tear
b medial collateral ligament tear c ACL tear d lateral patellar subluxation e osteochondral fracture. Which of the following is true when the knee is in full extension? a The posterolateral band of the anterior cruciate ligament and posteromedial band of the posterior cruciate ligament are tight. b The anteromedial band of the anterior cruciate ligament and anterolateral band of the posterior cruciate ligament are tight. c The anteromedial and posterolateral bands of the anterior cruciate ligament are lax. d The posteromedial and anterolateral bundles of the posterior cruciate ligament are tight. What external load and what knee flexion angle increase the anterior cruciate ligament graft force the most with a deficient posterolateral corner? a Posterior drawer at ∞. b Anterior drawer at ∞. c Varus moment at ∞. d External rotation moment at ∞. e Varus moment at ∞. Which of the following is true of the kinematics of the tibiofemoral joint? a The tibia rotates about the femur about one fixed axis. b The tibia can only rotate and cannot translate with respect to the femur. c The tibiofemoral joint can be assumed to be a simple hinge joint. d The tibia flexes and extends with respect to the femur along a moving axis. e The tibia can only translate with respect to the femur, not rotate. The medial collateral ligament is: a a ligament that restrains tibofibular distraction b a ligament that is composed of the tibial collateral ligament and deep medial collateral ligament structures c a ligament that attaches the patella to the medial proximal tibia d a ligament that is composed of an anterolateral and posteromedial bundles e a ligament whose primary function is to restrain varus opening of the joint.
Knee Which of the following factors does not affect ligament properties? a Age. b Load. c Orientation. d Loading rate. e Sex.
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Akeson W. Medial collateral ligament healing. A multidisciplinary assessment in rabbits. Am J Sports Med ; : –. Risberg MA, Beynnon BD, Peura GD. Proprioception after ACL reconstruction with and without bracing. Knee Surg Sports Traum Arthrosc ; : –. Risberg MA, Holm I, Seen H, Eriksson J, Ekeland A. The effect of knee bracing after ACL reconstruction. A prospective, randomized study with years followup. Am J Sports Med ; : –. Grøntvedt T, Pena F, Engebretsen L. Accuracy of femoral tunnel placement and resulting graft force using drill guides. A cadaver study on ten paired knees. Arthroscopy ; : –. Grøntvedt T, Heir S, Rossvoll I, Engebretsen L. Five-year outcome of patients with an initially undiagnosed anterior cruciate rupture. Scand J Med Sci Sports ; : –. Parolie JM, Bergfeld JA. Long term results of nonoperative treatment of isolated PCL in the athlete. Am J Sports Med ; : –. Fowler PJ, Messieh SS. Isolated PCL injuries in the athlete. Am J Sports Med ; : –. Kujala UM, Kvist M, Osterman K. Knee injuries in athletes. Review of exertion injuries and retrospective study of outpatient sports clinic material. Sports Med ; : –. Fredberg U. Local corticosteroid injection in sport. Review of literature and guidelines for treatment. Scand J Med Sci Sports ; : –. Martens M, Wouters P, Burssens A, Mulier JC. Patellar tendinitis: pathology and results of treatment. Acta Orthop Scand ; : –. Leadbetter WB. Cell matrix response in tendon injury. Clin Sports Med ; : –. Davies SG, Baudouin CJ, King JB, Perry JD. Ultrasound, computed tomography and magnetic resonance imaging in patellar tendinitis. Clin Radiol ; : –. Fritschy D, de Gautard R. Jumper’s knee and ultrasonography. Am J Sports Med ; : –. Vane JR. Inhibition of prostaglandin synthesis as a mechanism of action for aspirin-like drugs. Nature New Biol ; : –. Cryer B, Feldman M. Cyclo-oxygenase- and cyclooxygenase- selectivity of widely used non steroidal antiinflammatory drugs. Am J Med ; : –. Tsujii M, Kawano S, Tsuji S, Sawaoka H, Hori M, DuBois RN. Cyclooxygenase regulates angiogenesis induced by colon cancer cells. Cell ; : –. Morrison BW, Christensen S, Yuan W, Brown J, Amlani S, Seidenberg B. Analgesic efficacy of the cyclooxygenase-specific inhibitor rofecoxib in post-dental surgery pain: a randomized, controlled trial. Clin Therapeut ; : –. Fort J. Celecoxib, a COX- specific inhibitor: the clinical data. Am J Orthop ; : –. Lian Ø, Holen KJ, Engebretsen L, Bahr R. Relationship
Chapter .
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between symptoms of jumper’s knee and the ultrasound characteristics of the patellar tendon among high level male volleyball players. Scand J Med Sci Sports ; : –. Ferretti A, Puddu G, Mariani PP, Neri M. The natural history of jumper’s knee. Patellar and quadriceps tendonitis. Int Orthop ; : –. Roels J, Martens M, Mulier JC, Burssens A. Patellar tendinitis (jumper’s knee). Am J Sports Med ; : –. Lian Ø, Engebretsen L, Øvrebo RV, Bahr R. Characteristics of leg extensors in male volleyball players with jumper’s knee. Am J Sports Med ; : –. Pierets K, Verdonk R, DeMuynck M, Lagast J. Jumper’s knee: postoperative assessment. A retrospective clinical study. Knee Surg Sports Traum Arthrosc ; : –. Messner K, Gilquist J. Synthetic implants for the repair of osteochondral defects of the MCL. Biomaterials ; : –. Drogset JO, Rossvoll I, Grøntvedt T. Surgical treatment of iliotibial band friction syndrome. A retrospective study of patients. Scand J Med Sci Sports ; : –. Lockhart DJ, Dong H, Byrne MC et·al. Expression monitoring by hybridization to high-density oligonucleotide arrays. Nature Biotechnol ; : –. Mikkelsen C, Werner S, Eriksson E. Closed kinetic chain alone compared to combined open and closed kinetic chain exercises for quadriceps strengthening after an ACL reconstruction. Knee Surg Sports Traum Arthrosc ; : –. de Inocencio J. Musculoskeletal pain in primary paediatric care: analysis of consecutive general pediatric clinic visits. Pediatrics ; : E. Osgood RB. Lesions of the tibial tubercle occurring during adolescence. Boston Med Surg ; : –. Kujala UM, Kvist M, Heinonen O. Osgood–Schlatter’s disease in adolescent athletes. Retrospective study of incidence and duration. Am J Sports Med ; : – . Krause BL, Williams JP, Catterall A. Natural history of Osgood–Schlatter disease. J Pediatr Orthop ; : –. Ogden JA. Skeletal Injury in the Child, nd edn. Philadelphia: Lea & Febiger, . Ogden JA, McCarthy SM, Jokl P. The painful bipartite patella. J Pediatr Orthop ; : –. Klein W. Endoscopy of the deep infraparellar bursa. Arthroscopy ; : –. Medlar RC, Lyne ED. Sinding–Larsen–Johansson disease. Its etiology and natural history. J Bone Joint Surg (Am) ; -A: –. Blazina ME, Kerlan RK, Jobe FW, Carter VS, Carlson GJ. Jumper’s knee. Orthop Clinics N Am ; : –. Day B. The management of anterior knee pain in the adolescent. Am J Knee Surg ; : –. Fairbank JC, Pynsent PB, van Poortvliet JA, Phillips H.
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Mechanical factors in the incidence of knee pain in adolescents and young adults. J Bone Joint Surg (Brit) ; : –. Abernethy PJ, Townsend PR, Rose RM, Radin EL. Is chondromalacia patellae a separate clinical entity. J Bone Joint Surg (Brit) ; -B: –. Goldberg B. Patellofemoral malalignment. Pediatr Ann ; : –. O’Neill DB, Micheli LJ, Warner JP. Patellofemoral stress. A prospective analysis of exercise treatment in adolescents and adults. Am J Sports Med ; : –. Bennet JG, Stauber WT. Evaluation and treatment of anterior knee pain using eccentric exercise. Med Sci Sports Exerc ; : –. Eilert RE. Adolescent anterior knee pain. Instruct Course Lect ; : –. Green WT Jr. Painful bipartite patellae. A report of three cases. Clin Orth Rel Res ; : –. Bourne MH, Bianco AJJ. Bipartite patella in the adolescent: results of surgical excision. J Pediatr Orthop ; : –. Weaver JK. Bipartite patella as a cause of disability in the athlete. Am J Sports Med ; : –. Aichroth PM. Osteochondritis dissecans of the knee. In: International Cartilage Repair Society, rd Symposium. Gothenburg, Sweden: International Cartilage Repair Society, : Keynote Lectures A. Wilson JN. A diagnostic sign in osteochondritis dissecans. J Bone Joint Surg ; : –. Linden B. Osteochondritis dissecans of the femoral condyles: a long-term follow-up study. J Bone Joint Surg (Am) ; -A: –. Safran MR, Fu FH. Uncommon causes of knee pain in the athlete. Orthop Clinics N Am ; : –. Schwarz CMEB, Sisto DJ, Hirsh LC. The results of operative treatment of osteochondritis dissecans of the patella. Am J Sports Med ; : –. Peters TA, McLean ID. Osteochondritis dissecans of the patellofemoral joint. Am J Sports Med ; : –. de Ganzy S, Mousat C, Darodes PH, Cahuzac JP. Natural course of osteochondritis in children. J Pediatr Orthop ; -B: –. Johnson DP, Eastwood DM, Witherow PJ. Symptomatic synovial plicae of the knee. J Bone Joint Surg (Am) ; : –. Tindel NL, Nisonson B. The plica syndrome. Orthop Clinics N Am ; : –. Dorchak JD, Barrack RL, Kneisl JS, Alexander AH. Arthroscopic treatment of symptomatic synovial plica of the knee. Long-term follow-up. Am J Sports Med ; : –. Aglietti P, Bertini FA, Buzzi R, Beraldi R. Arthroscopic meniscectomy for discoid lateral meniscus in children and adolescents: -year follow-up. Am J Knee Surg ; : –. Connolly B, Babyn PS, Wright JG, Thorner PS. Discoid
Knee meniscus in children: magnetic resonance imaging characteristics. Can Assoc Radiol J ; : –. Stark JE, Siegel MJ, Weinberger E, Shaw DW. Discoid menisci in children: MR features. J Computer Assisted Tomogr ; : –. Washington ER III, Root L, Liener UC. Discoid lateral meniscus in children. Long-term follow-up after excision. J Bone Joint Surg (Am) ; -A: –. Aichroth PMPD, Marx CL. Congenital discoid meniscus in children; a longterm follow-up study and evolution of management. In: Aichroth PM, Cannon DC, eds. Knee Surgery. Current Practice. New York: Raven Press, : –.
Lauterburg MT, Segantini P. Post-traumatic knee joint arthroscopy in children and adolescents. Schweiz Z Medizin Traumatol ; : –. Maffulli N, Chan KM, Bundoc RC, Cheng JC. Knee arthroscopy in Chinese children and adolescents: an eight year prospective study. Arthroscopy ; : – . Angel KR, Hall DJ. The role of arthroscopy in children and adolescents. Arthroscopy ; : –. Tippett SR. Referred knee pain in a young athlete: a case study. J Orth Sports Phys Ther ; : –. a Gebhardt MC, Ready JE, Mankin HJ. Tumors about the knee in children. Clin Orth Rel Res ; : –.
Chapter 6.3 Hip, Groin and Pelvis PER HÖL MI CH, PE R A .F.H. RE NS TRÖM & TÖNU S AA RTOK
Classical reference Renström P, Peterson L. Groin injuries in athletes. Br J Sports Med ; : –. This paper was one of the first to discuss the problem of groin injuries in athletes in a systematic way. It tried to define some diagnoses and discuss the epidemiology and treatment of these, and for many years was the most frequently quoted paper regarding this subject.
Introduction Groin pain in association with sports activities continues to be a major problem in sports medicine. The incidence of groin pain among, for example, soccer players is –% per year [–]. The pain may originate from various anatomic structures such as muscle, tendon, ligament or bone, but abdominal or gynecologic disorders, referred pain and nerve entrapment can also cause groin pain. The majority of papers concerning groin problems in the athletic population are empiric in nature. One major problem is the lack of consensus regarding definitions of diagnosis, examination techniques or treatment. When reviewing and comparing the papers concerning this difficult problem it is imperative that definitions and terminology are agreed upon. The prerequisite for a successful treatment is to set a correct diagnosis, and the examining therapist needs to have knowledge about the differential diagnoses.
Anatomy The pelvic region is an essential part of the functional anatomy in most sports activities. The pelvis needs to be stable and well controlled for the athlete to perform with skill. The pelvis is the turning point between the upper and the lower part of the body. Multiple muscles and ligaments originate from and/or insert onto the pelvis, and to control and stabilize the pelvis a delicate balance exists between these structures to coordinate the movements passing through this region. Two of the most important ligaments in the pelvis are the sacrotuberal and the sacrospinal ligaments (Fig. ..). They both control the retroversion of the sacrum and are prone to overuse conditions. They are both phylogenetic new ligaments representing transformed parts of the hamstrings and the coccygeus muscle, respectively. The hip joints are the meeting points between the lower extremities and the pelvis, whereas the sacrum is the meeting point between the trunk and pelvis. The hip joint is one of the most stable joints in the body. Both the bony parts of the joint as well as the capsule and ligaments contribute to the stability. The iliofemoral, pubofemoral and ischiofemoral ligaments are the three main ligaments protecting the hip joint. They are very strong ligaments, especially the iliofemoral ligament which is one of the strongest ligaments in the body. The ligaments run spirally from the pelvis to the femur. When the hip joint is extended the
Hip, Groin and Pelvis
Sacroiliac joint
Sacrospinal ligament Sacrotuberal ligament
Fig. .. Male pelvis with its ligaments.
ligaments are tightened, thus protecting the joint from dislocation. The femur consists of a single bone and some very powerful muscles. These are: the quadriceps muscles: knee extensors and a hip flexor (the rectus femoris); the sartorius muscle: a hip flexor and external rotator as well as a knee flexor and internal rotator; the hamstring muscles (biceps femoris, semitendinosis and semimembranosis): hip extensors, knee flexors and knee rotators; the adductors (adductor magnus, adductor longus, adductor brevis, gracilis and pectineus): hip adductors, hip flexors and hip external rotators depending on the position of the hip joint; the posterior part of the adductor magnus can even extend the hip joint. The gracilis can also flex and internally rotate the knee joint; the abductors and gluteal muscles (tensor fasciae latae, gluteus maximus, medius and minimus): hip abductors, hip extensors, hip external and internal rotators and hip flexors; the external hip rotators (piriformis, gemelli, obturatorius externus and internus and quadratus femoris): external hip rotators and hip abductors when the hip is flexed; the iliopsoas muscle: primarily a hip flexor but also a hip external rotator and a flexor of the lumbar spine.
Symphysis joint
Muscle actions are usually defined according to the way they move the leg when the leg is non-weightbearing and the muscle is contracting concentrically. It is, however, important to realize that these muscles also function as stabilizers of the hip joints and the pelvis, and thereby the trunk. This function is especially evident in eccentric actions. Using this approach, it is easier to understand the importance of the adductors as a major stabilizing muscle group and not only as ‘adductors’ of the femur in the non-weightbearing situation. The abdominal muscles, including the rectus abdominis, external oblique, internal oblique and transversus abdominis, are important in the stabilization of the pelvis and in the control of the movements of the trunk in relation to the pelvis and the legs. They work in synergy with the muscles of the back (described elsewhere) and the above-mentioned muscles. As an example, the synergy between the transversus abdominis and the multifidus muscles seems to be of particular importance [,]. The tendons of the internal oblique and the transversus abdominis muscles blend to create the conjoined tendon (the falx inguinalis) and a close anatomic relationship seems to exist between the conjoined tendon, the rectus abdominis sheath and the common adductor origin [,] (Fig. ..). This relationship could explain the close connection often found between adductor-related groin pain and incipient hernia (see below).
Chapter . m. pectineus conjoined tendon m. rectus abdominis m. adductor longus
n. cutaneous femoralis lateralis n. genitofemoralis
n. iliohypogastricus
n. ilioinguinalis
n. obturatorius
m. gracilis m. adductor brevis m. adductor magnus Fig. .. Tendon insertions on the pubic bone close to the symphysis joint.
The pelvis has three joints: the pubic symphysis and the two sacroiliac joints (Fig. ..). They are dependent of each other, and much attention has been given to the sacroiliac joints in particular. The movements of these joints are very limited but seem nevertheless to be of importance. Sturesson concludes in his thesis [] that movements of the sacroiliac joints are small and the ilia in most situations moves around the sacrum as a unit. The movements are reduced by muscular forces and by increased load. It is not possible to detect the movements by manual examination, but pain provocative tests seem to be reliable. The nerves of the region represent both the lumbar and sacral plexuses. Important nerves are the ischial nerve to the posterior and lateral side of the leg and the femoral nerve to the anterior side. The clinically important cutaneous nerves are the obturator nerve, the ilioinguinal nerve, the genitofemoral nerve, the lateral cutaneous nerve and the iliohypogastric nerve (Fig. ..).
History and physical examination The history is extremely important. It will frequently give a good indication of the pathoanatomic site of the
Fig. .. The important nerves of the groin region.
diagnosis. It is important to realize that even when dealing with otherwise healthy and often young persons, more serious diseases (e.g. infection, cancer and systemic disease) are possibilities that should always be considered. If an acute episode was the start of the injury, a thorough description of the precise injury mechanism can be very helpful (see box).
Important questions to be asked in the case of an acute groin injury Was the trauma violent or was it just a minor episode? How did the patient move when the injury happened (e.g. speed, direction)? Was it a non-contact or a contact injury? Was a snap, click, pop or similar sensation felt or even heard? Could the sports activities be continued? What treatment has been given until now?
Hip, Groin and Pelvis If no acute episode can be recalled, an analysis of the athletic activities in the time preceding the injury can be especially helpful as well as a description of the development of symptoms (see box).
Important questions to be asked in the case of a chronic groin injury Any changes in the amount of sports activity (frequency, intensity and load)? Any changes in training methods, surface or equipment? Previous overuse injuries (underlying biomechanical abnormality)? What were the first symptoms and how have they changed? What treatment has been given until now?
A history of systemic, urogenital, abdominal or lowback symptoms should be taken as well. The present symptoms should be investigated (box).
Important questions to be asked about the present symptoms in athletes with groin pain What is the precise location? What are the symptoms? Does the pain radiate anywhere? What can provoke the symptoms? When does it happen? The present activity level is also important, including not only sports-related activities but also work and leisure time activities.
In some cases the history and the present symptoms leave very little doubt and a direct examination of the relevant region will promptly reveal the diagnosis. But in other cases, such as painful conditions involving the
groin or the gluteal region, a rather comprehensive examination is required. In such cases a systematic approach is imperative. It is important to realize that most examination methods are not evaluated scientifically and reproducibility might be a problem []. Another point to be aware of is the lack of consensus in the scientific literature on definitions and diagnostic criteria. It is a prerequisite for the correct evaluation of different treatment methods that the same definitions are used. An approach to solving this problem in the case of athletes with groin pain has recently been suggested []. The physical examination (box) should of course be focused on the region indicated by the history. However one should be aware of the possibility of pain radiating to this region from, for example, nerve entrapment, abdominal or genital organs, sacroiliac joints and the spine. An assessment of the patient’s gait and posture is a useful start of the examination. The region should be inspected for swelling, discoloration and other abnormalities. Various functional tests to evaluate the balance and the pelvic stability can be performed. These could include a one-leg balance test evaluating the ability to maintain balance (e.g. for s standing on one leg), exercises on a soft surface evaluating the athlete’s ability to adjust body posture to sudden changes in the surface, a lunge test to evaluate dynamic stability and others. The physical examination should include systematic palpation for tenderness and abnormalities and functional testing of the muscles and ligaments based on the anatomy and biomechanics. An evaluation of the range of motion and the musculoskeletal flexibility including the lumbar spine and the hip and knee joints should be included. The bony landmarks should be palpated systematically for tenderness and abnormalities, including the symphysis joint, the sacrum, the ischial tuberosity, the greater trochanter and the iliac crest.
Chapter .
The main points of the physical examination of athletes with groin pain Gait and posture Functional tests Inspection Systematic palpation Range of motion Sensibility Abdominal palpation Laboratory testing when indicated
The neurologic investigation should include sensibility of the relevant regions and an examination of the deep tendon reflexes may be indicated. The abdomen should be palpated, and especially in male patients, an examination of the hernial orifices is often indicated. If urogenital diseases are suspected from the history, relevant examinations (e.g. rectal palpation) should be performed. If infections or rheumatic and other relevant systemic diseases are suspected laboratory testing is indicated.
Imaging Plain radiographs are usually the first choice in most conditions involving the pelvis and the hip joints (Fig. ..). When osseous involvement is suspected a stan-
Fig. .. X-ray of a female long-distance runner with groin pain. The X-ray shows a stress fracture in the pubic bone (arrows).
dard radiologic examination should include an anteroposterior projection of the pelvis with the pubic symphysis visible and an anteroposterior and lateral projection of the hip joints. Depending on the symptoms and the findings of the physical examination, additional projections might be relevant. Tomography and computed tomography (CT) are an important supplement in the case of fractures and can be very helpful in preoperative planning. Technetium-m triple-phase bone scan can in some cases be very helpful. Increased uptake can be seen in the case of e.g. stress fracture, bone neoplasm, bone infection and arthrosis. In the case of enthesopathy also, as seen at the adductor insertions and the rectus femoris insertion, a bone scan will often show increased uptake (Fig. ..) [,]. Ultrasound is another possibility in many cases of soft tissue-related problems in the pelvic region. The method is cheap and fast and has a major advantage in the possibility of dynamic real-time scanning. Muscles and tendons can be visualized using linear high-resolution transducers (Fig. ..). These can also visualize bursae, cysts, excessive fluid in the hip joints, and pathology of the viscera, genitourinary tissues and blood vessels that might be related to the region. The visualization is real time and can be performed dynamically. The patient can perform the movements that provoke the pain during simultaneous ultrasound scanning, thus helping to identify the structures causing the pain. The pressure of the transducer against the injured site might also help to identify the injured structure. In the case of a palpable unidentified structure or clicking, the ultrasound can be helpful in identifying the nature of this. Ultrasound is also very useful as a guide for biopsies, punctures and steroid injections. Magnetic resonance imaging (MRI) has some obvious advantages: the lack of ionizing radiation, the high sensitivity, the capability to show soft tissue and the multiplanar capability. T2-weighted images in particular can reveal muscular and musculotendinous injuries as increased signals in muscle strains. Short tau inversion recovery (STIR) images are useful to show edema and hemorrhage in both soft tissues and bone marrow (Fig. ..). In the case of calcifications, plain radiographs or CT scan may be superior to MRI. MRI still
Hip, Groin and Pelvis
(a)
Fig. .. Ultrasound examination of the insertion into the pubic bone of a normal adductor longus tendon (left). In the case of longstanding enthesopathy the insertion is thickened and the signals close to the bone are hypoechoic (right, indicated by arrows). Courtesy of Michael Bachmann Nielsen.
Groin — muscles and tendons Acute myotendinous groin injuries Etiology
(b) Fig. .. (a) Technetium-m triple-phase bone scan of the pelvis showing increased uptake around the symphysis joint and down the inferior rami of the pubic bone indicating enthesopathy of the adductor longus insertion. (b) MRI of the symphysis region in a male patient suffering from longstanding adductor-related groin pain, showing increased signal from the pubic bone on one side of the symphysis joint indicating enthesopathy of the adductor longus insertion.
The iliopsoas can be strained by a forceful flexion against resistance as occurs when the ground is mistakenly kicked instead of the ball, or in eccentric contraction, e.g. when the thigh is forced into extension. The adductor muscles are usually strained in eccentric contraction, e.g. in a forceful abduction, often with some degree of hip joint rotation, as in a sliding tackle in soccer. The injury usually occurs in the myotendinous junction but can also occur in the tendon itself or at the bony insertion. Fatigue, lack of concentration or insufficient muscle coordination seems to be important etiologic factors. Other muscles in the groin region such as rectus femoris, sartorius, the abdominal muscles and the conjoined tendon can also be injured by a hyperextension of the muscle and tendon.
Clinical presentation has the disadvantages of limited availability and cost and the indication for MRI is often the presence of a doubtful clinical diagnosis or the wish to eliminate the possibility of a neoplasm.
Muscle lesions can be divided into three grades []. Grade I — a mild strain with only a minimal tear of the muscle.
Chapter . Grade II — damage of more muscle fibers but not a complete disruption. There is a definite loss of strength. Grade III — a total tear of the muscle–tendon unit with a total lack of function of the muscle. Grade I and II lesions are painful and often disabling. Except for the iliopsoas lesion a discoloration and swelling can frequently be found representing local hematoma and edema. Usually a ‘pull’ has been felt in the muscle with a sudden sharp pain and the athlete is often unable to continue the activity. Complete muscle tear (grade III) is rare and is in most instances located to the distal insertion [,]. At clinical examination the swelling can be palpated, and sometimes a localized defect in the muscle can be felt. There is pain at palpation, and usually pain at the injury site on both passive and resisted active functional testing of the injured muscle(s). An anteroposterior radiographic projection of the pelvis, sometimes in combination with other projections depending on the location of the injury, may be very helpful to exclude fractures or avulsions. Ultrasound examination can be very helpful to visualize the precise location and size of the injury, especially when an iliopsoas strain is suspected. When the lesion is a grade III rupture a retraction of the injured muscle can be seen. If the patient is examined at a late stage, the injured muscle often appears as a mass in the groin region and needs to be distinguished from a hernia or a tumor; additional examination with imaging techniques like ultrasound, CT or MRI is usually indicated. With a typical history of an acute myotendinous lesion and clinical findings to support it, further investigations are seldom necessary. But in doubtful cases the entire groin region should be examined carefully and a neurologic examination of the limb and an examination of the low back including the thoracolumbar region and the sacroiliac joints should be made.
Treatment — acute injuries The initial management of acute myotendinous strain consists of rest, elevation, compression and ice. Massage, active stretching, heat and ultrasound should be avoided the first – days to prevent rebleeding. Early passive range of motion exercises and the use of
crutches during the first few days are recommended. Careful muscle exercises consisting of isometric contractions without resistance progressing to isometric resistance exercises and eventually dynamic exercises may be started when possible. Moderate pain may be tolerated as long as the exercises are controlled. Proprioceptive exercises carefully re-establishing the muscle strength and pelvic balance and coordination, combined with a careful stretching program, are recommended. An aquatic training program can be helpful in the initial training period. Analgesics may be used for the first days. Non-steroidal antiinflammatory drugs (NSAIDs) are sometimes recommended, but the widespread use of these has, however, been questioned. When the initial exercise program can be performed without pain, and the muscle coordination is good, the sport-specific exercises can be initiated before a gradual return to sport. It may take – weeks or even longer before return to sport depending on the nature and degree of injury. When the adductor muscles are injured, it is the authors’ experience that reestablishing the muscular strength and balance around the pelvis is extremely important to avoid relapse or development of chronic injury.
Chronic myotendinous groin injuries In the athlete with longstanding groin pain the symptoms are often more diffuse. In some cases the symptoms even seem to be contradictory and confusing. The athlete describes the pain as ‘moving around’ and the examiner will have to be aware of the possibility that more than one cause for the chronic groin pain very often can be found [,]. The multiple clinical entities responsible for the chronic groin pain are probably the result of the ‘first’ injury causing an imbalance and altered function affecting the pelvic stability, thus stressing other structures related to the pelvis. Pain from the sacroiliac joints, the low back or the sacrotuberal ligaments are not uncommonly found in combination with myotendinous groin injuries. In the literature the three most frequently mentioned causes for chronic groin pain in athletes are (i) adductor-related groin pain, (ii) lesions to the inguinal canal and associated structures and (iii) iliopsoasrelated groin pain.
Hip, Groin and Pelvis Etiology Adductor-related pain is a frequent cause of groin pain [,]. Fatigue, overuse or acute overload of the adductor muscles during sports activities may lead to injuries. The adductor muscles act as very important stabilizers of the hip joint [], and as such are at risk if the load on the hip joints and the pelvis is no longer balanced. Injuries influencing the stability of the hip joints and the pelvis might thus precipitate overuse problems of the adductor muscles. The iliopsoas muscle (Fig. ..) is a very important contributor to the pelvic stability constantly involved in most sports activities. The precise functions of the iliopsoas muscle apart from hip flexion are not yet fully understood, but the muscle seems to work as a pelvic stabilizer as well as a stabilizer for the lumbar spine []. One reason why the muscle is at risk could be that the workload on the muscle includes a considerable amount of both eccentric and concentric work and fast changes between these work forms. Another reason
m. psoas minor
m. psoas major
m. iliacus
Fig. .. The pelvis with the iliopsoas muscle complex.
could be that this muscle is ‘hidden’ to the athlete’s knowledge and is difficult to examine clinically. Knowledge of the preventive measures usually practiced for other muscles at risk such as strength training and stretching is thus sparse, and both strains and overuse injuries in the iliopsoas muscle might develop into a chronic problem. Lesions to the inguinal canal and associated structures are probably in most cases of a myotendinous nature as well. In some cases a predisposition to hernia development might be present. In other cases an acute trauma or a period of overuse as a result of a misbalanced pelvis combined with a period of strenuous athletic activity can result in a chronic lesion. The primary lesion can be in the rectus abdominis muscle or insertion, the external oblique, internal oblique and/or transversalis muscle(s) or aponeurosis, and the conjoined tendon []. The nature of the lesion is not clear, since it may be a strain or tear, an inflammation or degeneration of certain points of excessive stress, or an avulsion, a
Chapter . hemorrhage or an edema. The problem is discussed further in the section on ‘Sports hernia’.
Clinical presentation The typical complaints from an athlete with myotendinous-related chronic groin injury are pain and stiffness in this region in the morning and at the beginning of athletic activity. This pain and stiffness decreases and sometimes disappears after a period of warming up, but may reappear when the athlete gets fatigued or after the sports activity has ceased. Pain when coughing and sneezing and when standing on one leg to pull on socks or pants is a frequent complaint. The athlete can usually run forward and straight without pain at a moderate speed, but with increasing speed and/or sudden changes of direction the groin pain reappears. Characteristic activities causing pain include sprinting, making cutting movements, kicking the ball and making a sliding tackle. When the pain is adductor related it is localized medially in the groin and may radiate down along the adductor group on the medial side of the thigh, whereas when the injury is iliopsoas related, the pain is localized to the central anterior part of the proximal thigh, and thus more laterally in the groin. It sometimes radiates down the anterior thigh and sometimes involves an element of lower abdominal pain lateral to the rectus abdominis muscle. Myotendinous pain localized to the lower abdomen is most prominent around the conjoined tendon insertion at the pubic bone and may radiate into the adductor region and in males to the scrotum. Chronic injuries related to the rectus femoris or the sartorius are more rare. They are usually located at the proximal end of the muscle and tendon close to the insertion. Chronic groin injuries are in some cases preceded by an acute episode, but more frequently the athlete has no recollection of this. A pattern of a sudden increase in training, including the intensity, the training methods or the total amount, in the period before the appearance of injury is typical. For example, an iliopsoas-related overuse problem can typically be sustained by increased repetitive hip flexion as when running uphill or by intensive kicking exercises in soccer or football. Stress fracture is an important differential diagnosis
including stress fracture of the femoral neck, the sacrum, the pubis and the ischium (see below). When there is a sudden onset of pain without an adequate trauma, when weight bearing is painful and when the pain is persistent without a corresponding palpation pain, a stress fracture should be considered. When clinically examining the athlete with longstanding groin pain, it is important that the palpation and functional testing is very accurate, as the muscle insertions as well as other potentially injured structures are closely located (Fig. ..), and the functions of the muscle groups are somewhat similar. Using a set of precisely defined and reproducible examination techniques, it has been suggested that a number of diagnostic entities concerning athletes with groin pain should be defined []. It is recommended that the term ‘diagnostic entities’ is used instead of the term ‘diagnosis’ since the evidence-based data needed to define a precise diagnosis are not yet available. Terms such as adductor tendinitis, osteitis pubis, symphysitis and others in relation to these patients are so far without scientific basis. Tenderness of the origin of the adductor longus and/or the gracilis at the inferior pubic ramus, and groin pain on resisted adduction are typical findings in what has been suggested to be defined as ‘adductorrelated groin pain’ (Fig. ..). Decreased adductor muscle strength and groin pain on full passive abduction often with a decreased range of abduction are also frequent signs. Tenderness over the pubic symphysis
Fig. .. Palpation of the adductor longus and gracilis insertions. The painful site is usually found at the bony part of the insertion into the pubic bone. Pain at the tendon itself is a more rare finding indicating a tendinosis inside the tendon.
Hip, Groin and Pelvis
Table .. Clinical signs of the three most common musculotendinous groin injuries in athletes. Adductor-related groin pain Tenderness at the adductor tendon insertion Pain at adduction against resistance Decreased muscle strength of the adductors Pain with passive stretching of the adductors Tenderness of the iliopsoas in the lower abdomen Pain with passive stretching of the iliopsoas Tightness of the iliopsoas Tenderness at the symphysis joint Tenderness at the conjoined tendon Tenderness of the inguinal canal
Iliopsoas-related groin pain
Inguinal canalrelated groin pain
*** *** ** *
**
*** *** ** **
** *** ***
***, Most common presenting sign; **, common presenting sign; *, less common presenting sign.
and sometimes also of the insertion of the rectus abdominis muscle on the pubic bone are findings often seen with adductor-related groin pain (Table ..). Examination techniques for these finding have proven to be reproducible []. The definition of ‘iliopsoas-related groin pain’ includes pain when palpating the muscle through the lower abdominal wall combined with pain at passive stretching of the muscle using the Thomas test position []. Frequently the iliopsoas muscle is also tight and palpating it just distal to the inguinal ligament is often painful (Table ..). The palpation of the muscle is done above the inguinal ligament and lateral to the rectus abdominis. It can also be palpated in the area just below the inguinal ligament lateral to the femoral artery and medial to the sartorius muscle (the only area where the iliopsoas is directly palpable). The Thomas test should be performed to assess the tightness of the iliopsoas, and if passive stretching of the muscle is painful. The test is done in the supine position: both knees are brought to the chest and then one leg is held in this position while the other leg is allowed to return to extension; the patient might lift the head and shoulders in order to straighten the lumbar lordosis (Fig. ..). Incomplete extension is a sign of a tight iliopsoas muscle. Pressure by the examiner’s hand to extend the hip further is a test for pain on passive stretching. The above-mentioned tests for the iliopsoas were all found to be reproducible []. Muscle weakness and pain when flexing the hip joint
Fig. .. The Thomas test is very useful for evaluating the flexibility of the iliopsoas muscle and the rectus femoris muscle. The position is also valuable in order to passively stretch the iliopsoas muscle and in testing it for pain during passive stretching.
against resistance at ° is often found. Sitting with the legs stretched and then elevating the heels might result in pain since only the active hip flexor in this position is the iliopsoas: this is known as Ludloff ’s sign []. Imaging techniques can sometimes be helpful in the diagnosis of musculotendinous groin pain. Osteitis pubis-like radiologic changes around the symphysis joint are frequently found but are not specific enough (see elsewhere in this chapter). Calcified spurs can in some instances be seen along the adductor insertions. Increased uptake on the affected side in a bone scan seems to be correlated with adductor-related groin
Chapter .
Fig. .. Ultrasound examination of the iliopsoas tendon (indicated by arrows) near the insertion at the trochanter minor of the femur (indicated by asterisk). The tendon is thickened and the signals from this part of the tendon are more hypoechoic than in the normal tendon. Courtesy of Michael Bachmann Nielsen.
pain [,]. MRI also seems to show increased uptake in the same region (Fig. ..). Ultrasonography can visualize the enthesopathy of the adductors, and is also useful in detecting pathology in the lower part of the iliopsoas muscle and tendon (Fig. ..). At the time of writing all three imaging techniques lack scientific documentation for these conditions.
Treatment — chronic injuries Various treatment modalities for chronic groin pain have been suggested in the literature. Most modalities are based on the experiences of clinical practice, lacking randomized trials. Adductor-related pain One clinical randomized trial [] has described a specific exercise program found to be highly effective in the treatment of adductor-related groin pain. The trial included male athletes. Seventy-five per cent of the patients trained at least times a week in the period before they sustained the injury. On average they had had their symptoms for months, and % had ceased to participate in sport. The control group was randomized to receive physiotherapy without training. The exercise group received a training program including static and dynamic exercises aimed at improving the
muscles stabilizing the pelvis and the hip joints, in particular the adductor muscles. Both groups received the same amount of physiotherapy, and after the treatment period they received identical instructions about sport-related rehabilitation before returning to sports participation. At follow-up months after the end of the treatment period, % of the patients in the exercise group vs. % in the physiotherapy group were without pain at clinical examination and could participate in sport at the same or a higher level of activity without any groin pain. The patients’ subjective assessment accorded with the objective outcome measures. The exercise program consisted of two modules. The first module was a period of weeks with careful static and dynamic exercises to teach the patient to reactivate the adductor muscles (Fig. ..). In most cases the athlete with adductor-related groin pain has difficulties activating these muscles, probably as a result of negative feedback caused by the pain. In the second module the exercises were gradually more demanding; heavier resistance training as well as challenging balance and coordination exercises were added (Fig. ..). The groin exercise program was performed three times a week and the exercises from module were done on the days in between the treatment days. The total length of the exercise training period was between and weeks. Sports activities were not allowed in the treatment period. Riding a bicycle was allowed if it did not cause any pain. After weeks of the treatment period jogging was allowed as long as it did not provoke any groin pain. The exercise rehabilitation program stopped when neither the treatment nor the jogging caused any pain. The athletes were then allowed to increasingly progress to demanding sports-specific training towards final sports participation. No stretching of the adductor muscles was allowed during this –-month exercise training period. However, stretching of the other lower extremity muscles was recommended, in particular stretching of the iliopsoas muscle. The iliopsoas muscle is often affected in patients with longstanding groin pain and it is the experience that proper stretching is a good treatment and prevention of iliopsoas-related pain. We do not recommend steroid injections to athletes with adductor-related groin pain. In our experience
Hip, Groin and Pelvis
Fig. .. (a) Static adduction against soccer ball for s with repetitions to reactivate the adductor muscles. (b) One foot sliding with pressure against the floor to activate the adductors and abductors, both eccentric and concentric, since both the sliding leg and the standing leg will be active.
Fig. .. One-leg coordination exercise flexing and extending the knee and swinging the arms in the same rhythm and at the same time keeping the truncus stable (cross-country skiing on one leg); five series of min for each leg.
there is no long-term beneficial effect in these patients, and if the injections affect the pain temporarily, it only makes it more difficult to monitor the training program needed to cure the groin pain []. There are a limited number of scientific studies supporting surgery in the treatment of adductor-related chronic groin pain. A number of papers concerning adductor tenotomy have been published. Åkermark and Rolf [] suggest an adductor longus tenotomy cm from the insertion, and Neuhaus [] suggests that the tendon be cut at the insertion. Meyers et al.
[] suggest that the adductor longus tendon be released – cm from the insertion and that multiple longitudinal incisions are made into the tendinous insertion. On the other hand Martens et al. [] suggest a tenotomy of the gracilis tendon close to the insertion combined with a rectus abdominis plasty. It is the experience of the authors that a tenotomy of the adductors is seldom indicated. Most patients can probably be treated successfully with the abovementioned training program combined with sufficient treatment of concomitant injuries.
Chapter . Iliopsoas-related groin pain The authors’ preferred treatment of this pain entity consists of stretching and careful dynamic strengthening — both concentric and eccentric — combined with a series of pelvic stabilization and balance exercises. Supplementary physiotherapy including massage and trigger point stimulation might also be helpful. If the treatment regimen is not progressing satisfactorily a steroid injection may be considered. The injection seems to alleviate the pain and the tension of the muscle thereby making it easier to stretch and strengthen the muscle. The injection can be technically difficult. It is placed just under the muscle fascia and along the tendon. Preferably the injection is done guided by real-time ultrasound. If ultrasound is not available the injection should be placed in the area just distal to the inguinal ligament, lateral to the femoral vessels and nerve and medial to the sartorius muscle.
The inguinal canal and associated structures A number of lower abdominal lesions giving rise to groin pain in connection with athletic activities have been described. They have been named sports hernia, sportsman’s hernia, incipient hernia, Gilmore’s groin, pubic pain, athletic pubalgia and others. The lesions seem to be non-specific and difficult to describe pathoanatomically. The pathologic findings at surgery have been described in subjective terms as: ‘loosefeeling inguinal floor’, ‘thinning of the fascia’, ‘tendency to bulge’, ‘weakening of the transversalis fascia’, etc. [,–]. Bias could be a relevant problem. To clarify these problems a scientific approach is necessary. No consensus regarding the clinical diagnosis, the use of imaging techniques, the surgical findings and the treatment of these lesions can be found in the scientific literature. Until now very few papers have dealt with these problems scientifically []. No randomized trials have so far been reported considering surgery to clarify the contribution of rehabilitation, placebo, denervation and time itself.
Sports hernia The term ‘sports hernia’ refers to a condition of chronic groin pain caused by a weakness of the posterior inguinal wall without a clinically obvious hernia. Be-
cause of the insidious onset and non-specific nature of the symptoms, there is often a prolonged course prior to diagnosis. In one study, the average duration of symptoms was months, with a range of weeks to years []. The etiology to these lesions is sometimes a traumatic episode where the athlete overstretches the front of the groin and lower abdomen, as in a forceful sliding tackle in soccer. In other cases the athlete cannot recall any single episode precipitating the pain but recalls it as developing gradually, often in connection with overuse over a period of time. The patient will often have multiple diagnoses contributing to the groin pain. Adductor-related pain, iliopsoas-related pain, sacroiliac pain and low back pain are typically concomitant findings in these patients [,]. Which lesion was the primary lesion resulting in the other(s) is seldom clear: it is often a question of ‘the chicken or the egg’. The pain in sports hernia is experienced ‘deep’ in the groin, slightly more proximal than the adductorrelated pain. Kicking and endurance running tend to increase the symptoms. The pain tends to be diffuse, with radiation along the inguinal ligament, the perineum, the rectus muscles, adductor muscles, and sometimes also to the opposite side. Scrotal pain may also be a component. Maneuvers that cause increased intra-abdominal pressure, such as coughing, sneezing or bowel movements, will usually cause increased pain. The most specific signs are tenderness at the conjoined tendon towards the pubic tubercle, tenderness and enlargement of the external ring of the inguinal canal, and tenderness of the posterior wall of the inguinal canal (Table ..). The posterior wall tenderness is usually worse and sometimes a bulge can be felt with increased intra-abdominal pressure from e.g. coughing. The pain may be exacerbated during coughing. An examination after vigorous exercise may be helpful in difficult cases. The examination of the inguinal canal must be performed through the scrotum, or in women through the labia majores, to be able to evaluate most structures. In addition, in males a scrotal and testicular examination are necessary to exclude tumors. If gastrointestinal or gynecologic diseases are suspected further examination must be undertaken.
Hip, Groin and Pelvis The diagnosis of a clinically apparent hernia is straightforward, with obvious clinical signs and symptoms. However, this is usually not the case for sports hernias, and in those athletes with continued groin pain despite adequate rest and no obvious hernia, herniography and/or ultrasonography can be helpful. Both methods have been described in the literature [,] but better scientific evaluation is needed.
Treatment of sports hernias Since the sports hernia by nature is an incipient hernia, rehabilitation should always be tried as a first step. A regular hernia has not yet developed, and a training program improving pelvic stabilization by training the strength, balance and coordination of the involved muscles may give the abdominal wall lesion a chance to heal. This strategy would allow simultaneous treatment of the other diagnostic entities causing groin pain often found at the same time as a sports hernia. The suggested treatment is, however, not yet supported by scientific evidence. If the pain continues despite this regimen, and examination or other tests detect no other pathoanatomic explanation, surgical treatment may be considered. Surgical treatment of painful sports hernia is aimed at repair and reinforcement of the weak posterior inguinal wall. A variety of open surgical procedures have been described to reinforce the posterior wall, either by plication and tightening of the existing tissue or by reinforcement with an artificial mesh graft. It has also been reported that a simple repair of small tears in the external oblique aponeurosis and/or the conjoined tendon will give good results []. Recently, laparoscopic procedures have been developed for hernia repair. This usually involves placement of synthetic mesh over the defect superficial to the peritoneum. Early results have been relatively encouraging, with recurrence rates near the level of open procedures []. However, the procedure is technically difficult with a significant learning curve, and the procedure is more costly than open procedures. After surgery rehabilitation before returning to sport is imperative. The rehabilitation program based on the experience of the authors is shown in the box.
Week — walking and lifting up to kg. Week — faster walking, careful jogging and normal day-to-day activities. Week — running carefully and gentle groinrelated strength training. Week — full participation in the pelvisstabilizing rehabilitation program performed before the operation. When running and rehabilitation program can be done pain free — careful gradual return to sport.
Symphysis joint-related pain Osteitis pubis is a term that was originally used to describe an infection in the pubic bone around the symphysis joint. This infection was seen especially in connection with suprapubic abdominal surgery []. The characteristic radiologic findings — bone resorption, widening of the symphysis and sclerosis along the rami (Fig. ..) — were in the s reported to appear on X-rays from athletes with chronic groin pain. However, it was soon evident that no bone or joint infection was present, and that this X-ray appearance was the result of a biomechanical problem applying stress on the symphysis joint and leading to the radiographic changes. Harris and Murray [] found that
Fig. .. The characteristic radiologic findings of longstanding stress to the symphysis joint (often seen without any symptoms) — bone resorption, widening of the symphysis and sclerosis — characterized as ‘osteitis pubis-like’ changes.
Chapter . these ‘osteitis pubis-like’ changes seemed to be correlated to the amount of physical activity — in particular soccer — undertaken and as such were a poor indication of groin pain in athletes. Groin straining activities such as soccer increase the shearing forces in the symphysis joint. The stress on this joint might thus lead to these radiologic signs, merely indicating an increased load of the joint rather than pathology. Some authors consider ‘osteitis pubis’ as a diagnosis based on vaguely defined findings and symptoms, that in most cases is covered by other diagnostic entities. It is described as a condition with a gradual onset of pain that may radiate to the sides and distally. The condition is considered to be self-limiting and sometimes a cortisone injection may be given under fluoroscopic control. It seems that, when a specific anatomic and pathologic diagnosis for chronic groin pain cannot be made, the term ‘osteitis pubis’ is often used as the diagnosis. McCarthy et al. [] described osteitis pubis in athletes as: ‘. . . a broader diagnostic category, that encompasses several different etiologic entities in or near the symphysis.’ The characteristic radiologic changes are often found in athletes without groin problems as well as in athletes with a specific groin-related diagnosis. In a study of adductor-related groin pain radiologic signs of osteitis pubis were found in % of the patients and scintigraphic changes in the bone in % []. It is the view of the present authors that ‘osteitis pubis’ should not be used as a specific diagnosis in the case of athletes with groin pain, unless an infection is present in the pubic bone. The term should be reserved to describe ‘osteitis pubis-like’ radiologic changes around the symphysis joint.
Inflammation in pelvic joints Inflammatory conditions may be seen in the joints of the symphysis and sacroiliac joints. Sacroiliitis is not uncommon in outdoor winter sports. Sacroiliitis can also be a symptom in a generalized disease such as rheumatoid arthritis or Bechterew’s disease. Pain and/or discomfort may radiate to the groin, to the hip joint, or to the thigh. Changes in the sacroiliac joints may be present without the athlete feeling any pain. The symptoms may be vague and most pronounced in the morning. Long intervals without symptoms may be present. The diagnoses are made by clinical exami-
nation and with the aid of CT scan. The treatment consists of anti-inflammatory medication and physical therapy.
Fractures Fractures of the pelvis, femoral neck and trochanteric region are common in the elderly but can also appear in adolescence and active adult athletes, in this case being a result of major trauma such as traffic accidents but also high-energy impact in sports. In sports the most common fractures in this region are stress fractures and avulsion fractures.
Stress fractures Many stress fractures probably remain unrecognized because the patients treat themselves by resting until the pain improves. Stress fractures are considered to occur from a repetitive cyclic load by submaximal forces leading to overload of the bone tissue, but the exact etiology is still unknown. The common factor is that cyclic forces cause breakdown of the bone that occurs faster than the bone’s remodeling capacity. The tibia is the most commonly affected bone, but stress fractures may appear in apparently all bones of the weight-bearing lower extremities. Stress fractures of the pubic rami seem to be particularly common among long-distance running athletes. These fractures appear to be associated with anorexia and amenorrhea among female athletes (Fig. ..). Barrow and Saha reported that stress fractures occurred in % of collegiate female distance runners that had less than five menses per year. In addition, of those athletes that were amenorrheic, % had an eating disorder. Stress fractures of the pubic rami present as an insidious onset of lower pelvic and groin pain that is worsened with pounding-type activities. The pain is often worse immediately after running, and will gradually improve with rest. Stress fractures are often related to a sudden increase in the intensity of the athlete’s training. Stress fractures are often not evident on plain radiographs until the formation of callus. Therefore, if early stress fracture is suspected, a bone scan or MRI is most sensitive in the early phases. Treatment of stress fractures in the pelvis, except for femoral neck fractures, is relatively straightforward. This involves a period of – weeks’ rest from the activities responsible. When the athlete is pain free,
Hip, Groin and Pelvis a graduated program of return to activities can begin. Any dietary or hormonal contributions to this diagnosis must be addressed to assist in healing and prevention of recurrence. The most serious stress fracture in the pelvis region is that to the femoral neck. An unrecognized stress fracture of the femoral neck can proceed to complete fracture with the high risk of avascular necrosis. This is a potentially devastating problem, so early recognition and treatment is the key. One study reported on athletes with femoral neck stress fractures. Of the seven patients that developed complications, five had a displaced fracture. This stresses the importance of early recognition and treatment of these injuries to prevent displacement and necrosis. Treatment of femoral neck stress fractures is based on the displacement and location of the fracture at diagnosis. All displaced fractures require surgery to anatomically reduce the fracture supported with internal fixation. Non-displaced fractures can be divided into two categories: (i) fractures that occur on the compression side of the bone, the inferior femoral neck; and (ii) fractures that occur on the tension side of the bone, the superior femoral neck. The compressionsided fractures have a good healing potential and they can be treated non-surgically. Activities should be restricted by pain and this usually requires a short period of crutch walking to prevent progression into a complete fracture. This is followed by a gradual return to normal pain-free activities. It is important to stress that no pain should occur either during or after the activity. Progression of healing should be monitored with serial plain radiographs. Return to light running cannot usually begin until – months after appearance, and only as long as there is no pain and the radiographs show healing of the fracture. Tension-side fractures are best treated with surgical internal fixation, e.g. using screws or pins. The tension-side fractures have a poor healing capacity and are more prone to proceed to complete fracture. For non-displaced fractures treated surgically as described above, return to pain-free light running can begin at about – months.
Avulsion fractures Avulsion fractures about the pelvis occur almost exclusively in the adolescent population. The apophyses
make a relatively weak connection to the central bony skeleton through the zone of provisional calcification of the growth plate. Powerful muscle contractions from the muscles around the hip and pelvis are occasionally able to overpower the stability of the growth plate and cause avulsion fractures. There are three typical locations for avulsion fractures of the pelvis: (i) anterior superior iliac spine (ASIS); (ii) anterior inferior iliac spine (AIIS); and (iii) ischial tuberosity. Avulsions from the ASIS typically occur from a strong contraction of the sartorius muscle during jumping in sports such as basketball. AIIS avulsions occur in kicking sports such as soccer, resulting from a violent contraction of the rectus femoris muscle. Avulsions of the ischial tuberosity occur from hamstring contractions and are most frequently seen in running and hurdling sports. For avulsion fractures of the ASIS and AIIS, most authors recommend non-operative treatment. This includes symptomatic activity restriction until the fracture heals. Although there are no large series in the literature, it does not appear that operative fixation results in either earlier return to activity or better return of strength than non-operative treatment. The treatment of the ischial tuberosity avulsion remains controversial. Although again there are no randomized studies reported, some authors have indicated no functional deficits following nonoperative treatment, while others have reported a decrease in strength and function resulting from ‘widely displaced’ fractures. These fractures can sometimes cause massive callus formation that can cause pain and may occasionally mimic an osteosarcoma. Therefore, in these cases, some reports have advocated early surgical fixations, while others have pointed out that late excision of the massive callus can be performed to relieve symptoms. We presently recommend that large fragments that are displaced more than –. cm need surgical reduction and fixation. Rehabilitation after an avulsion fracture depends on the stability of the fracture. If it is operated on and evaluated as stable, range of motion exercises can start immediately with increasing strength training. If it is not stable exercises may be delayed for – weeks depending on the location. If the avulsion fracture is not operated on, the patient can often start mobilizing
Chapter . activities fairly early and let pain decide the level of these. Physiotherapy should be used.
Hip joint changes As with the groin region, with pain in the hip it must be ascertained what tissues are involved. According to Cailliet four specific structures about the hip joint may cause pain: the fibrous capsule and its ligaments; the surrounding muscles; the bony periosteum; and the synovial lining of the joint. The most painful condition of the hip joint is degenerative joint disease — osteoarthrosis. In athletes late degenerative changes in the hip joint is probably a risk. In runners some papers have not been able to find any increased risk for developing arthrosis. There are however, increasing indications that extensive toplevel running may be a risk factor in causing late degenerative changes in the hip joints. The same may be true for top-level soccer, but the scientific evidence is not yet conclusive. Top-level sport of the highest intensity is probably a risk factor for developing late degenerative changes in the hip. Pain in the hip joint may be an early symptom of localized changes in the joint such as low-grade arthrosis–arthritis, osteochondritis dissecans, or loose bodies. In rare cases the outer rim of the joint labrum or limbus can be avulsed, and the torn end can rotate into the joint. These injuries may produce a sharp and catching pain during exercise and often persistent pain after exercise. Pain elicited by rotation in the hip joint may indicate an intra-articular lesion and requires radiographic examination. If a plain X-ray is negative, sometimes a CT scan, an MRI or an MRI arthroscan is necessary to establish a diagnosis. Arthroscopy is of less diagnostic help but can be of value, especially in the management of loose bodies. The most common cause of painful hip in children is transient synovitis or capsulitis. This is assumed to be a benign self-limited condition seen in children younger than years of age. This condition should be differentiated from serious lesions such as congenital dislocation of the hip, Legg–Calvé–Perthes disease, osteomyelitis, bone disorders, osteoid osteoma, tuber-
culosis and rheumatoid arthritis. Two significant hip conditions in adolescents are slipped capital femoral epihysis and osteochondritis dissecans, both of which will cause pain in the groin area.
Bursitis There are at least permanent bursae present in the hip region, and they are often localized between tendons and muscles and over bony prominences. The pathologic conditions involving the bursae can be divided into traumatic and inflammatory conditions. Traumatic bursitis can be called hemorrhagic bursitis, or hemobursa. The most common cause of hemorrhagic bursitis is either a direct trauma, e.g. a fall against the bursa, or an indirect trauma through a strain in a passing tendon with hemorrhage. In a hemorrhagic bursa, the hemorrhage can be extensive and if it is not treated adequately, the blood will coagulate, and eventually fibrinous adhesive tissue of fibrin bodies will be formed in the bursa. These adhesions or free bodies will produce a chronic inflammatory bursitis with recurrent problems. The treatment of acute hemorrhagic bursitis should be evacuation of the hematoma. A fluctuation over the bursa may be palpated; a common example is the superficial trochanteric bursa, which is often subject to direct trauma. In acute cases the hematoma may be aspirated. Ultrasound-guided puncture can sometimes be helpful and endoscopically assisted lavage has been proposed. If the condition becomes chronic, surgical excision of the bursa is often the treatment of choice. Inflammatory bursitis may be divided into friction bursitis, chemical bursitis and infection bursitis. Friction bursitis may be caused by repeated frequent movements of a muscle tendon against a bursa, e.g. iliopsoas against the iliopectineal bursa. The iliopectineal bursa is the largest synovial bursa in the whole body and it is located anterior to the hip joint and dorsal to the iliopsoas tendon. This bursa communicates with the hip joint in about % of adults. This bursa may be the location for inflammation, whether isolated or combined with iliopsoas pathology. Iliopectineal bursitis may give a feeling of tenderness and swelling in the middle of the groin, which may spread across the inguinal ligament.
Hip, Groin and Pelvis On the lateral proximal femur, deep to the iliotibial band, there is a superficial bursa. Between the tendons to the gluteus medius and tensor fascia latae and behind the greater trochanter there is a deeper-located bursa. Both these bursae may be the location for an inflammation, e.g. because of untreated hemorrhage. Malalignment with increased pronation and compensatory internal leg rotation can cause overload in this region. Trochanteric bursitis will cause pain and tenderness just lateral and posterior to the greater trochanter. The pain can radiate down along the outside of the thigh and be erroneously diagnosed as referred pain from herniated disk lesions in the lumbar spine. Pain may be elicited by rotation of the hip joint at ° of flexion. Careful palpation around the lateral posterior aspect of the trochanter region may reveal localized tenderness. Ultrasonographic examination is very helpful in localizing and diagnosing the bursitis. Initial treatment consists of cold packs, NSAIDs and rest. After the acute phase cortisone injection — preferably ultrasound guided — may give relief. Foot orthotics are sometimes of value to address any malalignment of the leg. This condition can be long lasting and therapy resistant, and surgery may therefore sometimes be indicated. The chemical bursitis that is sustained after a chemical irritation from products and seen after inflammation or degeneration in tendon tissue is not common in the groin. Bursitis due to infection may be septic or caused by a bacterial immigration through lacerated skin, and can occasionally be seen over the trochanteric region.
The snapping hip This condition can be ascribed to a number of very different causes. The snapping sensation is audible but not always associated with pain. When the snapping is just associated with the sound of the snapping and no discomfort or pain is felt, the condition can usually be ignored and considered to be without any pathologic importance. The snapping can be located externally, that is on the lateral side of the hip, or internally on the medial side. The external snapping hip is normally easily palpated on the lateral side of the hip, often in the area of
the greater trochanter. The condition is in most cases caused by a thickened border of the iliotibial band or by the anterior border of the gluteus maximus. In both cases they are tight in relationship to the bone prominence and the friction produces a bursitis. The problem is most prominent in female athletes, perhaps as a result of their broader pelvis and/or hyperpronation. The treatment consists of correction of any malalignment that might have caused the problem combined with stretching of the affected muscle. NSAID or steroid injections into the bursa may occasionally give long-term relief. In rare cases surgical treatment releasing the tight part of the tendon and excising the bursa can be necessary. The internal snapping hip can be either an intraarticular problem in the hip joint or a snapping iliopsoas tendon. Intra-articular loose bodies in the hip joint caused by a trauma, osteochondritis dissecans or osteochondromatosis can result in intra-articular locking, clicking and pain. A labral tear might also result in a painful snapping internal hip. A more common cause is a tight and/or fibrotic iliopsoas tendon snapping over the iliopectineal eminence or over the femoral joint. The tendon lies in a groove between the iliopectineal eminence and the anterior inferior iliac spine; it crosses over the femoral head and capsule and inserts into the lesser trochanter (Fig. ..). When the hip is extended, especially from the flexed and externally rotated position, an audible and sometimes painful snap is felt. Palpation over the hip joint can often reveal a snapping sensation against the fingers. An iliopsoas bursography can demonstrate the snapping of the iliopsoas tendon, but real-time ultrasound examination with a small MHz convex array transducer can show more clearly in a fast, cheap and noninvasive way the snapping of the iliopsoas tendon. The intra-articular lesions can be diagnosed with MRI or CT scan combined with an arthrography. Hip arthroscopy can also be indicated, both as a diagnostic method and as the method of choice for extracting loose bodies or debriding a labral lesion. The painful snapping iliopsoas can in most cases be treated non-surgically with a combination of stretching and careful dynamic strengthening exercises. Sometimes a steroid injection (see iliopsoas injury) may be tried. If the non-surgical treatment fails, a sur-
Chapter . gical release of the tendon in some form of a lengthening procedure can be effective [].
Nerve entrapment Peripheral nerves may become entrapped after direct trauma or inflammatory conditions. Nerves most commonly affected are the ilioinguinal, genitofemoral and lateral cutaneous femoral nerves. The obturatorial and iliohypogastric nerves may also be involved (Fig. ..). The ilioinguinal nerve transmits sensations from the proximal part of the external genitals and parts of the medial thigh. Pain in these areas should lead to suspicion of engagement of the nerve. These sensations may be elicited by e.g. intensive abdominal muscle training leading to entrapment of the nerve where it passes through the different layers of the abdominal muscles and their fasciae. The intensity and character of the pain vary. Hyperextension of the hip joint might augment the pain. It is usually possible to detect skin hyperesthesia, which is demonstrated by drawing a needle across the skin from a non-painful area to a painful area. The diagnosis is confirmed by a block of the nerve with local anesthetics that will promptly relieve the pain. If the pain is severe, surgical treatment may be considered. The genitofemoral nerve is divided into two parts: (i) the ramus genitalia, which transmits sensations from the labium major/scrotum; and (ii) the ramus femoralis, which gives sensations from the skin of the thigh just distal to the ilioinguinal ligament. The symptoms are similar to those mentioned for the ilioinguinal nerve. Westman has reported on seven cases of entrapment of the ilioinguinal and genitofemoral nerves, which were operated on. He considers a lasting cure to be obtained only by local nerve resection. A sensory mononeuritis of the lateral cutaneous nerve of the thigh is called meralgia paresthetica. The posterior branch of the nerve transmits cutaneous sensations from the superior lateral part of the buttock. The anterior branch, which is the most important clinically, passes through the fascia lata through a small canal and transmits sensations, and occasionally causes skin hyperesthesia. Usually there is no history of any trauma, but factors such as tight belts or corsets or long periods of acute hip flexion may cause the condition.
Posture exercises that decrease lordosis are considered valuable. Anti-inflammatory medicine may be tried, but most often surgical decompression is the treatment of choice.
Tumors Tumors are not uncommon in the groin area, and we have seen several cases in which the pain was first experienced in the groin area in connection with a soccer game or similar sports activity. The pain was often considered to be caused by strain in the groin muscles and tendons. After a couple of months, the patients are often referred to surgical or orthopedic departments because of persistent pain or tumor-suspicious findings on X-ray. Osteosarcomas, chondrosarcomas, malignant schwannomas and other tumors have been diagnosed often at a late stage, due to both patient’s and doctor’s delay. Persistent pain or an unexplained ‘mass’ in the groin region should be carefully investigated to exclude a tumor, and a radiology examination should always be included at an early stage in patients with diffuse groin pain. Ultrasound, MR imaging or CT scan will secure the diagnosis.
Summary Injuries and pain in the groin and pelvic area remain one of the more difficult areas in sports medicine due to their highly variable pathoanatomy. The incidence of these injuries seems to be increasing. Earlier, such injuries mostly occurred, or were at least diagnosed, in soccer and ice hockey. As a result, top-level athletes in soccer and ice hockey have recently been participating in preventive groin exercise programs, and the incidence of groin pain seems to be leveling off. These injuries are, however, now being recognized in sports such as basketball, American football and baseball, and also in long-distance runners and other athletes. Some of these groin injuries are apparently secondary to acute strains that have been neglected or not treated properly. Others are often caused by muscle imbalances and poor biomechanics resulting in chronic conditions, when proper rehabilitation and treatment is lacking. The dilemma remains that there are many different causes, from many organs and tissues, of groin pain. The only way to successfully treat groin injury and pain is to base the treatment and rehabilitation proto-
Hip, Groin and Pelvis col on a correct diagnosis, even though this may be highly challenging. It is imperative that the athlete, the coach, the trainer and the physician have great respect for groin problems and do not neglect these symptoms. If the athlete experiences groin pain, he/she should limit activities to those that are pain free until a probable diagnosis is secured. If these injuries are mismanaged or, more commonly, ignored, there is a high risk of developing a chronic groin pain condition. If there is any difficulty or doubt about the diagnosis, then these athletes should be referred to specialists in this area, who have often developed a multidisciplinary approach to groin injuries.
Even if knowledge in this area is developing, information about chronic groin pain problems is still limited, being mostly based on clinical experience. There remains a need for much more research in this area. In conclusion, groin injuries may not in themselves be serious injuries. However, they may lead to chronic pain and impair athletic ability and performance, especially if not correctly diagnosed, and promptly adequately treated. Groin injuries and pain may prevent an athlete from participating in sport activities over a long period of time — or even end his or her career — something bound to distress the dedicated athlete.
Case story 6.3.1 A male football (soccer) player, years old, has played at elite level for months. He is suffering from pain in the right groin and remembers one painful episode of hyperextension of the right hip during a match months ago. The physiotherapist in the club has treated him with ultrasound, stretching, massage and some abdominal and back exercises. Six weeks after the groin pain started, he was examined at our sports medicine center. Clinical signs of adductor-related pain, iliopsoas-related pain and incipient hernia were found. These findings were confirmed by ultrasonography. Treatment was initiated. It consisted of the exercise program for adductor-related groin pain, combined with exercises to stimulate and stretch the iliopsoas. A combination of abdominal and back exercises was added to improve pelvic and lumbar stability. The program was performed times a week and jogging was allowed after weeks. At clinical control after weeks of treatment no pain from the adductors or the iliopsoas was found any more. With regard to the lower abdominal pain there are two possible endings to this case story: A or B. A The previous treatment had only slightly reduced the abdominal pain. The patient still had
lower abdominal pain both at palpation and at functional testing. It was still painful to sprint, make fast turns and do resisted sit-ups. The patient was operated on and a small rupture of the external oblique aponeurosis was seen and repaired. A soft posterior wall was repaired with a mesh onlay. No hernia sac was found. Four weeks after surgery he was able to run fast and make fast turns, and during the next weeks he was allowed to sprint and participate in football training. Seven weeks after surgery he played his first match and had no groin pain. B The pain in the lower abdomen was reduced considerably and he was able to run straight without pain. The treatment program was continued and after weeks he returned to football times a week without any groin pain. At clinical examination no pain was found at the adductors, the iliopsoas, the conjoint tendon or in the inguinal canal. At follow-up months after the first symptoms the patient was without any groin problems. Both scenarios are commonly found and our problem is that it is not possible from the clinic to decide which treatment is the best. Which patient should have surgery right away and which patient needs no operation but can be managed solely with the exercise treatment?
Chapter . Multiple choice questions Ultrasound examination is of value in diagnosing groin injuries because: a it is pain free b it can be done on the sports field c it is real-time and can be performed dynamically d it is easy to visualize cartilage e it can show bone edema around the symphysis joint. Among the three most common causes of groin pain in athletes are: a adductor-related pain b stress fracture of the femoral neck c lateral hernia d snapping iliopsoas e incipient hernia. Typical findings in the athlete with adductorrelated groin pain are: a pain when jogging b tenderness at the insertion of the adductor longus muscle insertion at the pubic bone c tight lower leg muscles d increased range of abduction e groin pain on resisted adduction. The most serious stress fracture in the pelvis region is: a the superior pubic bone b the inferior pubic bone c the sacrum d tension side femoral neck fracture e compression side femoral neck fracture. Treatment of adductor-related groin pain should include: a strengthening exercises of the adductor muscles b steroid injection c balance and coordination exercises for the pelvis d stretching of the adductor muscles e transverse friction massage.
References Ekstrand J, Gillquist J. Soccer injuries and their mechanisms: a prospective study. Med Sci Sports Exerc ; : –. Ekstrand J, Hilding J. The incidence and differential diagnosis of acute groin injuries in male soccer players. Scand J Med Sci Sports ; : –. Engström B, Forssblad M, Johansson C, Törnkvist H. Does a major knee injury definitely sideline an elite soccer player? Am J Sports Med ; : –. Nielsen AB, Yde J. Epidemiology and traumatology of injuries in soccer. Am J Sports Med ; : –.
Renström P, Peterson L. Groin injuries in athletes. Br J Sports Med ; : –. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic following resolution of acute first episode low back pain. Spine ; : –. Wilke HJ, Wolf S, Claes LE. Stability increase of the lumbar spine with different muscle groups: a biomechanical in vitro study. Spine ; : –. Gibbon WW. Groin pain in athletes (letter). Lancet ; : –. Gibbon WW, Jenkins CN, Crowe MTI, Freeman SJ. Groin pain in soccer players; MRI appearences. Br J Sports Med ; : . Stureson B. Load and movement of the sacroiliac joint. Lund University, Sweden, . Hölmich P, Uhrskou P, Ulnits L, Kanstrup I, Nielsen MB, Bjerg AM et·al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet ; : –. Le Jeune JJ, Rochcongar P, Vazelle F, Bernard AM, Herry JY, Ramée A. Pubic pain syndrome in sportsmen: comparison of radiographic and scintigraphic findings. Eur J Nuclear Med ; : –. O’Donoghue DH. Principles in the management of specific injuries. In: O’Donoghue DH, ed. Treatment of Injuries to Athletes. Philadelphia: W.B. Saunders, : –. Peterson L, Stener B. Old total rupture of the adductor longus muscle. Acta Orthop Scand ; : –. Symeonides PP. Isolated traumatic rupture of the adductor longus muscle of the thigh. Clin Orth Rel Res ; : – . Lovell G. The diagnosis of chronic groin pain in athletes: a review of cases. Aust J Sci Med Sport ; : –. Gibbon WW. Groin pain in professional soccer players: a comparison of England and the rest of Western Europe. Br J Sports Med ; : . Morrenhof JW. Stabilization of the human hip-joint. Thesis: Rijksuniversiteit of Leiden, Holland, . Andersson E, Oddsson L, Grundström H, Thorstensson A. The role of the psoas and iliacus muscles for stability and movement of the lumbar spine, pelvis and hip. Scand J Med Sci Sports ; : –. Harris NH, Murray RO. Lesions of the symphysis in athletes. Br Med J ; : –. Hölmich P. Adductor-related groin pain in athletes. Sport Med Arthrosc Rev : : –. Mozes M, Papa MZ, Zweig A, Horoszowski H, Adar R. Iliopsoas injury in soccer players. Br J Sports Med ; : –. Neuhaus P, Gabriel T, Maureo W. Adduktoren-insertionstenopathie, operative therapie und resultate. Helv Chir Acta ; : –. Åkermark C, Johansson C. Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes. Am J Sports Med ; : –. Meyers WC, Foley DP, Garrett WE, Lohnes JH,
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Mandlebaum BR. Management of severe lower abdominal inguinal pain in high-performance athletes. Am J Sports Med ; : –. Martens MA, Hansen L, Mulier JC. Adductor tendinitis and musculus rectus abdominis tendopathy. Am J Sports Med ; : –. Hackney RG. The sports hernia: a cause of chronic groin pain. Br J Sports Med ; : –. Polglase AL, Frydman GM, Farmer KC. Inguinal surgery for debilitating chronic groin pain in athletes. Med J Aust ; : –. Taylor DC, Meyers WC, Moylan JA, Lohnes J, Bassett FH, Garrett WE. Abdominal musculature abnormalities as a cause of groin pain in athletes. Am J Sports Med ; : –. Lovell G, Malycha P, Pieterse S. Biopsy of the conjoint tendon in athletes with chronic groin pain. Aust J Sci Med Sport ; : –.
Orchard JW, Read JW, Neophyton J, Garlick D. Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in Australian Rules Football. Br J Sports Med ; : –. Smedberg SGG, Broome AEA, Gullmo Å, Roos H. Herniography in athletes with groin pain. Am J Surg ; : –. Williams P, Foster ME. ‘Gilmore’s groin’ — or is it? Br J Sports Med ; : –. Ingoldby CJH. Laparoscopic and conventional repair of groin disruption in sportsmen. Br J Surg ; : –. Adams RJ, Chandler FA. Osteitis pubis of traumatic etiology. J Bone Joint Surg ; : –. McCarthy B, Dorfman HD. Pubic osteolysis — a benign lesion of the pelvis closely mimicing a malignant neoplasm. Clin Orth Rel Res ; : –. Jacobson T, Allen WC. Surgical correction of the snapping iliopsoas tendon. Am J Sports Med ; : –.
Chapter 6.4 Head LIYING ZHANG, KI NG H. YA NG, ALBERT I . KI NG & LA RS E NGE B RE TSE N
Lissner H, Lebow M, Evans F. Experimental studies on the relation between acceleration and intracranial changes in man. Surg Gynecol Obstetr ; : –. In the United States, Wayne State University initiated fundamental research in biomechanics in . Biomechanics is defined as the application of the principles of mechanics to living biologic material. Specifically, the study of head injury, initiated jointly by a neurosurgeon, Dr E. Stephen Gurdjian, and an engineer, Prof. Herbert R. Lissner, was the earliest known collaborative effort in biomechanics. From to , the Wayne State group pioneered a long series of head injury experiments. These included the dropping of metal balls onto dry human skulls, impacts to the foreheads of embalmed cadavers against rigid and padded surfaces and the application of an air pressure pulse directly onto the dura of anesthetized animals. Based on clinical observations that moderate levels of concussion were usually accompanied by a linear skull fracture in % of the patients, they hypothesized that head accelerations causing cadaveric skull fracture could be used to infer the onset of concussion. Their work led to the development of a concussion tolerance curve in . It is now known as the Wayne State tolerance curve (WSTC) (see Fig. ..). It basically states that the brain can tolerate a larger magnitude of translational acceleration if the acceleration duration is shorter, and that there is an acceleration limit for the occurrence of concussive
injury due to frontal impact over a range of impact durations. The complete WSTC was constructed by combining data from cadaveric skull fracture tests, animal intracranial pressure studies and the voluntary sled ride of Col. John Paul Stapp. In the cadaveric tests, linear fractures of the frontal bone were associated with an effective acceleration of G, with peaks of up to G and with an intracranial pressure build-up of kPa. The average impact duration was . s. Other data in the range of .–. s were obtained by dropping a group of intact cadavers and decapitated heads onto a rigid slab. These skull fracture data anchor the short-duration end of the curve, up to . s. For longer durations of up to . s, concussion data from animal experiments along with head acceleration and pressure data obtained from cadaver head impacts 300 ACCELERATION-GUNITS
Classical reference
WAYNE STATE UNIVERSITY TOLERANCE CURVE
250 200 150 100 50
5
10
15 20 25 TIME-MILLISEC.
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Fig. .. Wayne State University Tolerance Curve.
40
Head with automobile dash panels were used to plot that part of the WSTC. The asymptotic tolerance level for durations of . s and longer was based on the sled ride of Col. Stapp. He experienced an estimated peak deceleration of G and sustained a detached retina in one eye. This level was later raised to G because the injury was not related to the brain. There was a lot of scatter in the data but a tolerance curve in the form of a hyperbola was drawn through the data points. The WSTC is a plot of effective head acceleration vs. impact duration and is an assessment of injury potential of the head due to impact. Later, the WSTC was used by Gadd [] to arrive at a weighted impulse criterion, known as the Gadd Severity Index. It was further modified by Versace [] who proposed the Head Injury Criterion (HIC). This acceleration–time function, derived from the WSTC, is currently used by the US Government as a safety standard for automobile crashes. This standard has now been adopted in many other parts of the world as well. In real-world collisions, however, head injury occurs when there is combination of translational and rotational acceleration, both of which do not need to be extremely high. It is recommended that any new criterion should reflect the contribution of both forms of acceleration.
Introduction Injury to the head is a major cause of serious disability and fatality and tends to have a greater long-term effect than injuries to the extremities. Acute head injury is also commonly referred to as traumatic brain injury (TBI). The most common causes of TBI are automotive and contact sports-related accidents. Head and facial injuries in contact sports have been around since the first pugilists and wrestlers began competing thousands of years ago. The specter of serious head injury in athletes leading to death, permanent brain damage or quadriplegia, although infrequent, has been consistently associated with American football, ice hockey, boxing, water sports, motorcycling and gymnastics. The most common head injury in sports is minor traumatic brain injury (MTBI) or concussion. According to the National Health Interview Survey (NHIS), there are more than MTBIs attributed to sports or recreational activities each year in
the US []. American football alone is responsible for more than concussions. Estimates regarding the likelihood of an athlete in a contact sport experiencing a concussion vary, but may be as high as %. Furthermore, the effects of concussions are now known to be cumulative, even when the concussive blows are relatively minor. Recent data suggests that college football players who have experienced two or more prior concussions perform more poorly on tests of cognitive functioning (speed and problem solving) relative to those who have experienced one or zero previous concussions. In boxing, the MTBI rate for amateurs has been set at % while for professionals this figure rises to .%. While many concussions are minor, some can be quite serious with long-term brain dysfunction. One serious issue in sports is the frequency and cumulative neurologic damage of repeated concussions. It is also recognized that a second concussion occurring while an individual is still symptomatic from an earlier concussion can be catastrophic or fatal. This phenomenon, termed second impact syndrome, is now being reported more frequently in sports medicine with a mortality rate as high as % in the most severe cases []. Public awareness of the severity of repeated concussion has only started to increase because careerthreatening concussions have affected some wellknown players. Although head injury has been a serious problem since the dawn of mankind, little is known about the basic mechanism of head injury. The discipline of biomechanics studies the effects of forces and motion on the body, and the strength of biologic tissues. Head injury biomechanics research started in at Wayne State University when Professor H. R. Lissner, a professor in engineering, and Dr E. S. Gurdjian, a neurosurgeon, started working on a joint project to study the mechanism of skull fracture. Their work, outlining the first human cerebral concussion tolerance curve, was published by Lissner et al. []. This tolerance curve, as replotted by Gadd [] and further modified by Versace [], is used to determine the safety characteristics of automobiles, sports helmets, etc., to this day.
Biomechanics of head injury A number of studies have been performed to provide and improve our understanding of brain injury. They
Chapter . point to brain deformation or strain as a principal cause of injury. Unfortunately, direct measurements of tissue deformation are almost impossible during an in vivo impact. Therefore, input variables, such as head acceleration, are used as alternate parameters to characterize the injury mechanism. Currently, impacts with head contact (translational acceleration) and inertial loading without head contact (rotational acceleration) have been postulated as the two major mechanisms that cause head injury. Rotational acceleration can produce both focal and diffuse brain injuries, while translational acceleration is considered to produce mainly focal brain injuries. These two major theories of brain injury are discussed below. Note that in realworld injury events, the head sustains a combination of both translational and rotational accelerations because the resultant force does not pass through the center of gravity and the force system is not a couple. At the beginning of a head impact, translation is frequently predominant. Eventually, rotational acceleration takes over as the effect of neck restraint comes into play. In addition to these two mechanisms, hypotheses for the mechanism of concussion are also presented under a separate heading.
Translational acceleration theory The translational acceleration theory hypothesized that intracranial damage is mainly caused by injurious pressure gradients developed in the brain due to brain motion and skull deformation [,]. Studies included the use of embalmed cadavers and anesthetized animals. Focal injuries such as cerebral contusions and intracerebral hematomas are considered to be the consequence of translation of the head in the horizontal plane []. Concussion can be produced in experimental monkeys solely by translational acceleration from a direct impact while no correlation exists between the occurrence of concussion and rotational acceleration [].
Rotational acceleration theory The rotational head injury concept was formulated by Holburn [] using a photoelastic model of the head. This theory hypothesized that shear deformation generated by rotational acceleration could produce shear strain throughout the brain, resulting in diffuse injury, cerebral concussion and rupture of the bridging veins.
Later experimental studies using live subhuman primates and physical models [,] suggest that rotational acceleration is the most injurious in the production of concussive injuries, diffuse axonal injuries and subdural hematomas. They claimed that virtually every known type of head injury could be produced by angular acceleration. However, the level of angular acceleration used was inordinately high.
Concussion mechanisms Concussion, a common result of a blow to the head, has been studied the most of all types of head injury. Various injury mechanisms were proposed by researchers to explain their experimental results. Several injury mechanisms hypothesized for cerebral concussions are: (i) shear strains generated by rotation []; (ii) relative displacement between the brain and the skull producing coup/contrecoup cavitation []; (iii) shear deformation or mass movement in the brainstem principally caused by pressure gradients due to impact loading and translational acceleration [,]; and (iv) disturbance of consciousness caused by strains affecting the brain in a centripetal sequence of disruptive effect on function and structure. The effects of this sequence always begin at the surface of the brain in the mild cases and extend inwards to affect the core at the most severe levels of trauma []. Considerable controversy exists within the biomechanics community regarding the validity of competing hypotheses because they do not always correlate with clinical and pathologic observations. Although both translational and rotational acceleration can individually cause brain injuries in test animals, the severity of impact needed to produce these injuries is much higher than that experienced by humans involved in vehicular crashes or sports collisions. As a matter of fact, there is rarely an impact that is purely rotational or translational in the real world. Because there is no direct way of verifying these hypotheses on living humans, experiments using laboratory animals and computer models will be needed in order to advance knowledge on head injury mechanisms.
Types of acute head and maxillofacial injuries The extent of sports-related head injury can range from minor concussion to fatal injury. Generally, acute
Head head injuries are classified as open head injury or closed head injury. Open head injuries are caused by objects impacting the head leading to damage to the skull, such as scalp injury and skull fracture, dural tear and sometimes laceration of the brain. Closed head injuries, which may take place without skull fracture, are classified as focal and diffuse. The face is particularly vulnerable because major sense organs are housed inside the fragile facial bones. Maxillofacial injuries can occur in all kinds of sports, particularly in contact sports. All of these injuries can occur separately or in combination.
Scalp injuries The scalp is – mm thick and consists of five layers of tissue, namely, the skin, the connective tissue layer, the aponeurosis epicranialis, the loose connective tissue and finally, the periosteum of the skull. The scalp is susceptible to all types of injury, particularly lacerations, as it is readily crushed and split against the underlying bone. Such lacerations are often linear due to the convexity of the underlying skull. Upon impact, the scalp often swells markedly due to edema or hematoma above or below the galeal layer.
Maxillofacial injuries Maxillofacial injuries refer to damage to the soft tissues and bones of the face. There are bones in the face. Complex midfacial fractures are routinely observed in sports injury. Usually, fractures with upper facial involvement are at greater risk for serious craniocerebral injuries while midface and mandibular traumas are associated with mild closed head injuries. Le Fort classified maxillary fractures into three types. Most maxillary fractures are severely commuted and consist of a combination of Le Fort fractures. A Le Fort I fracture is horizontal and segmented across the maxilla. The teeth are often contained in the detached bony portion, thereby shearing off the hard plate and upper dental alveolus. This fracture responds well to intramaxillary fixation. Le Fort II is also a fracture of the maxilla. The body of the maxilla is separated from the facial skeleton, across and through the infraorbital foramen, and across the dorsum of the nose. The fractured portion is a pyramid-shaped section of the facial bone. Surgical fixation is required. Le
Fort III is a fracture causing craniofacial dissociation. The entire maxilla and one or more bones are completely separated from the cranium through the front zygomatic region, the orbital floor, and across the nasal pyramid. Sufficient force to produce a Le Fort III fracture usually results in Le Fort II and I fracture as well (‘total facial smash’).
Skull fractures The head is composed of eight cranial bones, each of which is made up of an outer and an inner table of compact bone and a diploë layer of spongy bone. When the head is directly impacted by an object, skull fracture occurs if the force and deformation is over the tolerance level of the skull. Fracture of the skull may be linear, depressed or comminuted depending upon the geometry and stiffness of the object the head collides with. Skull fracture may result in no signs or symptoms of neural injury. Conversely, severe neural injury may occur in the absence of skull fracture. Linear skull fractures occur when a blunt object impacts the head. The fracture initiates from the point of impact to the nearest weaker portion of the skull, such as a suture line. Linear fractures comprise approximately % of fractures of the skull, with a low fatality rate. Clinically, linear fractures are not indicative of the extent of brain injury. A depressed skull fracture occurs when cranial bones are depressed or driven inward into the vault of the skull. It happens when the head collides with sufficient force against a blunt surface of small area and with a sharp radius of curvature, such as a cylindrical or hemispheric rigid surface. The concentrated stress could produce circumferential cracks about the impact site resulting in local failure of the bone. Another type of skull fracture is the basal (basilar) skull fracture, defined as fractures involving the floor of the anterior, middle or posterior cranial fossae. They can be fatal, causing direct brainstem damage or placing the central nervous system in contact with the contaminated paranasal sinuses, predisposing patients to meningitis.
Focal brain injuries Focal brain injuries usually involve some noticeable localized damage to cranial tissues and blood vessels. These include epidural hematoma, subdural
Chapter . hematoma, intracerebral hematoma and cerebral contusion. A hematoma is a blood clot within the brain or on its surface. Epidural hematoma is an infrequently occurring sequel to head trauma (.–%). It occurs as a result of tears of the middle meningeal artery and is not due to a brain injury. Due to pressure cased by the hematoma on the brain, this is an extreme medical emergency. Be aware that there may be an interval of several hours between the blow to the head and emergence of symptoms followed by signs of increased brain pressure. Subdural hematomas are the most common acute pathologic brain injury in boxing and are the leading cause of boxing and American football fatalities. Acute subdural hematoma is mainly caused by direct lacerations of cortical arteries and veins, large contusion bleeding into the subdural space, or tearing of veins bridging the brain surface to various dural sinuses. Subdural hematoma is often associated with relative motion between the skull and the brain causing stretch (strain) of vessels. Intracranial hematomas occur primarily in the parasagittal regions of the cortex and subcortical white matter as well as in the deep white matter. Some cases of hematoma extend to the corpus callosum and cerebellar peduncles []. A severe headache usually presents if the patient remains conscious. A contusion may be thought of as an area of bruised brain. Contusions may accompany concussion but need not do so. Contusions generally occur at the site of impact (coup contusions), as a result of increased pressure due to either local deformation of the bone or caused by skull fracture, and at the opposite site from the impact due to pressure wave propagation (contrecoup contusions). It is well established in both the clinical and neuropathologic literature that contusions occur predominantly at the frontal and temporal poles. It has been hypothesized that the responsible agents are the rough and irregular anterior fossae and the knife-like edge of the sphenoid ridge. Contusions are most often multiple and are frequently associated with cerebral hemorrhage, subdural hematoma and epidural hematoma.
Diffuse brain injuries Diffuse brain injuries are fundamentally different and associated with widespread tissue damage. They in-
volve damage to the neuronal, axonal, neurovascular and dendritic structures. This damage may only involve physiologic disruption of brain function as in the case of concussion, or cause sufficiently severe damage to the cerebral hemispheres or the brainstem to induce prolonged coma. This form of injury is called diffuse axonal injury (DAI). Diffuse axonal injury (DAI) is characterized by widespread, microscopic damage to axons, macroscopic hemorrhages and overt tissue tears. It involves anatomic disruption of the white matter of brain tissue, generally associated with immediate loss of consciousness. It is caused by a sudden stretching or shearing of axons at the moment of impact []. Diffuse damage to axons exemplified by the presence of hemorrhagic foci is commonly found in the cerebral hemispheric subcortical lobar white matter, the cerebrum semiovale, the corpus callosum, the basal ganglia, the dorsolateral part of the rostral brainstem and the cerebrum. The outcome depends largely upon the severity of the impact sustained by the brain. Microscopic evidence of axonal damage takes the form of axonal balloonings in short survival cases (from – h to several days) [], long tract degeneration in long survivals (several weeks to months), or diffuse gliosis of white matter in survivals of several years. A milder form of DAI in the chronic phase may cause neuropsychiatric problems, including cognitive deficits. Concussion is the most common head injury in sports. Historically, concussion was described as traumatic paralysis of nervous function with a tendency to recover without deficit and revealing no anatomic abnormality. There are many definitions of concussion in the literature. Most recently, the American Orthopaedic Society for Sports Medicine Concussion Workshop Group has defined cerebral concussions as any alteration in cerebral function caused by a direct or indirect force transmitted to the head resulting in one or more of the following acute signs or symptoms: a brief loss of consciousness, light-headedness, vertigo, cognitive and memory dysfunction, blurred vision, difficulty concentrating, amnesia, headache, nausea, vomiting, photophobia or a balance disturbance. In , Gerberich et al. surveyed the head coaches and players of secondary school football teams in Minnesota. The incidence of cerebral concussion in foot-
Head ball was per participants, and % of all football injuries were listed as concussions. In Powell and Barber-Foss in their study on high school contact sports found a much reduced incidence of concussions — the figure was reduced from per year to approximately per . million high school football players.
Management guidelines Many grading systems have been developed in sports medicine to assess the severity of brain injury. None of the current guidelines for concussion and return to play has been developed on the basis of specific scientific knowledge regarding the process of recovery from concussion. All of the guidelines with the exception of one assume that traumatic loss of consciousness is associated with greater morbidity and poorer outcomes. This assumption seems to be based on the concept that injuries that result in traumatic loss of consciousness require a greater deal of mechanical force than do blows to the head that do not result in loss of consciousness. Lovell et al. [] recently evaluated the importance of loss of consciousness for patients with mild head injuries who were admitted to a major trauma service. The a priori assumption was that the patients who had experienced a loss of consciousness would perform worse on neuropsychologic tests known to be sensitive to MTBI. In a comparison of concussed patients who did and did not experience loss of consciousness, however, those authors found no support for weighting the loss of consciousness more
heavily than other factors such as amnesia or confusion, in making decisions regarding the return to previous activities. Recently, one of the classifications of such brain injury, Standardized Assessment of Concussion (SAC), has been developed by the Quality Standards Subcommittee of the American Academy of Neurology (Table ..). It is used on the sideline to assess the orientation, memory and concentration as a mental status examination of athletes who are suspected of having suffered concussion []. The SAC is used by the American football league and the National Hockey League (NHL) to manage concussion on the field. In , Schneider [] described two young athletes who experienced initial concussive syndromes and subsequently died after relatively minor second impacts. Since then deaths from second impact syndrome (SIS) have been documented in the US. Furthermore, successive concussive impacts may also lead to milder but still significant impairment of cognitive processes (attention, memory), personality, language functioning and somatic concerns (sensitivity to light, dizziness), commonly referred to as ‘postconcussion syndrome’. Based on the perception that MTBI still has a high incidence and may cause late problems, renewed interest in neuropsychologic testing of athletes has occurred. While neuropsychologic tests were used in the early seventies [], it was first in that Barth et al. [] published their results on more than college athletes participating in football. The study
Table .. American Academy of Neurology Guidelines for Concussion Grading and Management. Grade
Grade 1 concussion
Grade 2 concussion
Grade 3 concussion
Definition
Transient confusion, no loss of consciousness. Concussion symptoms or mental status abnormalities resolve in less than 15 min
Transient confusion, no loss of consciousness. Concussion symptoms or mental status abnormalities last more than 15 min
Any loss of consciousness, either brief (seconds) or prolonged (minutes)
Management recommendations
May return to play the same day if normal sideline assessments at rest and with exertion
Defer contact until 1 full week without symptoms at rest and with exertion
If brief (seconds), defer contact for 1 week without symptoms; if prolonged (minutes), defer for 2 weeks without symptoms (minimum)
Chapter . showed that effects of mild head injuries can be assessed by neuropsychologic tests and that the majority of players typically returned to their baseline score within days after injury. In soccer, Mastser et al. [] recently suggested that participation in amateur soccer might be associated with chronic MTBI based on impaired scores in memory and planning tests compared to a control group. Lovell et al. [] and Maroon et al. [] based on their own preliminary work developed specific protocols for testing US professional athletes. These tests are currently being used in all teams in the National Hockey League and most teams in the National Football League. The test is based on a baseline neuropsychologic computer-guided assessment. The group based in the University of Pittsburgh Medical Center for Sports Medicine has emphasized the importance of baseline data. Individual players vary tremendously with respect to their levels of performance on tests on memory, attention/concentration, mental processing speed and motor speed. Without prior knowledge it is difficult to know whether any defects detected during testing may be attributed to the effects of the concussion or to previous unrelated factors. In addition to the evaluation of cognitive defects, the Pittsburgh group stresses the importance of evaluating players’ reports of postconcussive symptoms. They divide these symptoms into three general categories: (i) somatic symptoms such as headaches, dizziness, balance problems or nausea; (ii) neuropsychiatric symptoms such as anxiety, depression or irritability; and (iii) cognitive complaints, such as impairment of attention, memory or processing speed.
Future directions Current research is working in part on head injury modelling to predict impact and impact tolerance in head injuries, and in part on developing neuropsychologic tests that will be able to measure the injury to the patient and prevent the second impact problem. The Pittsburgh group has developed the Immediate Measurement of Performance and Cognitive Testing (IMPACT). This test battery has been designed to evaluate multiple aspects of neuropsychologic functioning among athletes, including attention span, sustained and selective attention, reaction time and several dimensions of memory. The test battery can be administered using a microcomputer and may involve the kind
of tests where the sports physician will be able to differentiate between a player with mild head trauma with no symptoms who can return to sport early vs. a player with a mild head trauma who may on the basis of the test results have to sit out until the test results are normal. It remains to be seen whether this will reduce the number of players with postconcussion problems.
Summary The most common head injury in sports is concussion, which is a diffuse brain injury. The effects of repeated concussions are cumulative, and secondary minor impacts to the head shortly after a concussion can be fatal (secondary impact syndrome). Focal brain injuries include epidural, subdural and intracerebral hematomas and cerebral contusion. Mechanisms of brain trauma are theoretically divided into acceleration and rotational forces, but most injuries are probably created by a combination. An established human cerebral concussion tolerance curve is described. As neuropsychologic performance varies individually it has recently been suggested that all athletes register a baseline neuropsychologic assessment to enable comparison after a concussion. The time till recovery after concussion is unknown. Maxillofacial injuries are classified according to Le Fort and surgical intervention is often necessary.
Multiple choice questions When an impact force acts on a rigid sphere, the sphere has only translational acceleration, if the force passes through the center of the sphere. What motion will the sphere undergo if the line of action of this force impacts it at some distance away from the center of the sphere? a Rotational acceleration only. b Higher translational acceleration plus rotational acceleration. c Same translational acceleration plus rotational acceleration. d Lower translational acceleration plus rotational acceleration. e Translational acceleration only. How does a helmet protect the brain during impact? a By absorbing the impact energy. b By distributing the impact loading over a large surface area. c By prolonging the loading time on the head.
Head d By reducing the acceleration transferred to the head. e All of the above. Which of the following statements is correct? a A collision between two bodies of different size and mass results in an equal and opposite time varying force, which acts on each body during the period of contact. b Given two moving objects with the same energy (E = / mv2), proportionately more of the energy of the smaller, faster-moving object will be spent in producing local deformation at the impact site, than that of the heavier, slower-moving body which will tend to cause more head acceleration. c By increasing the area of impact, an increased amount of energy can be absorbed. d Skull fractures are the result of tensile strains that exceed the strength of the compact bone of the skull. e All of the above. Cranial and facial injuries resulting from a collision depend on the following: a force and direction of the collision b area of load distribution c impact interface geometry d stiffness and energy absorption characteristics of the head and opposing object e all of the above. When a water-filled oval-shaped rigid shell is subjected to a force which passes through the center of the shell as shown in the Fig. .. a pressure gradient is developed across the water. Which pressure distribution is correct? a The pressure is highest (positive) at A and lowest (negative) at B. b The pressure is highest at A and lowest at C c The pressure is highest at B and lowest at A. d The pressure is highest at B and lowest at C. e The pressure is highest at C and lowest at A.
Force
A
B
C
Fig. .. A water-filled oval-shaped rigid shell is impacted by the force acting at location A.
Case story 6.4.1 A -year-old-male fell during alpine skiing and hit his head on a tree. He was unconscious for – s, woke up but was a bit dizzy. After min he felt well, except for a minor headache, and he returned home. If the period following this is uneventful, how should he be treated? When can he return to skiing? If he was a boxer, when could he return to boxing? Because he also injured his arm, he went to the emergency room. When he arrived — h after the injury — he was alert. On examination a possible forearm fracture was discovered and he was admitted for X-ray investigation. While waiting he suddenly became drowsy. There were no other neurologic findings. What would you do as the emergency room doctor? What has most likely happened?
References Gadd C. Use of a weighted impulse criterion for estimating injury hazard. Proc th Stapp Car Crash Conf ; SAE paper no. . Versace J. A review of the severity index. Proc th Stapp Car Crash Conf ; SAE Paper no. . Thurman D, Branche C, Sniezek J. The epidemiology of sports-related traumatic brain injuries in the United States: recent developments. J Head Trauma Rehabil ; (): –. Saunders R, Harbaugh R. The second impact in catastrophic contact-sports head trauma. J Am Med Assoc ; : –. Lissner H, Lebow M, Evans F. Experimental studies on the relation between acceleration and intracranial changes in man. Surg Gynecol Obstetr ; : –. Gurdjian ES, Lissner HR, Patrick LM. Concussion — mechanism and pathology. Proc th Stapp Car Crash Conf ; : –. Gurdjian E, Lissner H. Photoelastic confirmation of the presence of shear strains at the conjunction in closed head injury. J Neurosurg ; : –. Gennarelli T, Ommaya A, Thibault L. Comparison of translational and rotational head motions in experimental
Chapter .
cerebral concussion. Proc th Stapp Car Crash Conf ; SAE P-: –. Ono K, Kikuchi A, Nakamura M, Kobayashi H, Nakamura H. Human head tolerance to sagittal impact: reliable estimation deduced from experimental head injury using subhuman primates and human cadaver skulls. Proc th Stapp Car Crash Conf ; SAE Paper no. . Holburn A. Mechanics of head injuries. Lancet ; : –. Gennarelli T, Thibault L, Adams J, Graham D, Thompson C, Marcincin R. Diffuse axonal injury and traumatic coma in the primate. Ann Neurol ; : –. Thibault L, Gennarelli T. Biomechanics of diffuse brain injuries. Proc th Stapp Car Crash Conf ; SAE Paper no. . Gross AG. Impact thresholds of brain concussion. J Aviation Med ; : –. Ommaya A, Gennarelli A. Cerebral concussion and traumatic unconsciousness: Correlation of experimental and clinical observations on blunt head injuries. Brain ; : –. Lampert P, Hardman J. Morphological changes in brains of boxers. J Am Med Assoc ; : –. Strich S. Shearing of nerve fibres as a cause of brain damage due to head injury. Lancet : –. Povlishock J, Becker D, Cheng C, Vaughan G. Axonal
change in minor head injury. J Neuropathol Exp Neurol ; (): –. Lovell MR, Iverson GL, Collins W, McKeag D, Maroon C. Does loss of consciousness predict neuropsychological decrements after concussion? Clin J Sports Med ; : –. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: The management of concussion in sports. Neurology ; : –. Schneider R. Mechanisms of injury. In: Schneider R, ed. Head and Neck Injuries in Football: Mechanisms, Treatment and Prevention. Baltimore: Williams & Wilkins, : –. Yarnell PR, Lynch S. Retrograde memory immediately after concussion. Lancet ; : –. Barth JT, Alves WA, Ryan TV, Macciocchi SN, Rimel RW, Jane JA, Nelson WE. Mild head injuries in sports: neuropsychological sequel and recovery of function. In: Levin HS, Eisenberg HM, Benton AL, eds. Mild Head Injury. New York: Oxford University Press, : –. Mastser EJ, Kessels AG, Lezak MO, Jordan BD, Troost J. Neurophysiological impairment in amateur soccer players. JAMA ; (): –. Maroon JC, Lovell MR, Norwig J, Podell K, Powell JW, Hartl R. Cerebral concussion in athletes. Eval Neuropsychol Test Neurosurg ; : –.
Chapter 6.5 Spine JENS IVAR BROX
Classical reference Indahl AA, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. Spine ; : –. It has been suggested that the more seriously low back pain has been treated, the worse it has become. In this study Indahl et al. reported that low back pain treated as a benign, self-limiting condition with recommended light mobilization gives superior results with regard to return to work compared to conventional medical treatment. At days % were still on sickness leave in the control group compared with % in the intervention group. The study included patients on sickness leave from work for at least weeks. Patients were randomized into either a control or an intervention group. The control group was not called in for examination, but was treated within the conventional medical system which includes rest, medication, restricted activity, physiotherapy or chiropractic treatment. The intervention group was given a standardized examination, physical tests, plain radiographs and computed tomography scans. In addition they were told that involvement of the disk could cause a reflex activation in the paraspinal muscles. Then they were given assurance that light activity would not further injure the disk or any other structure that could be involved. It was emphasized that the worst thing they could do to their backs was to be too careful. The therapist set no fixed exercise goals, but rather the patients were given the guidelines and encouraged to set their own goals. Information was reinforced after months. The new intervention is very different from conven-
tional treatment. The results oppose some of the myths concerning low back pain. This study has inspired a future paradigm shift in the treatment of low back pain (Fig. ..).
Anatomy and biomechanics The spine or vertebral column consists of vertebrae: seven cervical, thoracic connected with the ribs, five lumbar, five sacral fused together, and three or four rudimentary vertebrae forming the coccyx. A typical vertebra consists of a body with paired pedicles upon its posterior surface to support the laminae, paired transverse processes for attachment of muscles (and, in the thoracic region for attachment of the ribs), and a spinous process, also for the attachment of muscles. The laminae and the pedicles together form an arch; between the arch and body is the vertebral foramen (Fig. ..). Successive vertebral foramina form the vertebral canal. The intervertebral foramen is formed by a notch in the upper surface of the pedicle. The lateral recess is the entrance portion of the intervertebral foramen. Articular processes or zygapophyses make up the facet joints (Fig. ..). Synovial joints formed by the articular processes, cartilaginous connections between the bodies and fibrous bands between other parts of the arches, connect most of the vertebrae. Two vertebrae and their connections are termed a motion segment. Normally, the two lower segments have to absorb the heaviest load. Correspondingly, degenerative changes commonly occur in these segments. Only a weak association is found between degenerative disks and back pain. The concepts hyperand hypomobility, albeit not documented by radiologic
Chapter .
Fig. .. Neuromuscular network connecting the central nervous system to peripheral structures (shown in boxes): intervertebral disk, ligament, zygapophysal joint, skin and spinal muscles. In low back pain where no specific pathoanatomic findings can be demonstrated, the cause of pain may be mainly a functional disturbance. Overload of specific parts can be detected by high-threshold nerve endings, and in due course, inhibit muscle actions responsible for the increased loading, and thereby prevent injury. This may be the reason why heavy physical loading does not seem to have the impact on degeneration of the spine that was earlier assumed. The common clinical findings of decreased range of motion in low back pain patients point to increased muscle activity, which therefore points to an alteration in the recruitment system. For example an irritation of the nerve endings surrounding the annulus fibrosus may cause increased activation of the paraspinal muscles in a bracing pattern and subject the muscles to static work, which is thought to be responsible for muscle pain. Original drawing by Ane Reppe. Reprinted with permission from Aage Indahl. Low back pain—a functional disturbance. Thesis. University of Oslo, Norway, .
methods, are often used to describe abnormal loaddisplacement behavior of motion segments. The vertebral column serves two main purposes: supporting the trunk and protecting the spinal cord. In addition to this, the back must be prepared to stabilize the upper body in movements of the head and the limbs. The stability of the spine depends on a number of factors. When weight is properly balanced and the spine is close to the center of gravity, minimal muscular activity is needed for stabilization. Only human beings habitually use the vertebral column in an upright position. The two lordotic curves (cervical and lumbar) characterize the regions with the greatest mobility and enhance the ability of the vertebral column in weight-bearing (Fig. ..). The two kyphotic curves (thoracic and sacral) are present at birth and are dictated largely by the shape of the constituent vertebrae. Spinal motion is usually described in three planes: the frontal plane, the sagittal plane and the coronal plane. In the thoracic spine the normal frontal
(kyphotic) curve is –°. Abnormal kyphosis is observed in congenital disorders, fractures, Scheuermann’s disease and ankylosing spondylitis. Thoracic motion in the sagittal and coronal planes is limited by the facet joint orientation and the ribs. Normally approximately ° flexion/extension, lateral flexion and axial rotation takes place at each vertebral segment. Lordosis is the normal sagittal plane alignment of the lumbar spine. The normal lumbosacral angle is –°. Excessive lordosis may stress the posterior elements and the anterior longitudinal ligament considerably. Normally, the lumbar spine range of motion from maximal flexion to maximal extension is approximately °. In athletes the length of the hamstring muscle/tendon complex may limit the range of motion. Extension is limited by the orientation of the facet joints. Movements that force the spine to exceed this limitation, for example in gymnastics, will stress the vertebrae, disks and ligaments in this region considerably.
Spine
ra
vb
zj p
vf
tp (a)
sap la sp
(a) sap
ra
zj
tp vb
(b)
iap (b)
Fig. .. Lumbar vertebra. Top (a) and side (b) view of a lumbar vertebra. vb, vertebral body; ra, ring apophysis; p, pedicle; la, lamina; sp, spinous process; tp, transverse process; sap, superior articular process; iap, inferior articular process; vf, vertebral foramen.
Fig. .. Two vertebrae and their connections are termed a motion segment. Regional differences in the orientation of the zygoapophyseal joints as seen in lateral views.
Scoliosis is the lateral curvature of the spine (Fig. ..). Scoliosis may be structural or non-structural. In structural scoliosis the deformity cannot be corrected by alteration of posture. In idiopathic scoliosis, several vertebrae at one or two levels (primary curve) demonstrate a rotational deformity (the spinous processes rotate into the concavity and the bodies which carry the ribs rotate into the convexity). Above and below the relatively fixed primary curve, more mobile secondary curves develop to maintain the normal position of the head and pelvis. Thoracic curves do not appear to be associated with pain, but limited curves may interfere with shoulder function in athletes. Superficial and deep layers of muscles work in a complex synergy with the support offered by the lumbosacral fascia and spinal ligaments. Their activity is
often peculiar to an individual — and thus postural advice should be given with this point in mind. The deep muscles (multifidi) run from one segment to another (Fig. ..). They act as a functional unit together with the deep abdominal muscles, the diaphragm and the pelvic muscles. Their main function is segmental stabilization of the spine in movements of the arms and legs. Back muscles become inactive in a maximal forward bending position (Fig. ..). The muscle relaxation phenomenon describes how the electromyographic activity of the erectores spinae is decreased just when the load has been lifted off the ground contrary to the increased activity in the midrange of forward flexion. This phenomenon presented a challenge to schools that promote the role of the lumbar muscles in lifting. Recent models propose that the force necessary to perform a lift is generated by
Chapter . (a)
(b)
1 Cervical 7 1
C7 spine (vertebra prominens)
External occipital protuberance
Thoracic
Inferior angle of scapula (Th 7) 12 1 Lateral border erector spinae
Lumbar
Iliac crest (L4) 5 Sacral
Posterior superior iliac spine underlying sacral dimple Gluteal fold
Fig. .. (a) The vertebral column and its curves (cervical and lumbar lordosis and thoracic kyphosis) viewed from the lateral side with the vertebrae numbered. (b) Anatomical landmarks.
the hip extensors and then transmitted from the ileum to the upper extremities through the lumbosacral fascia portion of the posterior ligamentous system []. Prolonged isometric muscle activity in the midrange forward bending position is often painful. Also pain can inhibit flexion relaxation. The absence of this phenomenon discriminates patients with low back pain from controls []. In addition, muscular activity is influenced by emotional distress — therefore back muscles have been called our largest ‘mimic muscles’. Neural structures at the L– level are schematically described in Fig. ... For each lumbar vertebra there is an associated lumbar spinal nerve. The spinal nerves divides into a dorsal and ventral ramus which innervate various passive and active structures. Free nerve endings and mechanoreceptors are located in these structures and are potential pain sensors and proprioceptive transducers for monitoring the position
and movements in the motion segment. The neurologic feedback from passive structures provides sensory information needed to regulate muscle tension, and hence the stability of the spine. Normal locomotion requires multiple levels of neural control. An example of a functional disturbance of this control is the lack of flexion relaxation in chronic low back pain patients described above. The intervertebral disks make up about % of the total height of the vertebral column. They connect the bodies, allow motion, and absorb and distribute the load acting on the vertebral column. They receive nutrition by diffusion from the vertebral endplates and surrounding soft tissue. Only the outer part, termed the annulus fibrosus, is innervated. The annulus fibrosus consists of collagen lamellae organized in different directions. It provides strength to the disk in bending and twisting. The inner part, termed the nucleus pulposus, consists of % water into the third decade of
Spine
Fig. .. Scoliosis resulting from tilting of the pelvis through shortening of the left leg. Note the convexity of the lumbar curve pointing at the shortening leg. Compensatory thoracic and cervical curves and an apparent difference in shoulder height are shown.
life. Compressive load on a healthy disk is mainly borne by the nucleus pulposus. The hydration depends on the amount of proteoglycan present and over the next four decades the water content gradually diminishes to –%. Sufficient dehydration can occur during a day’s activity to result in a loss of height of cm in an adult man. Dehydration is visualized as black disks on magnetic resonance imaging (MRI). This is often recognized as an early sign of degeneration and is observed in asymptomatic and symptomatic individuals. The intradiscal pressure may be increased about tenfold from the supine position if kg is lifted without compensatory use of the quadriceps muscles. On the other hand, the intradiscal pressure may be higher while sitting compared to jumping. The load is reduced by increasing the intra-abdominal pressure. Stimulation of the intervertebral disk activates the deep back muscles. This may elict a functional disturbance, for example the protective scoliosis observed in patients with acute low back pain.
Acute injuries of the spine Epidemiology Traffic accidents are the single most common cause of spinal cord injury, followed by sports activities. The -year prevalence of spinal cord injury in sports in
Fig. .. Schematic showing the polysegmental attachments of the multifidus fascicles originating from L vertebrae. Their function is that of fine adjustment of loads of polysegmental spinal structures. Original drawing by Ane Reppe. Reprinted with permission from Aage Indahl. Low back pain—a functional disturbance. Thesis. University of Oslo, Norway, .
Chapter . (a)
1
2
3
4
0.2 mV 500 ms
0.2 mV 0.1 0 1
2
3
4
5
6s
(b)
1
2
3
0.2 mV 500 ms
0.2 mV
4
0.1 0 1
2
3
4
5
6s
Fig. .. Flexion/relaxation phenomenon. Reprinted with permission from [].
North America is about per million. About % of all sports-related spinal cord injuries result in complete quadriplegia. This is one of the most serious sequelae after injury in sports with major consequences for the injured athlete and society. More than % of all vertebral fractures and about % of all fractures/ luxations of the cervical spine result from diving accidents. Major spinal injuries are also reported in riding, motor vehicle sports (including snowscooter driving),
parachute jumping, hang gliding, paragliding, climbing, ice hockey, biking, snowboarding, downhill skiing and ski-jumping. In a recent study from Canada, the prevalence of vertebral fractures was . and . per skiing days for downhill skiing and snowboarding, respectively []. Most snowboard injuries resulted from jumps, while most skiing injuries were related to falls. About % are burst fractures, most commonly located to Th and L. Nine per cent of the injured snowboarders and % of the skiers had a neurologic injury, about half of them a spinal cord injury. American football and ice hockey have become increasingly more popular. The incidence of non-fatal catastrophic injuries was . injuries per in American football and . injuries per injuries in ice hockey. The number of spinal cord injuries in American football peaked at in []. In Canadian ice hockey, the number of spinal cord injuries was about per year through the s []. More than % of these injuries occurred in the –-year-old group. In Finnish ice hockey there were eight spinal cord injuries in the s and s []. Burst fractures and dislocations are the most common fractures of the cervical spine and about half of these fractures result in spinal cord involvement. Biomechanically the greatest forces are applied to the cervical spine, in slight flexion. This injury position is consistent with actual injury situations in ice hockey and football. Most injuries in ice hockey result from head-first contact with the boards after a check from behind. There is today a general acceptance of the importance of injury prevention through education, personal safety routines, more stringent competition rules and improved equipment. Research to improve knowledge about injury frequency and injury-specific mechanisms should be given a high priority within sports organizations and sports medicine.
Diagnostic thinking Direct back trauma most commonly causes muscular contusions associated with acute intense pain and hematoma. Fall injuries may cause a muscular rupture, ligamentous injury, fracture, and occasionally a disk herniation. For a proper differential diagnostic evaluation, it is essential to consider the injury mechanism and the forces involved according to what is required to cause a
Spine
Fig. .. Active and passive structures and sensory innervation at the L– level. Original drawing by Ane Reppe. Reprinted with permission from Aage Indahl. Low back pain—a functional disturbance. Thesis. University of Oslo, Norway, .
particular injury, and to consider its possible progression and consequences. A vertebral fracture may result in a spinal cord injury. There may be no signs of spinal cord injury at the primary examination at the sports arena. The patient should not be moved until a neurologic examination has been completed and a spinal cord injury or an unstable fracture has been ruled out. Dysesthesia and lower extremity numbness should be interpreted as symptoms indicating a spinal cord injury. In a conscious patient, a reflectory spasm or scoliosis of the cervical spine may reflect a protective mechanism and therefore should not be corrected. The unconscious patient should not be moved until the cervical spine has been stabilized. Unexpected
movements may result in permanent neural damage in a patient without symptoms and signs indicating spinal cord injury. Proper knowledge about the consequences of an injury and practical skills for handling the patient with an acute spinal injury are important to prevent neural damage resulting from incorrect transportation of the patient. Guidelines for emergency management of patients with a suspected spinal cord injury are described in Table ... In contact sports, associated injuries of the kidney, spleen and liver should be excluded. These injuries may be acutely life-threatening because of major intraabdominal bleeding and drop in blood pressure. Patients with vertebral fractures should be eva-
Chapter . Table .. Emergency management of patients with a suspected spinal cord injury. Establish free airways and stop bleeding Most experienced person takes command Stabilize head — do not correct position if the patient is conscious Carry out primary examination Call for ambulance Organize turning — the neck should be stabilized in an unconscious patient Check if adequately stabilized — the ambulance should be driven carefully
Table .. Mechanisms of neck injury. Direct compression injury of the head/neck Fall with opponent’s body weight superimposed Fall from height Equipment failure, illegal procedure Attempting maneuvers beyond skill Direct violence Forced excessive range of motion
Classification systems for thoracolumbar fractures are based on history and on particular knowledge about the injury mechanism — and may improve the understanding of the consequences for various injuries. The most common classification systems are by Denis, Gaines and the AO group (Magerl/Aebi) []. Denis introduced the concept of three columns []. According to this system, an unstable fracture requires that at least two columns are injured (Fig. ..). Gaines’ system and indications for surgery are mainly based on the degree of contusion of the vertebrae. Fractures are classified (A, B, C) according to history and radiologically evaluated injury mechanism (Figs ..– ..). A Compressive forces (burst fracture without ligamentous injury, e.g., by a fall on the buttocks or landing on the feet in paragliding or parachute jumping).
ISL LF C AF
luated at an orthopedic or neurosurgical department. When the diagnostic evaluation is completed less serious injuries are treated by the primary health care physician.
History Knowledge about the various sports makes it easier to understand the injury mechanism. It is important to discriminate between injuries that result from a simple fall to the ground or collision on the track, or more complex mechanisms like a simultaneous twisting and collision. Acute back pain in throwing suggests a fracture of the transverse process or vertebral arch or a muscular rupture. Cervical injury mechanisms are outlined in Table ... Forceful extension associated with a sudden force applied to the forehead may result in a rupture of the anterior spinal ligament, avulsion fracture or spondylolysis. The intervertebral disk and posterior structures are vulnerable in compression/rotation injuries.
PLL SSL
ALL
Fig. .. Vertebral fractures. The three column concept. The anterior, middle and posterior column are illustrated. SSL, superior spinous ligament; ISL, intraspinous ligament; LF, ligamentum flavum; PLL, posterior longitudinal ligament; ALL, anterior longitudinal ligament.
Spine
Fig. .. Compressive forces resulting in an endplate impaction. This is a common fracture in juvenile and osteoporotic bone.
Fig. .. Tension forces in flexion. Anterior subluxation with fracture of articular processes and an associated complete burst fracture.
B Tension forces in flexion or extension (discoligamentous injuries or A combined with an injury of the posterior ligament). C Isolated rotational injuries or in combination with B and C. Injuries are then subclassified according to how serious they are (degree of neurologic injury). The highest percentage of neurologic injury is found in rotational injuries. Group A: % neurologic injury. Group B: % neurologic injury. Group C: % neurologic injury.
tion. Fractures, luxations, and discoligamentous injuries with malalignment and instability that may affect the spinal cord during transportation may be present without neurologic signs at clinical examination. Occasionally, numbness and dysesthesia may be the only symptoms that suggest a spinal cord injury. The spinal shock may mask hyperreflexia. Table .. describes neurologic injury by level, function, reflex and sensibility.
Clinical examination If a serious spinal injury is suspected, it is important to evaluate the level of consciousness, circulation and respiration and then perform a neurologic examina-
Imaging If an acute traumatic cervical injury is suspected, flexion and extension views should be omitted until screening lateral views are done. A negative lateral screening does not exclude an unstable neck injury, and bilateral symptoms in association with an acute trauma indicate that further evaluation is necessary. This
Chapter .
(a)
(b)
(c)
Fig. .. Rotational injury with complete burst fracture: (a) vertebral body; (b) posterior elements; (c) lateral view.
Table .. Level of spinal cord or nerve root injury. Level
Function
C3–5 C5 C6 C7 C8 Th1 L1–2 L3–4 L5 S1 S2–4
Respiration (diaphragm) Shoulder abduction (deltoid) Elbow flexion Elbow extension Finger flexion Finger abduction Hip flexion Knee extension Hallux extension Plantar flexion and toe flexion Sphincter function at rectal expl.
includes extension and flexion views conducted by a skilled person in a specialized radiological department. The unconscious patient should be examined to exclude cervical injury. MRI is the best method for evaluation of soft tissue structures including the spinal cord and nerve roots. In discoligamentous injuries this is the only method for detailed description of the injury, while instability is assessed by plain films. Radiologic assessment of burst fractures includes an evaluation of the eventual reduction of the diameter of the spinal foramen and the degree of vertebral body collapse. An isolated burst fracture without major col-
Reflex
Sensibility
Biceps Brachiorad. Triceps
Lateral shoulder Lateral arm Index finger Little/ring finger Medial arm
Patellar Achilles Achilles
Medial thigh Basis hallux Lateral foot
lapse is stable, but an associated rupture of the interspinous ligament indicates instability and requires surgical stabilization.
Spinal cord injury Symptoms and signs. Neck pain, numbness and dysesthesia. Inability to move the hands and feet. The level of injury should be established by neurologic examination (Table ..). Diagnosis. According to clinical symptoms and signs and injury mechanism. It is important to remember
Spine that neurologic symptoms and signs may be absent in a person with an unstable vertebral fracture. Treatment. Transportation to hospital (Table ..). Methylprednisolone mg/kg body weight should be started within h and continued with a dose of . mg/kg for – h to reduce the degree of a permanent paralysis []. Surgical treatment consists of decompression and eventual fusion of at least two contiguous vertebrae. Decompression is always recommended in a patient with a partial spinal cord injury if CT or MRI indicates compression of the spinal cord. This surgical procedure may reduce the extent of pareses even in patients without progressive neurologic signs. In patients with a complete injury of the spinal cord, a decompression may be effective only if it is performed in the acute phase.
Unstable fractures Symptoms and signs. Muscular spasm and crooked neck may reflect a protective mechanism in a patient with an unstable fracture or spinal cord injury. A palpable defect may reflect a rupture of the posterior ligaments. Diagnosis. Radiologic evaluation including plain films and MRI. Treatment. Skull traction or surgical treatment in unstable cervical fractures. Surgical treatment of unstable thoracolumbar fractures.
Stable fractures Vertebral body fractures Symptoms and signs. Depends on the mechanism and localization of the injury. A localized muscular spasm and pain at the fracture site with a dermatomal radiation corresponding to the fracture and on palpation of the spinous process of the affected vertebra is common. Diagnosis. Radiologic evaluation. Exclusion of unstable fracture and tumor. Treatment. Surgical treatment of thoracolumbar frac-
tures is usually recommended if the anterior part of the vertebral body is reduced by more than % of the average height of the vertebral bodies above and below []. The rationale for this strategy is that surgical treatment stabilizes the fractures, makes it possible to mobilize the patient within a short time and prevents further collapse of the vertebral body. However, recent literature debates the indication for surgery and claims the prognosis is good without surgical treatment []. There is a poor correlation between the degree of kyphosis resulting from the fracture and complaints. According to the present view, there is a need for randomized studies to compare the effectiveness of surgical and conservative treatment. It seems important to mobilize the patient as soon as a proper diagnostic evaluation is complete []. Early mobilization will reduce the risk for venous thrombosis and does not seem to increase the degree of kyphosis. It is not documented that specific back muscle exercise is more effective than simple mobilization. Return to competition should not be expected until the fracture is radiologically healed. A corset limits large movements of the upper body, but does not limit segmental motion. Even a hyperextension corset does not affect stabilization or the degree of vertebral body collapse. A corset may be indicated if pain makes it impossible to mobilize the patient. In a few patients, pain becomes chronic and interferes with return to previous sports activities.
Fractures of the spinous and transverse process Isolated fractures of the spinous processes are rare. Specific treatment of an isolated fracture of the spinous process is not indicated. It is important to exclude a simultaneously occurring and more serious injury. An isolated fracture of the transverse process is more common. The fracture is commonly located to the lumbar spine, and is related to the insertion of the iliopsoas and the quadratus lumborum muscles. Symptoms and signs. Intense acute pain that is worsened by hip flexion, lateral bending and rotation. Distinct unilateral pain upon paravertebral and abdominal palpation. Bleeding from the fracture and the muscle may result in a drop in hemoglobin rate. Diagnosis. Plain films will reveal the fracture, but CT is the best method for detailed evaluation.
Chapter . Treatment. The patient should be sent to hospital for a complete evaluation, but the treatment is conservative. A corset may be useful for the first weeks and makes it possible to maintain general physical fitness. The fracture will normally heal within – weeks, but full contact sports are not recommended until weeks.
Prevention A group of neurosurgeons in the USA have claimed to have reduced the incidence of spinal cord injury by % by an educational campaign aimed at teenagers. The campaign used a ‘feet first — first time’ slogan. The results from this preventive intervention indicate that it is cost-effective when it is successful (Table ..). In ice hockey, the introduction of helmets and facial masks has dramatically reduced the number of ocular injuries resulting in blindness. The helmet, however, adds mass to the head and may shift the head mass anteriorly sufficiently to result in flexion of the neck on impact []. The sense of invulnerability by players when wearing a helmet may cause them to engage in more aggressive play []. Rules have been introduced to reduce the number of spinal cord injuries, including major penalties for checking from behind. However, rules are only helpful if they are enforced. It seems reasonable to increase the severity of penalty for dangerous play in contact sports like ice hockey. High and acrobatic jumps are some of the various challenges in snowboarding. The jumps increase the risk for serious injuries, but at the same time there is no reason to believe that signs like ‘jumps not allowed’ are effective. Well-prepared jumps and improved skills may reduce the number and consequences of injuries. Table .5. Guidelines for reducing diving injuries. Do not dive into water shallower than twice your height Do not dive into unfamiliar water Check out first what is underneath the surface Do not assume the water is deep enough Remember the influence of tides on water depth Do not dive near dredging or construction work, as water levels change and dangerous objects may be underneath the surface Do not dive until area is clear of other swimmers Do not drink and dive Limit horseplay to safe areas, do not include as part of diving
Neck pain Epidemiology Neck pain is a commonly occurring complaint. Its yearly prevalence is comparable with low back pain and is about % in the adult population. Neck pain is the main complaint in about % of those who consult a physician. The yearly prevalence of cervical radiculopathy is – per []. Repeated collision injuries in contact sports not resulting in fractures or spinal cord injuries are associated with neck pain and paresthesia. The symptoms are commonly recurrent, existing just for seconds during a match, and result from traction of the brachial plexus or nerve root irritation. In a large Finnish survey the neck and head accounted for % of all soccer injuries []. A heading in soccer involves hyperextension and compression of the cervical spine and may affect the vertebrae, intervertebral joints, disks, ligaments and muscles. Chronic complaints of pain and limited range of motion of the cervical spine were found in about % of former players from the Norwegian national soccer team []. Degenerative changes of the cervical spine were significantly more frequent and present about – years earlier as compared with a control group. Disk herniation with radicular symptoms and signs has been reported in conjunction with heading in soccer. Neck pain associated with traffic accidents has been epidemic for the last two to three decades in Western societies. The complaint is usually difficult to explain from a biomechanical point of view, and there are no particular pathophysiologic changes or clinical signs. These complaints seem to be less frequent in athletes who frequently are exposed to similar or more pronounced biomechanical forces during sports. By unduly focusing on the injury mechanism, somatic symptoms, imaging and prolonged treatment and rest, physicians, physiotherapists and chiropractors may actually have reinforced symptoms [,]. Thus, this epidemic in Western societies may be at least partly iatrogenic. The patient may become overcautious and complain about diffuse symptoms of tiredness, dizziness and pulsation in the neck together with chronic pain and disability.
Spine Diagnostic thinking Neck pain may be classified according to etiology, pathophysiology and biomechanics, or symptom localization. Commonly neck pain radiating to the arm (cervicobrachialgia) is discriminated from neck pain (cervicalgia). The pain may radiate in a nerve root pattern (cervical radiculopathy), or may be aggravated on elevation of the arm and palpation of the brachial plexus (thoracic outlet syndrome) or result from entrapment by peripheral nerves. A common clinical challenge is to discriminate primary neck pain radiating to the shoulder and arm from primary shoulder pain associated with secondary cervical myalgia. Neck pain may also result from collar tumors or infections. In the elderly population, a vertebral artery stenosis may result in dizziness and neck pain. Acute neck pain and reflectory muscle spasm may be frightening. The emotional security represented by a careful and confident primary consultation is therefore of utmost importance. Most patients with acute neck pain improve within a short time without specific treatment. In patients with chronic pain the clinician should screen for somatization symptoms. Imaging is indicated in patients with radicular symptoms or atypical pain. For evaluation of neck pain associated with traffic accidents most patients will benefit from a careful primary evaluation. The efficacy of physiotherapy and chiropractic treatment is undocumented, and prolonged manipulation or soft tissue or exercise therapy is not indicated.
Neurologic examination. This is indicated in patients with radiating pain. Range of motion. Examine active and passive range of motion. Normal passive range of motion is ° extension, ° flexion and side bending and ° bilateral rotation. In patients with muscular pain the reduced range of motion observed in the sitting or forwardflexed position is commonly recovered when assessed in the supine and relaxed position. Specific segmental examination includes palpation of the spinous and transverse processes and particular techniques to assess segmental motion. Stress tests. A positive Spurling maneuver suggests nerve root involvement, but the test may give a false negative (Fig. ..). The test has a good inter-
History Did the complaints start following trauma or gradually? It is important to get a precise description of pain localization: is the pain distinct or widespread? Does it radiate to the upper extremity? Is the pain aggravated by coughing? Are there associated symptoms like headache, fatigue, dizziness or nausea?
Clinical examination Inspection. Torticollis may reflect a serious injury, involvement of the facet joints or cervical disks, a congenital disorder, inflammatory, malignant or infectious pathology, or psychological stress. General muscular tension and shoulder shrugging should be noted. Look for collar tumors.
Fig. .. The Spurling test is applied to detect radiculopathy. The neck is first laterally flexed, rotated and extended. Then an axial compression is applied. Reprinted with permission from Norsk Fysikalisk Medisin. Niels Gunner Juel (editor). fa*gbokforlaget, Bergen, Norway, .
Chapter . examiner reliability [].The test may accentuate limb pain or paresthesia because neck extension causes posterior disk bulging, whereas lateral flexion and rotation narrow the ipsilateral neural foramina. The Spurling maneuver is performed by extending the neck and rotating to the side of the pain and then applying downward pressure on the head. When radiating pain or extremity numbness is produced, the test is positive and should be stopped. Roos’ test for thoracic outlet syndrome is performed with the arm abducted and externally rotated. The patient is then instructed to repetitively clench his fist for min. The test is positive if the patient’s symptoms are reproduced or aggravated. Palpation. Palpate upper neck muscles, the trapezius bilaterally and in the supraclavicular fossa. Sore neck muscles are common, but localized sharp pain should be noted.
therapists or chiropractors claim that the muscle spasm results from subluxations of the facet joints, and that the patient will benefit from gentle mobilization.
Cervicalgia Repeated monotonous activity, prolonged unfamiliar activity, degenerative changes and psychosocial factors may contribute to pain. Symptoms and signs. Neck pain that may radiate to the shoulder or upper extremity. In patients with paininhibited active range of motion a full range of motion is commonly found by passive examination with the patient in a relaxed supine position. Typical stressrelated symptoms such as tiredness, concentration difficulties, dizziness and nausea may predominate. Diagnosis. Radicular symptoms and referred pain should be excluded by clinical examination. Imaging is normally not indicated at the primary consultation.
Imaging An anterior–posterior cervical radiograph including flexion and extension views should be performed as they may detect unsuspected fractures or tumors. Evaluate the intervertebral foramina. Current radiologic opinion is that MRI is the technique of choice in patients with radicular pain. Electromyography (EMG) is useful to differentiate between central and peripheral involvement and entrapments and nerve root pain.
Acute torticollis Acute neck pain associated with side flexion and rotation. Symptoms and signs. Frequently athletes are awakened from sleep by the pain, or when they wake up in the morning the neck is stiff and sore. Diagnosis. History will usually rule out differential diagnoses. In non-traumatic torticollis, search for underlying malignant, inflammatory or infectious pathology if the condition does not resolve within a short time. Treatment. Muscle relaxants, anti-inflammatory medication or paracetamol. Inform the patient that the condition usually resolves within a few days. Manual
Treatment. Anti-inflammatory medication or paracetamol for – days and information for patients with acute pain. The patient should be told not to be overcautious, and that the symptoms will normally resolve within – weeks. The effectiveness of various modalities including ergonomic interventions and rest is not well documented, but if acute pain is not reduced, short-term mobilization may improve symptoms []. Treatment should attempt to reinforce active coping strategies. Rest may not relieve symptoms if the stressor is not identified. Manipulation of the neck is not recommended because of potential complications. Athletes should continue general training, but in some athletes with chronic neck pain, contact sports may need to be discontinued permanently.
Cervical radiculopathy The most common cause of cervical radiculopathy is the herniated disk. In patients older than years, symptoms may result from hypertrophic facet and uncovertebral joints and reduced disk height. The prevalence of disk herniations and protrusions is about % in the asymptomatic population. Compared to the prevalence of radicular pain ‘pathologic’ changes such as disk herniation and protrusion most commonly are not recognized by the patient.
Spine Symptoms and signs. Pain in the neck often lasting a few weeks and radicular distribution of symptoms in one or both upper extremities. The pain may at times be atypical and present as chest, breast or facial pain. Paresthesia, hyperesthesia or dysesthesia, and muscle weakness usually interfere with daily activities. Concomitant sensory changes, weakness, atrophy and unilateral diminished tendon reflexes or MRI correlating with radicular symptoms are definite diagnostic criteria. Despite the variations in clinical findings, single nerve root involvement can be diagnosed by manual muscle testing –% of the time. The neck compression test first described by Spurling has a high specificity, but the sensitivity is low. It is performed by extending the neck and rotating to the side of the pain and then applying downward pressure on the head. When cervical myelopathy is present, pain is described in the back and the legs. Other important signs include balance and walking difficulties, and bowel or bladder complaints. Diagnosis. The diagnosis is mainly clinical. An anterior–posterior cervical radiograph including flexion and extension views should be performed as this may detect unsuspected fractures or tumors. Current radiologic opinion is that MRI is the technique of choice. Treatment. Corticosteroids and anti-inflammatory medication is the first choice. Epidural steroids can be administered in experienced hands as an alternative where surgery may otherwise be indicated. Usually most patients recover without surgical treatment. A recommendation of a specific treatment strategy including surgery cannot be based on present randomized studies []. A rigid collar restricts extension and can be used intermittently until extremity pain has disappeared. These collars may be uncomfortable to wear, which is reported to reduce compliance. Manipulation is contraindicated []. Bladder and bowel paralysis or progressive walking difficulties require admission to a neurologic or neurosurgical department. Athletes can normally maintain general training activities with some modifications. Recovery may be long term and, depending on the type of sports activity, many athletes have to take a long break from competitions and plan for the next season.
Thoracic outlet syndrome The term is used to describe several disorders attributed to mechanical compression of neural and/or vascular structures between the base of the neck and axilla. Symptoms and signs. Aggravation of symptoms with the arm in the elevated position, paresthesia corresponding to segments C–T, tenderness over the brachial plexus supraclavicularly, and a positive Roos’ test. Diagnosis. When at least three of the four criteria listed above are positive. Treatment. Good results after surgery are achieved in less than % of patients, and complications after surgery for thoracic outlet syndrome may be severe. Thus, a proper evaluation of symptoms and disability is important to rule out differential diagnoses and initiate the best conservative treatment. The evaluation should include measurements of range of motion and muscle strength, and a screen for somatization symptoms. According to a large recent study, most patients seem to recover with a conservative model that is based on the functional findings in each patient. Therapy includes exercises emphasizing stretching and strengthening (Figs ..–..) []. The program seeks to restore the function of the cervical spine and thoracic aperture.
Transient pain and paresthesia of the upper extremity Frequently reported in contact sports like American football and rugby []. Symptoms and signs. Burning pain and numbness in the upper extremity. Symptoms are commonly more circular than dermatomal. May be present as short-term recurrent complaints or chronic paresthesia and muscle weakness. Diagnosis. Exclude cervical radiculopathy and thoracic outlet syndrome. The risk for chronic complaints is increased in patients with a ratio of the sagittal diameter of the spinal foramen to vertebral body diameter of < ..
Chapter .
Fig. .. Shoulder girdle exercises. Reproduced with permission from [].
nique or associated collisions with an opponent may result in long-term complaints. Soccer seems to include more close contact, and it is reasonable to enforce standing rules and increased severity of penalty for dangerous play. The mass of the football is about g and it may hit the head at speeds exceeding km/h. Based on various assumptions, the calculated force against the head may exceed N. The forces that have to be counteracted by the neck muscles can thus be far beyond the forces occurring in common car collisions.
Low back pain Epidemiology Fig. .. Exercise for the upper cervical spine. Reproduced with permission from [].
Treatment. Prevent development of complaints by recommending to athletes with an increased risk for relapse and chronic pain that they discontinue their sports career.
Rehabilitation Strengthening and stretching exercises are illustrated in Figs ..–... Recovery is normally not shortened by exercise therapy in the acute stage. The athlete should be able to perform his or her ordinary training schedule before returning to competition.
Prevention A correctly performed heading in soccer demands technical skills that should be aimed for in organized training of younger players. Improper heading tech-
The lifetime, -year and point prevalence of low back pain in the adult general population is reduced in persons who are physically active for at least h/week []. Back pain is more common in the general population than in former elite athletes []. Weight-lifting is associated with degeneration of the entire spine, and soccer with degeneration in the lower lumbar region. The prevalence of back pain and degeneration is low in runners. The incidence of chronic low back pain varied from to % in a Swedish epidemiologic study including soccer and tennis players, wrestlers and gymnasts []. In –% of the athletes, the radiologic examination was interpreted as abnormal. Low back pain is reported to interfere with sports activity at least once a year in about –% of elite swimmers and more than % of elite cross-country skiers. The complaints in cross-country skiing are more related to the double-poling and diagonal stride techniques than to skating techniques [].
Spine
Fig. .. Exercise for the scalene muscles. Reproduced with permission from [].
Fig. .. Stretching of the anterior muscles of the cervical spine. Reproduced with permission from [].
Several epidemiologic studies report the prevalence of spondylolysis in athletes being three to four times higher in athletes than among the general population, which varies between % and %. Its prevalence in a large epidemiologic study in elite Spanish athletes was %, with the highest percentages occurring in throwing (%), rowing (%) and gymnastics (%) []. Although the prevalence of spondylolysis among wrestlers is reported to be – times higher than in the normal population and the prevalence of back pain in former wrestlers is about twice as high as that in the normal population, absence from work due to illness is lower. Low back pain is the second most frequent site for pain in dancers. The prevalence is about the same in dancers with and without spondylolysis. Thus, spondylolysis frequently appears incidentally in
radiologic examinations, and it is considered that only about % have pain. The cumulative prevalence of low back pain in adolescence is about % []. Watching television or performing vigorous exercise for more than h daily are associated with increased back pain in the growth period []. The majority report mild complaints and only % of those with pain seek medical treatment. It is reported that radiologic examinations demonstrate spondylolysis in about % of young athletes with back pain who consult an orthopedic surgeon.
Diagnostic thinking In most athletes, low back pain resolves within – weeks even without the seeking of medical care. The physician or therapist should acknowledge this obser-
Chapter . vation and not institute unnecessary imaging or treatment at this stage. Often those who seek advice have tried to continue for weeks despite significant pain, and therefore present with a chronic problem. At this stage, an understanding of differential diagnosis, careful history and physical examination is obligatory to pinpoint the problem. Based on this evaluation, simple advice or a functional rehabilitation program will help most athletes to return to their sport. Imaging procedures are only supplementary and cannot replace the clinical examination. Sensitive procedures like MRI may describe abnormalities that are not specific because of their high prevalence in the asymptomatic population. In adults radiologic spondylolysis/spondylolisthesis correlates poorly with low back pain. In young athletes, an isthmic stress fracture may explain acute low back pain. Low back pain and walking difficulties in the elderly that are relieved by forward bending suggest spinal stenosis; alternatively, coxarthrosis or cardiovascular disease may give similar symptoms and can occur at the same time. Most people with back pain do not (and probably should not!) visit a physician, a physiotherapist or a chiropractor. The challenge is to perform or request the right procedures and to give the right information to the right patient. Table .. outlines the most common reasons for back pain in various age groups. In athletes with radiculopathy, the physician has to consider surgery and inform the patient about the alternatives according to short- and long-term consequences associated with continued sports activity. Lack of bladder or rectal control may indicate the need for immediate surgery — thus the patient should be sent to hospital as an emergency because the prognosis may be worsened after a delay of more than h. Intraspinal tumors, mononeuritis caused by entrapment of peripheral nerves or neurologic disease, a pelvic stress fracture, or the sacroiliac joint syndrome may present as radiating pain. Entrapment of the fibularis nerve as it passes the fibular head usually presents with drop-foot or paresis of dorsal flexion of the ankle and leg pain. Pain referred from the gluteal muscles (including the hip rotators) may radiate below the knee. In patients with chronic pain the examiner should make an effort to pinpoint why pain has become
Table .. Age-related spinal diagnoses. Young child Genetic (structural) disturbances, such as unsegmented vertebrae and scoliosis Spondylolysis In severe low back pain, neoplasm, discitis or juvenile disk herniation should be excluded Adolescent Structural disturbances affected by growth spurt: idiopathic scoliosis, Scheuermann’s kyphosis, spondylolysis Osteomyelitis Osteoid osteoma Juvenile disk herniation Extreme loading in weight-lifting or gymnastics Young adult Fractures in high-risk sports Soft tissue injury Stress fractures in anorexia or hormonal disturbances Middle age Disk and facet joint degeneration Ankylosing spondylitis and other inflammatory diseases Elderly Spinal stenosis Neoplasm or secondary tumor
chronic. Key questions are as follows. Have diagnostic procedures failed in the acute stage? Should a prolonged course be expected according to the natural course of a specific disorder? Did the patient return to sports too early? Has previous treatment been adequate? Are there other factors influencing complaints? The diagnostic evaluation in patients with chronic pain should include psychological and social factors (Table ..). Elite athletes who usually tolerate psychological stress well may be vulnerable and demonstrate fear of avoidance, muscular defence and even abnormal illness behavior if their career or goals for the season are threatened.
History The chief complaint should be clearly established. Most commonly it is pain, but occasionally the main complaint is stiffness, specific functional loss or structural abnormality. Pain localization and disability should be clarified precisely. Pain may be absent or not disabling in normal activity, but triggered by certain
Spine Table .. Common mechanisms of back pain. Mechanism of injury
Sport
Repetitive loading Repetitive loading in contact sports
Roller skiing, rowing, kayaking Soccer, European handball, ice hockey, wrestling, judo, karate Ballet, dance, figure skating Weight training, gymnastics Throwing sports
Lifting human bodies Loading an immature spine Sudden violent muscle contraction Hyperextension/torsion
Throwing sports, gymnastics
sport-specific movements — thereby suggesting functional overload of a specific structure. It is important to know whether the patient suffers from back pain, leg pain, or both. An acute disk herniation may present as unilateral leg pain without back pain. Isolated back pain is usually not discogenic in young individuals. Pain in young athletes that is worsened by trunk hyperextension (but not forward bending) suggests spondylolysis/spondylolisthesis. The nature of the onset and the association with trauma may point towards muscular strain, contusion or discogenic involvement. Muscular pain may be localized and provoked by specific exercise, or present as diffuse widespread pain worsened by physical and psychological stress. The degree of disability should be clarified. The level of activity and the degree to which pain is aggravated by or interferes with training or competition should be noted, along with the goals of the athlete. A detailed history is required to pinpoint the level of discomfort during each of the activities. This may help to explain why pain has developed. In throwing, skiing and weight-lifting, inflammation and/or partial muscle/tendon ruptures may be caused by acute or repetitive loading. For example, pain located at the iliac crest, groin and leg that is worsened by side flexion, extension and rotation may be referred from the quadratus lumborum muscle. Common mechanisms of back pain in sports are outlined in Table ... Significant chronic back pain and disability in patients under the age of should raise the question of tumor or discitis. Spinal tumors in this age group commonly have a –-year delay in diagnosis. Similarly, a first-time history of back pain in anyone over the age of
Table .. Red flags in the evaluation of back pain. First-time back pain in patients 55 years Constant, progressive, non-mechanical pain History: drug abuse, cancer, human immunodeficiency virus Weight loss Widespread neurologic signs and symptoms Structural deformity Thoracic pain or chronic cough Intermenstrual bleeding Violent trauma Altered bladder control Associated visual disturbance Balance problems or upper limb dysesthesia Persisting severe restriction of lumbar flexion
should introduce the possibility of tumor. Red flags are outlined in Table ... If responses to these possibilities are negative, one can focus on expanding the history of the presenting complaint. Severe pain and disability are commonly associated with fear. Athletes, like other patients with acute pain, may demonstrate helplessness and fear which may be more related to the consequences of pain than the pain itself. If a careful history and examination do not suggest serious back pain or specific treatment, the evaluation should focus on the functional limitations, and the athlete should be encouraged to gradually return to former activity. Sometimes the athlete for various reasons may not want to return to former sports activity (Table ..). It is therefore important to explore what beliefs and expectations the patient has about pain, treatment and sports. For evaluation of chronic back pain, it is important to reassess the patient with an open mind. Let the patient tell his history in his own words, and then reexamine him before previous reports including imaging are considered. Ask the patient if he has experienced similar complaints previously, and what kind of explanations, advice and treatment he has previously received.
Clinical examination Acute pain The purpose of the clinical examination is to discriminate between patients who need further examination
Chapter . Table .. Yellow flags or risk factors for chronicity. Previous history of low back pain Total absence from sports or work over the last year Radicular pain Reduced trunk muscle strength, endurance and flexibility in relation to sport-specific demands Disproportionate illness behavior Psychological distress, depressive symptoms, disturbed sleep and social isolation Dissatisfaction Personal problems: alcohol, marital, financial Adversarial medicolegal proceedings Belief that back pain is dangerous Fear of physical activity Expectation of passive treatment
or hospitalization and patients who do best with simple advice and analgesics. Nerve root signs assessed by conventional neurologic examination are reliable, but palpation of tenderness in the lumbar spine is highly unreliable []. If rectal or bladder function is disturbed, sensitivity in the saddle area and sphincter function should be examined. Weakness in patients with sciatic pain is rapidly assessed by asking the patient to walk on toes (S) and heels (L), and bend the knees (L). Does the patient present a limited range of motion or a protective scoliosis? Are all movements painful or is pain provoked by one leg extension only (spondylolisthesis)? Examination of the abdomen and peripheral pulses should be performed. Rectal or vagin*l examination may be required where indicated by the history. Does palpation confirm the pain reported on history? Is pain localized or widespread? Chronic pain Gait (rolling, limping, functional) should be assessed when the patient enters the room and on demand when undressed. A systematic examination should then be performed in as few positions as possible. Standing. Important landmarks are the prominent vertebra (C or Th), the inferior angle of the scapula (Th), the lowest rib (Th) and the tops of the iliac crest (L) (Fig. ..).
Leg length differences > cm and scoliosis can be observed. In patients with a protective scoliosis, apparent spasm of paravertebral muscles is confirmed by gentle palpation. If the lateral curve remains on forward flexion, this suggests that the scoliosis is fixed or structural. A rib hump confirms the diagnosis (Fig. ..). Is the range of forward flexion limited? Measure fingertip– floor distance. What is the cause of the limitation: thoracic kyphosis, low back pain or short hamstring muscles? In a patient with a complaint of sciatica, forward flexion may provoke pain down the leg by increasing tension of the ischiadic nerve, the hamstring muscles or the deep gluteal muscles. Patients with low back pain often present with a dysfunctional movement pattern clearly demonstrated as they assist by using their arms and legs to straighten up from the forward flexed position. It should be kept in mind that measurements of range of motion as well as muscle strength in patients are always affected by the patient’s pain and motivation. Therefore assessment of pain intensity and psychological tests can add information that assists interpretation of the results from physical tests in patients. Assess lateral flexion. Record the point reached from the floor. Note whether there is an asymmetric movement pattern or a sharp break in the curve that may suggest segmental pain. Assess rotation. Then ask the patient to keep his hands firmly at his sides and repeat. The major part of the motion will now take place in the legs and not interfere with back pain (Fig. ..d). A series of heel raises with either leg is the best way to test S function. The examiner may look for evidence of a Trendelenburg sign and gluteus medius atrophy while the heel raise is being performed. Supine. Muscle strength of the tibialis anterior and toe extensors (L), and peroneal muscles and triceps surae (S) are examined with the knees flexed. Weakness of knee extension (L) and hip flexion (L) indicate that the femoral nerve is affected. Widespread weakness suggests overlay or pain-inhibited weakness (Fig. ..e). Deep tendon reflexes (patellar, Achilles and plantar) are examined with the knees in ° flexion. All reflexes may be augmented by having the patient ‘clench’ their
Spine
Fig. .. Structural scoliosis. A rib hump on forward flexion confirms the diagnosis.
teeth, lock the fingers and tense the upper limb muscles (Fig. ..). Straight-leg raising should be examined with and without reinforcement (bending the neck and dorsiflexion of the ankle).This test is positive if pain radiates beyond the knee at ° elevation (Fig. ..). This test is false positive if the patient (while the examiner uses the pretext of examining the back from behind) is able to sit up on a bench without spontaneously flexing his knees (Fig. ..a). Test sensation to pinprick for nerve roots L, L and S and finally for peripheral nerves. Diminution of sensation at the side of the foot is the most common finding (S). Stocking anesthesia indicates that sensory loss is not radicular (Fig. ..). Hip flexion is evaluated with the knees flexed. The examiner should limit sacral tilting and lumbar lordo-
sis. A positive Faber test (passive flexion/abduction/ external rotation) (Fig. .., p. ) suggests involvement of the sacroiliac joint or coxarthrosis. The quadratus lumborum muscle is assessed with the patient lying on their side with the arms upright and a pillow underneath the lumbar spine. The muscle is assessed by palpation as the patient contracts the quadratus lumborum by performing a combined abduction/retraction maneuver of the lower extremity. Prone. The femoral nerve stretch test is performed by passive hip extension with knee flexion and produces pain on the anterolateral part of the thigh (L–). If this maneuver triggers sciatic pain, it suggests L root irritation. Osteoarthritis of the hip and low back pain are
Chapter .
(a)
(b) (c)
(d)
Fig. .. Waddel signs: (a) straightleg raising; (b) pressure to the head; (c) superficial stimulation; (d) pelvic rotation; (e) widespread weakness or cogwheel compliance on motor examination.
(e)
frequently confused. A full range of hip rotation with the absence of pain at the extremes is generally required to eliminate the former. If pain is provoked by the combined motion of hip flexion/external rotation/adduction, pain referred from the external hip rotators is suspected. The paravertebral muscles, the spinous processes, the sacroiliac area with the gluteal muscles, the insertion of the hamstring muscles on the ischial tubercle, and the great trochanter are palpated for pain. Is pain localized or widespread? Is paravertebral palpation more painful than palpation of each spinous process? Does the patient scream or withdraw on light palpation?
Imaging Based on a proper clinical examination, appropriate imaging investigations may be ordered. History, main symptoms and clinical signs should be precisely described. Unless a fracture or serious back pain is suspected or neurologic signs are demonstrated at the clinical examination, imaging is usually not requested in a patient presenting with back pain for the first time. Routine X-rays are indicated if a fracture is suspected, and in elderly patients without sciatic pain. A lateral thoracic view is taken in patients with kyphosis. In cases of suspected spondylolysis, an oblique view or a CT scan through the vertebral arch gives additional information. CT is the first choice in patients with
Spine
L1 L2
L4
L3
L4 L5 S1
L5
S1 Fig. .. Neurologic examination in patients with L–S radiculopathy. Reproduced with permission from Norsk Fysibalisk Medisin, Niels Gunner Juel (editor), fa*gbokforlaget, Bergen, Norway, .
Fig. .. Straight-leg raising test. Pain must be below the knee if the roots of the sciatic nerve are involved. Passive dorsiflexion of the foot or palpation of the stretched tibial nerve aggravates pain.
sciatic pain. CT is also the best method of visualizing the facet and sacroiliac joints. Scintigraphy is indicated if history and clinical examination indicate spondylolysis in a patient with acute pain. MRI is the first choice if an infection (discitis or vertebral abscess) or tumor is
suspected. MRI is also the best method to discriminate between scar tissue and a disk herniation in patients with back and leg pain who have had previous disk surgery. Discography may be used preoperatively to evaluate discogenic pain. This evaluation is positive if pain
Chapter .
Anterior
Posterior
T10 T12 T2
S4
L1
T11
S3
L2
S2
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C6
L3 L5 S1
C8 S1
S1 S1 L4 S1 L5
L5
C7 Fig. .. Neurologic examination. Sensory assessment.
is concordant, but the number of false-positive ratings is high. The recent opinion therefore is that it is difficult to interpret the information from a positive discography. Facet joint anesthesia should reduce pain intensity by at least % and be supplemented by a negative placebo injection to be considered positive. The expense of a procedure and its therapeutic consequences should be considered before ordering an investigation [,]. Limited imaging is recommended, particularly in patients with low back pain without objective clinical findings. Repeated radiologic investigations should be limited because of radiation exposure.
Muscle contusion Muscular contusions are common in many collision sports. Diagnosis. History and exclusion of other diagnoses by clinical examination, imaging if a fracture is suspected. Treatment. Ice, compression and anti-inflammatory medication. Disability is short-lived, and return to sports activity is usually possible within a few days.
Spine Muscle rupture Muscular ruptures are common in sports with rapid movements including torsion and twisting. Occasionally there is an associated avulsion fracture of the transverse process by the quadratus lumborum or the iliac crest by the external oblique. Diagnosis. Distinct unilateral pain on palpation. Pain is usually associated with muscle spasms during the first weeks. Treatment. As for muscle contusion. Alternate exercise for endurance and exercise for muscular strength after a few days. Additionally, a thoracolumbar orthosis may be helpful during the first – weeks. Gradual progression in activity that allows for competitive training after – weeks. In the case of an avulsion of the transverse process or the iliac crest up to months may be required before the athlete can return to competition that involves contact activity or rapid movements through a full range or sudden twisting or deceleration.
Ligament strain Diagnosis. Acute localized pain not provoked by isometric contraction. Usually located to the cervical, interscapular or lumbosacral area. Treatment. As for muscular contusion. Manual mobilization may be indicated in patients with chronic pain.
Radiculopathy Radicular pain in athletes is most commonly related to disk herniation. Recent research has found only a weak correlation between disk degeneration and herniation. In the middle-aged or elderly athlete reduced disk height and facet joint degeneration contribute to radicular pain. Inhibited motor function indicates nerve root compression. The association between pain or a positive Lasegue’s test and nerve root compression is more uncertain []. Current knowledge indicates that acute radicular pain is caused by an inflammation induced by an autoimmunologic process involving the herniated disk and irritation of the dorsal root ganglion [,]. Under chronic conditions ischemic, inflammatory, metabolic and neurophysiologic changes
affecting the nerve root or the dorsal root ganglion and central inhibiting or enhancing mechanisms may contribute to the pain-producing process. Symptoms and signs. Pain radiation below the knee that is provoked by coughing. Prolonged standing and sitting is difficult. At consultation the patient may present with a limp, the upper body forward flexed, and a protective scoliosis. The diagnosis is supported by positive neurologic signs in a nerve root pattern and a positive straight-leg raising test. Diagnosis. The diagnosis is based mainly on clinical symptoms. CT is indicated if the complaints do not improve within weeks or in patients with progressive paresis. Treatment. A patient with a large central herniation producing bladder disturbance, diminished perineal sensation and even paraplegia is a surgical emergency, and immediate exploration is imperative. All other patients are first treated with conservative methods. Anti-inflammatory medication is recommended. Corticosteroids, – mg prednisolone for – days is usually well tolerated. Analgesics (including opiates) are indicated in patients with pain-related sleep difficulties. The patient should be informed that the prognosis is good without surgery, and that improvement is not delayed by ordinary activities or improved by bed rest. In the long term extrusion of disk material leads to narrowing of the disk space. Participation in competition should normally be delayed until the athlete is able to conduct his normal training program although this may sometimes be controversial. Recently a Norwegian cross-country skier won the World Championship title despite sciatica with motor disturbances. Reduced activity is recommended in patients with unaltered or progressive complaints. Twisting and bending when lifting should be avoided. The physiotherapist should motivate the athlete to remain active, to use and flex his back in order to maintain general physical fitness, and to maintain a positive attitude. In general there is no reason to be overcautious. The effect of traction is limited at best to short-term pain relief, and has no documented effect on recovery. Exercises to improve the function of the deep stabiliz-
Chapter . ing trunk muscles have no documented effect on recovery, but may reduce the risk of relapse. In dancers and in athletes in other sports that include lifting a partner, a corset or a stabilizing belt can make it possible to maintain performance. Progressive pareses or muscle weakness and radicular pain for – weeks indicate surgery. The effect of extirpation of the herniation with or without arcotomy or laminectomy improves radicular pain and muscle weakness in about % of the patients, but the effect on back pain is more variable. Therefore, the indication for surgery in patients with a disk herniation and back pain (but no radicular pain) is more controversial. Percutaneous nucleotomy is not indicated. There is no consensus about rehabilitation after surgery. A recent study suggests that the patient should resume ordinary activities as soon as the operative wound is healed []. From this baseline, the athlete should gradually increase his training volume and intensity. Absence from sports in athletes with radiculopathy is highly variable. In patients without muscle weakness we expect a setback of – weeks; in patients with objective neurologic signs the setback is commonly – weeks or longer. Therefore, long-term planning is an important part of the rehabilitation process, preferably in agreement with the physiotherapist, coach and athlete. In some cases it may be wise to recommend reduction of ambitions and eventually giving up the sports career in order to set new, more realistic goals in another arena.
Spinal stenosis Encroachment of the spinal canal, usually by hypertrophic bone, produces signs of neural claudication, and is particularly problematic in the elderly runner or orienteering athlete (> years). Symptoms may present at an earlier age when associated with previous fracture or spinal surgery. Symptoms and signs. Leg aching and numbness with or without back pain and morning stiffness. Reduced walking or running distance. Pain is normally reduced by forward flexion. In patients with a central spinal stenosis symptoms are almost always bilateral. Muscle weakness and loss of the patellar reflex is common. The patient may present with a foot drop.
Diagnosis. According to clinical symptoms and signs described above and confirmation of decreased canal size based on CT scan. MRI is used preoperatively. Myelography is used if more than one level is affected or if patients have scar tissue after previous surgery. It is important to exclude other diagnoses that can produce signs of claudication: compartment syndrome, diabetic neuropathy, disk herniation, vascular claudication and tumor. Treatment. Anti-inflammatory medication. The athlete should possibly change activity from running to swimming or cycling. Group exercise (e.g. aerobics) is recommended in inactive patients to improve general flexibility, strength and endurance, and to reduce depressive symptoms. Analgesics (including opiates) may be indicated if sleep is disturbed by pain. The effectiveness of surgical treatment is uncertain in patients with back pain, but surgery is indicated in patients with progressive claudication and muscle weakness.
Spondylolysis/spondylolisthesis Spondylolysis is defined as a defect in the vertebral isthmus (lysis) or most commonly the pars interarticularis. Multiple factors may be involved in its genesis. In athletes, a stress fracture is considered to cause the defect, predominately located at the L level. Biomechanically, torsion against resistance, hyperextension and rotation are possible causative movements. Previous studies have described that spondylolisthesis is found in about % of spondylolytic lesions, but the frequency was only about % in a large current study. Spondylolisthesis is classified into five grades: grade I is defined as a % forward slip of L in relation to S, whereas grade V is a % slip (opthosis) (Fig. ..). Grades I–II are most frequent. Instability is usually minimal because the vertebrae are anchored by ligaments and stabilized actively by trunk muscles.The slip rarely increases after growth is complete. Symptoms and signs. Low back pain that may be referred to the buttock. Activity usually aggravates pain. May present with associated spasms of the erector spinae or hamstring muscles. Sciatica in the young patient is sometimes observed in grades III and IV.
Spine Sciatica from disk and facet joint degeneration or hypertrophic tissue in the pseudarthrotic defect is sometimes observed in adult patients.
Diagnosis. Distinct back pain aggravated by one leg extension and a positive bone scan indicate that the defect is the source of discomfort (Fig. ..). Radiologic examination with front and side projections will usually
reveal the lysis; diagnosis is confirmed by an oblique view (Fig. ..). Instability is assessed by comparison of measurements of the slip in forward flexion and extension. CT is the best method to describe the defect in detail. Spondylolysis appears frequently incidentally in radiologic examinations. It is considered that only about % of those with a positive radiologic examination have pain.
Fig. .. Patrick or FABER test to detect pelvic or hip pain. Combined flexion, abduction, external rotation of the hip with the patient supine, the knee flexed and the foot placed on the opposite patella. The flexed knee is then pushed laterally.
Treatment. It is not documented that a corset is effective for pain relief or healing of the lytic defect in patients with acute pain and a positive bone scan. Treatment involves training modification, antiinflammatory medication and proprioceptive exercises to activate the transversus and multifidus muscles (Figs .. & ..) []. The physiotherapist should instruct, give feedback and supervise treatment over a few sessions. Progression is made not so much by increasing the number of repetitions as by integration of the stabilizing activation of the deep trunk muscles in more complex motions (from four-foot kneeling to the soccer kick) (Fig. ..). Surgery is indicated in grades III and IV and in grade II if conservative treatment does not improve function.
Normal
Fig. .. Classification of spondylolisthesis.
Grade 1
Grade 3
Grade 2
Grade 4
Chapter .
Fig. .. Spondylolisthesis grade II–III in a -year-old soccer player and snowboarder. He has performed his sports without any restrictions for years.
reduced penetration. There is a tendency for increasing curves until growth is finished.
Fig. .. Spondylolisthesis: one-leg hyperextension test. Reprinted with permission.
Scoliosis Scoliosis is a lateral curvature of the spine (Fig. ..). Scoliosis may be structural (idiopathic, congenital, neuromuscular, iatrogenic or due to rare syndromes) or non-structural (tilting of the pelvis, apparent shortening of one leg or due to unilateral protective muscle spasm — particularly that accompanying a prolapsed intervertebral disk). Non-structural scoliosis disappears when the patient is bending forward. The prevalence of structural scoliosis is %. About ‰ of the population should be offered specific treatment according to current guidelines. The prevalence ratio of idiopathic scoliosis in girls compared with boys is /. Structural scoliosis is a multifactorial inherited disorder characterized by either dominant inheritance or
Symptoms and signs. Patients with a structural scoliosis do not usually seek treatment because of pain. A simple screening examination can be conducted by the gymnastics teacher by asking the children to bend forward at yearly examinations. A marked asymmetrical curve with the shape of a boatkeel corresponding to the rib girdle on the convex side will appear in scoliosis (see Fig. ..). The muscular activity on the concave and the convex side of a curve will be different, and the patient may sometimes complain about fatigue associated with monotonous activities. Diagnosis. Admission to an orthopedic department for evaluation. The diagnosis is verified and classified by radiologic examination. Treatment. Natural course, brace or surgery. Treatment should be started and controlled regularly at an orthopedic department which can offer both conservative and surgical treatment. The patient should be
Spine
Fig. .. Integrative exercise for back stabilization.
Fig. .. Teaching the test action in the four-point kneeling position: (a) with the abdomen relaxed; (b) following the abdominal drawing-in action. Reproduced with permission from [].
encouraged to participate in physical activity. A brace is generally recommended if the curve increases and exceeds ∞. The brace should be worn day and night, but can usually be taken off during physical activity. The patient is advised against carrying a heavy bag; therefore it is recommended that these patients have two separate sets of school books.
is the most likely pathophysiologic mechanism. The necrosis is most pronounced in front, giving the vertebrae their characteristic wedge shape (Fig. ..). Repetitive traumatization during the growth spurt may increase the risk. A high prevalence of radiologic changes, but with mild or no symptoms, have been observed in cross-country skiers. Excessive rollerskiing during the growth spurt has been suggested as a possible mechanism. Symptoms and signs. The kyphosis of the thoracic spine is usually obvious when the patient is viewed from the side. When mobility is normal in the kyphotic spine the deformity is most frequently postural in origin. Thoracolumbar curves are more frequently associated with pain than thoracic curves.
Scheuermann’s disease Originates during the growth spurt, and is more common among boys than girls. The prevalence is about %. In % of patients, the disorder is localized in the thoracic spine. An aseptic necrosis of the thoracic vertebral bodies caused by ischemia of the growth zone
Diagnosis. The radiologic definition is at least three adjacent vertebral bodies showing ° or more anterior wedging. The epiphyses of the vertebral bodies are often irregular, and may be disturbed by herniations of the nuclear pulposus.
Chapter . Symptoms and signs. Increasing pain and stiffness in the thoracic and lumbar spine and the sacroiliac joints. Occasionally, hip, knee and shoulder pain, and/or pain at the insertion of the Achilles tendon or the plantar fascia, is the presenting symptom. Night pain and morning stiffness is common. Symptoms usually improve during the day and by physical activity. Palpation of the spinous processes, the sacroiliac joints, and the insertion of the Achilles tendon and the hamstring tendon is usually painful. In a late stage the thoracic kyphosis may be pronounced with associated neck pain because of stiffness and difficulties in keeping forward vision. A characteristic gait is normally seen at this stage. Diagnosis. The diagnosis is clinical according to the symptoms and signs described above. The thoracic excursion may be reduced (< . cm) in the early stage. Radiologic examination of the spine may demonstrate characteristic features (bambooing spine), but subchondral sclerosis and arthritis of the sacroiliac joints are found on CT at an earlier stage. The sedimentation rate may be high. HLA-B is not diagnostic.
Fig. .. Mb. Scheuermann. The radiologic definition is at least three adjacent vertebral bodies showing ° or more anterior wedging.
Treatment. Physiotherapy, exercises, or breaststroke swimming to strengthen back and interscapular muscles. If the curve reaches ° in adolescence, a brace should be worn for – months. The prognosis is good. Surgical treatment is rare.
Ankylosing spondylitis The prevalence is about –‰ with a yearly incidence of – patients in Norway. The incidence is greatest during the third and fourth decade and, unlike rheumatoid arthritis, it is rare in women. The disorder is characterized by progressive ossification of the joints of the spine and sacroiliac joints. Its etiology is unknown, but a hereditary tendency is reported.
Treatment. Regular physical activity is an important part of the treatment. Anti-inflammatory medication is given periodically. Manual mobilization may help to postpone deformation in a forward flexed position. When kyphotic deformity is gross, a thoracic wedge osteotomy can improve the erect posture and normalize forward vision.
Unspecific low back pain Low back pain may be caused by a variety of spinal structures, and may be inhibited or reinforced by the human mind []. Disorders discriminated by either characteristic history, symptoms, signs or pathophysiologic features are described above. Clinical techniques developed by chiropractors, manual therapists and osteopaths, and various imaging procedures are widely used, but the diagnostic specificity of these procedures is either low or poorly documented with regard to the asymptomatic population. Furthermore, facet joint injections and discography may be used to discriminate pain elicted from these structures from muscular pain. However, the number of false-positive
Spine tests and the modest effectiveness of specific treatments have turned the focus to interaction of the various structures. Experimental studies have demonstrated the existence of neural pathways between various spinal structures and also between the sacroiliac joint and the spinal and gluteal muscles (Fig. ..). Regardless of the cause of low back pain, free nerve endings and mechanoreceptors located in the outer annulus of the intervertebral disk, the zygapophyseal joints, the ligaments, the muscles and the tendons provide sensory information needed to regulate muscle tension. Reflex activity, that is, an involuntary response to a specific stimulus, may interfere with previously programmed movement patterns. At the same time, pain and fear of pain influence muscle activity. Low back pain may therefore be regarded as a functional disturbance. Of particular interest is the activation of postural muscles prior to lifting and pulling (or actually any motion of the arms and legs), to maintain equilibrium before the movements are executed. Muscular insufficiency may also occur in extremely well-trained athletes. Increased fatigability of the multifidus muscles verified by EMG was associated with chronic low back pain in a study including elite rowers []. Disk injuries in the adolescent athlete are observed in sports that involve a large training volume and particular stress of the spinal structures during growth, for example in gymnastics (Fig. ..). Efforts are continuously made to prevent such injuries, but the volume of training needed to achieve a high level of performance at a young age makes these athletes particularly vulnerable. Symptoms and signs. Low back pain with or without radiation to the hip, groin and buttocks. Occasionally the patient presents with a protective scoliosis. All movements may be painful and the range of motion limited. Diagnosis. A thorough clinical examination is important to eliminate differential diagnoses and gain confidence. In patients with subacute or chronic pain, a CT scan and a clinical evaluation of inorganic signs are recommended if symptoms have lasted longer than – weeks (Fig. ..).
Fig. .. MRI — disk herniation and degenerative signs suggesting injuries at the vertebral endplates during adolesence.
Treatment Acute pain. Inform the patient that he or she should attempt to continue with ordinary activities — including general physical activity. Analgesics or antiinflammatory medication for – days shortens the recovery period. Opiates are rarely indicated. The effectiveness of manipulation and exercise regimens in the acute phase is not documented and is therefore rarely indicated []. General physical activity can usually be continued, at times after a rest period for a couple of days. The athlete can return to competition when he or she is able to continue ordinary training activity. The prognosis is good. About % of patients have recovered within a week after their first episode of low back pain []. The physician and physiotherapist should acknowledge this information. The patient should be treated with empathy, but overcautiousness may reinforce fear and functional complaints.
Chapter . Chronic pain. Information about the nature of the problem, emphasizing reduction of fear, will give the patient confidence to resume light activity. Guidelines recommending avoiding twisting and bending when lifting and excess carrying that involves prolonged isometric activity, and encouraging use of the thighs when lifting heavy objects can be given. The patient should be instructed to use the back and flex it []. Information may be reinforced at repeated appointments. It is documented that patients with chronic low back pain will benefit from exercise therapy. A recent study indicates that low-impact aerobics is the most cost-effective physiotherapy method []. A variety of other methods have also been offered. The effect of disk surgery in patients with a disk herniation and low back pain is controversial []. Surgery is the ultimate treatment, with the drama of preparation, contact with the surgical team, anesthesia and invasion of the body. Surgery carries strong implications of success. For example, relief of sciatica and back pain has been reported in at least one-third of back surgery patients who proved to have no disk herniation []. On the other hand it is estimated that the concept of failed back surgery contributes to as much as % of all patients with chronic pain. The effectiveness of fusion surgery or disk prosthesis is, with the exception of one study, not documented by randomized, prospective studies and should at present be considered as experimental treatment for only a few patients.
Rehabilitation The main goals are to help the athlete to return to previous sports activity and to prevent relapse. Some athletes with recurrent or chronic pain may need advice and support in order to reduce activity or to turn to another sport, while other patients with chronic pain should be encouraged to be more active. A careful evaluation, reassurance, simple advice and reduction in competitive activity, followed by a graded increase in training intensity and volume, will enable most patients to return to their previous sports level. Treatment in the acute phase is described above. Considering the efficacy of anti-inflammatory medication as compiled from randomized trials with various pain conditions, the number needed to treat (NNT) was about – []. This means that of every two to three patients who receive the drug at clinical
doses, one patient will report at least % pain relief. In contrast the NNT for codeine ( mg) was –. Also, opiates like codeine are associated with abuse and are illegal to use while driving. The consumption of these drugs should preferably be limited. The analgesic action of anti-inflammatory medication remains a controversial subject, but recent studies support the view that both a direct peripheral and a spinal effect of inhibition of cyclooxygenase contribute to pain relief. Anti-inflammatory medication as analgesic treatment over – days for relief of mild to moderate pain is well tolerated and equivalent to paracetamol, and is recommended because of the potential risk of paracetamol overdose []. In patients with recurrent or chronic complaints a functional evaluation by a physiotherapist with sportspecific knowledge is recommended. For example, gymnastics requires a full range of motion at the shoulder and the hips. In gymnasts with limitations of these movements, acceptable skills may be achieved to compensate for the limited range of motion by increasing the lumbar lordosis. Therefore, a thorough functional evaluation includes observation of the athlete during competition and exercise, tests for muscle strength and range of motion and finally analysis by high-speed video camera and measurement of EMG activity. The rehabilitation program should be individualized, based on the findings from the functional evaluation and sport-specific demands. According to this some athletes may benefit from stretching exercises while others may need specific strengthening exercises. The use of passive therapies such as soft tissue treatment, electrotherapy and corsets should be kept at a low level. Despite the widespread use of manual therapy for millennia, evidence of its effectiveness from clinical trials is still controversial. The mechanism by which it produces pain relief — according to a recent postulated model based on experimental studies — is probably by involvement of a supraspinal control center []. Most athletes have to modify training activity, and it may not be possible to enter forthcoming competitions. It is therefore important to maintain long-term goals. Relatively minor injuries can turn into a personal catastrophic experience for the athlete if they disqualify him or her from major competitive events. In this situation, the major duty of the medical team is to
Spine support the athlete and to set new goals. Clinicians should strive to understand how their patients view the world and should provide a rational explanation about their disease and its treatment within this framework. Treatment will be most effective if time is spent searching for the best possible treatment and then administering it with utmost confidence. Psychosocial factors should be recognized in patients with chronic pain (Table ..). Questionnaires can be helpful as a screening procedure for somatization symptoms, fear-avoidance beliefs and depression. Most patients with symptoms of somatization and depression will benefit from participation in exercise groups by improved coping skills and reduction of symptoms. Some patients may need to consult a psychologist or a psychiatrist. The screening questionnaires are helpful for use in athletes who demonstrate inappropriate symptoms and signs or an abnormal treatment response. The commonly used principle ‘let pain be your guide’ is a misleading approach to use in the rehabilitation of patients with chronic low back pain. Exercise regimens should be based on a dose–contingency principle and not on pain [,]. This is particularly important in patients who prefer passive treatment regimens because of pain. It is advisable to set the quotas (doses) from baseline observations. This includes results of – functional tests in which the patient has to perform each exercise until fatigue or pain limits activity. The exercise dose is normally set to % of the baseline result and the dose is increased by – repetitions every other day. When the patient is able to do repetitions a more demanding exercise is chosen. Exercise is always to be followed by rest. The main indication for this program is pain restricting participation in exercise programs founded on exercise physiologic principles. Group exercise such as low-impact aerobics is the most cost-effective type of physiotherapy []. Specific exercises or training with devices may be equally effective but at a higher cost, at least when physiotherapy regimens are applied to patients with low back pain in the general population. The main effect of exercise therapy may be to reduce fear of avoidance. In athletes, results from the functional evaluation should be considered because of specific demands in each sport. The volume of competition-specific train-
ing should be gradually increased before entering a competition. Recent studies indicate that activation, size and fatigability of the deep stabilizing trunk muscles are different in asymptomatic individuals and patients []. In back pain caused by a disk herniation, ligament injury or muscle strain, the stabilizing trunk muscles are normally inhibited while other muscles such as the iliopsoas and the erector spina are activated. Atrophy of the deep muscles and increased activity of the outer muscle may in turn increase the functional disturbance. Proprioceptive exercises emphasizing the function of the trunk may therefore be included at all stages in the rehabilitation process. The principles may easily be applied to group exercise as well as to training for specific sports. Treatment normally starts with certain movements (e.g. ‘draw in your navel’) (Fig. ..) supervised by a physiotherapist, and these movements are then gradually incorporated in more complex activities including specific sports (Fig. ..).
Summary A steady rise in the rates of consultations, disability sickness and invalidity payments for low back pain has been observed in the Western world since the s despite advances in imaging procedures and surgical techniques. The focus of research has gradually shifted from the intervertebral disk to more integrative models including neural mechanisms, fear-avoidance beliefs and ‘yellow flags’. About % of patients will have recovered within a week after their first episode of low back pain. The patient should be encouraged to continue with ordinary activities and limit bed rest. In subacute and chronic low back pain, low-impact aerobics is the most costeffective physiotherapy method. This suggests that physical activity to improve fitness and reduce fearavoidance beliefs may become a key factor for reversal of the exponential growth in disability caused by low back pain. Sport is the second most common cause of spinal cord injury. Knowledge about primary diagnostics, treatment and proper stabilization before transportation, can reduce the number of patients with life-long quadriplegia after spinal sports injury. In risk sports like ice hockey, the rules should be reinforced, in particular the penalty for checking from behind.
Chapter . An understanding of differential diagnosis, careful history and physical examination is obligatory to pinpoint the neck or back problem. Pain localization and disability should be clarified precisely. An acute disk herniation commonly presents as unilateral leg pain. Isolated back pain is usually not discogenic in young individuals. Pain in young athletes that is worsened by trunk hyperextension suggests spondylolisthesis. For evaluation of chronic low back pain it is impor-
tant to reassess the patient with an open mind. Severe pain and disability are commonly associated with fear, and athletes, like other patients, may demonstrate helplessness and fear-avoidance. Imaging procedures for neck and back pain are only supplementary and cannot replace the clinical examination. Sensitive procedures like MRI may describe abnormalities that are not specific because of their high prevalence in the asymptomatic population.
Case story 6.5.1 The patient is a -year-old semiprofessional soccer goalkeeper. He has previously been treated for a complicated fracture of the distal phalanx of the right thumb and minor finger injuries, had resected an exostosis of the lateral region of the right distal femur and glenoid labral lesions in both shoulders, and has had surgical treatment of both Achilles tendons because of tendinopathy. He has played compulsory matches in a row without missing one single match because of injury. During his -year-long soccer career he has been manipulated – times yearly because of slight to moderate low back pain, but never missed a soccer game until January . He was periodically moderately impaired by pain, but his impairment did not make him disabled and did not interfere with his participation in soccer games at an outstanding level. In he had a CT scan which showed a central protrusion at the L–S level not affecting the S nerve roots. Considering the activity patterns of a goalkeeper struggling for the ball in various positions, he had an excellent performance level and the protrusion appearing on the CT scan was most likely an incidental, asymptomatic finding. He had no back pain during the summer and spring season in , periodically low back pain during the autumn season, but played all the matches for his team.
In a soccer exercise session in the beginning of he slipped and experienced severe low back pain radiating below the knee. He was recommended bed rest for days. At the clinical examination after days he had a protective muscle spasm, scoliosis and marked reduced flexibility of his back, but negative radicular signs. Magnetic resonance imaging (MRI) revealed both degenerative findings and a lateral herniation (Fig. ..). Recent scientific opinion states that the process leading to herniations may be somewhat different from that leading to degenerative findings []. As previously, a central protrusion was observed at the L–S level, and in addition a left-positioned disk herniation was revealed at the L–L level. Schmorl’s nodels in the endplates of the upper lumbar vertebral bodies suggesting injuries during the growth period were also visualized. The abnormalities of the vertebral bodies on the MRI scan could be an outcome of torsional forces reflecting the biomechanics of the soccer keeper, including bending, twisting and jumping, combined with collisions against other players. In particular the endplate irregularities may reflect this type of activity during adolescence []. The patient had cortisone tablets for two -day periods, and some physiotherapy including massage and traction. He gradually increased his
Spine
Case story 6.5.1 (continued) activity level and managed to perform ordinary activities. Clinically he developed moderate signs of radiculopathy with paresis of dorsiflexion of the foot and a positive Lasegues sign. Three different consultant surgeons did not recommend surgery. During the spring he increased his activity level to regularly exercising – times a week, and the radiating pain and weakness of the calf muscles in the left leg gradually disappeared. He was not able to return to soccer and missed matches in the European Cup. By the beginning of June he had returned to office work. He continued to exercise regularly, and in November he tried to perform specific goalkeeper sessions including jumping, twisting and fighting for the
Multiple choice questions Scheuermann’s disease is: a a congenital structural deformity b an aseptic necrosis of the (thoracic) vertebral bodies caused by ischemia of the growth zone during the growth spurt c associated with progressive ossification of the joints of the spine d a defect in the vertebral isthmus or pars interarticularis e encroachment of the spinal canal, usually by hypertrophic bone. A spinal cord injury: a is always associated with a vertebral fracture b can be excluded if no signs of neurologic injury have been detected at the primary examination c occurs less frequently where helmets have been obligatory in ice hockey d is commonly not detected in the multitrauma patient, and is often caused by inproper stabilization of the neck in the injured athlete during transportation to hospital e is usually complete in younger patients. Cervical radiculopathy: a is characterized by neck pain and a disk herniation on MRI
ball. He was not able to finish the training sessions because of increasing pain. He eventually retired from soccer, but returned to full-time work. At the clinical examination years after the injury the flexibility of his lower back was still markedly reduced for lateral bending and forward flexion and backward bending. The lumbar lordosis was straightened and he had a minor left scoliosis and protective muscle spasm. The fingertip to floor distance was about cm. He had no muscle atrophy. The neurologic examination revealed normal findings except for dorsiflexion of the left ankle. Lasegues test and Waddel signs were negative. He is permanently disabled as a soccer goalkeeper, but not for regular work.
b is associated with balance and walking difficulties, and bowel and bladder complaints c describes pain in the neck and radicular distribution of symptoms in one or both upper extremities, concomitant sensory changes, weakness, atrophy and unilateral diminished tendon reflexes or MRI correlating with radicular symptoms d usually demands surgical treatment e requires complete rest from physical activity for weeks. Spondylolysis/spondylolisthesis: a is a stress fracture of the vertebral isthmus or pars interarticularis that is always treated by corset or surgery b appears rarely in radiologic examinations in asymptomatic individuals c is a congenital deformity predominately located at the L level d describes a bony defect associated with pain and segmental instability that is not altered by proprioceptive exercises to improve the stabilizing function of the truncus muscles in sports and daily activity e is associated with hyperextension/torsion injury in athletes and is most frequently observed in javelin throwers. Patients with unspecific low back pain:
Chapter . a should be recommended bed rest until an MRI examination has been conducted b should be informed that exercises and activities such as aerobics will increase the risk for reinjury c can effectively be treated with instrumental fusion surgery d should have an MRI examination in order to get a correct, specific diagnosis e should be treated with empathy but not overcautiousness which may reinforce fear and functional complaints. Information about the nature of the problem, emphasizing reduction of fear, will give the patient confidence to resume light activity and gradually return to former sports activity.
References Bogduk N, Macintosch JE, Pearcy MJ. A universal model of the lumbar back muscles in the upright position. Spine ; : –. Sihvonen T, Partanen J, Hänninen O, Soimakallio S. Electric behavior of low back muscles during lumbar pelvic rhythm in low back pain patients and healthy controls. Arch Phys Med Rehab ; : –. Tarazi Dvorak MFC, Wing PC. Spinal injuries in skiers and snowboarders. Am J Sports Med ; : –. Cantu RC. Catastrophic injuries of high school and collegiate athletes. Surg Rounds Orthop ; : –. Reynen PD, Clancy WG. Cervical spine injury, hockey helmets, and face masks. Am J Sports Med ; : – . Mölsä J, Kujala U, Näsman O, Lehtipuu T-P, Airaksinen O. Injury profile in ice hockey from the s through the s in Finland. Am J Sports Med ; : –. Aebi M, Thalgott JS, Webb JK. AO ASIF Principles in Spine Surgery. Berlin, Heidelberg: Springer, . Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine ; : –. Bracken MB. Pharmacological interventions for acute spinal injury. Cochrane Database Syst Rev [CD], . Seybold EA, Sweeny CA, Fredrickson BE, Warhold LG, Bernini PM. Functional outcome of low lumbar burst fractures. Spine ; : –. Kraemer WJ, Schemitsch EH, Lever J. Functional outcome of thoracolumbar burst fractures without neurologic deficit. J Orth Trauma ; : –. Radhakrishan K, Litchy WJ, O’Fallon M, Kurland LT. Epidemiology of cervical radiculopathy. Brain ; : –. Lüthje P et·al. Epidemiology and traumatology of injuries in elite soccer: a prospective study in Finland. Scand J Med Sci Sports ; : –. Tysvær AT, Sortland O, Storli O-V, Løchen EA. Hode- og
nakkeskader blant norske fotballspillere. Tidsskrift for Den Norske Laegeforening ; : –. Cassidy JD, Carroll LJ, Cote P, Lemstra M, Berglund A, Nygren A. Effect of eliminating compensation for pain and suffering or outcome of insurance claims for whiplash injury. N Engl J Med ; : –. Linton S. A review of psychological risk factors in back and neck pain. Spine ; : –. Viikari-Juntura E. Interexaminer reliability of observations in physical examinations of the neck. Phys Ther ; : –. Aker PD. GAGCPP: conservative management of mechanical neck pain: systematic overview and meta-analysis. Br Med J ; : –. Persson LCG, Carlsson CA, Carlsson JY. Long-lasting cervical radicular pain managed with surgery, physiotherapy or a cervical collar. Spine ; : –. Powell FC, Hanigan WC, Olivero WC. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar and cervical pain. Neurosurgery ; : –. Lingren K-A. Conservative treatment of thoracic outlet syndrome: a -year follow-up. Arch Phys Med Rehab ; : –. Meyer SA, Sculte KR, Callghan JJ, Albright JP, Powell JW, Crowley ET, El-Khoury GY. Cervical spinal stenosis and stingers in collegiate football players. Am J Sports Med ; : –. Harreby M, Hesselsø G, Kjær J, Neergaard K. Low back pain and physical exercise in leisure time in -year-old men and women: a -year prospective cohort study of school children. Eur Spine J ; : –. Videman T, Sarna S, Battie M, Koskinen SK, Gill K, Paananen H, Gibbons L. The long-term effects of physical loading and exercise lifestyles on back-related symptoms, disability, and spinal pathology among men. Spine ; : –. Swärd L, Hellström M, Jacobsson B, Peterson L. Back pain and radiologic changes in the thoraco-lumbar spine in athletes. Spine ; : –. Eriksson K, Nemeth G, Eriksson E. Low back pain in elite cross-country skiers. Scand J Med Sci Sports ; : –. Soler T, Calderon C. The prevalence of spondylolysis in the Spanish elite athlete. Spine ; : –. Kujala UM, Taimela S, Erkintalo M, Salminen JJ, Kaprio J. Low-back pain in adolescent athletes. Med Sci Sports Exerc ; : –. Waddel G, Main CJ, Morris RW et·al. Normality and reliability in the clinical assessment of backache. Br Med J ; : –. Buirski G, Silberstein M. The symptomatic lumbar disc in patients with low back pain. Spine ; : –. vanTulder M, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. Spine ; : –. Takahashi K, Shima I, Porter RW. Nerve root pressure in lumbar disc herniation. Spine ; : –. Rydevik B, Brown MD, Lundborg G. Pathoanatomy and
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pathophysiology of nerve root compression. Spine ; : –. Satoh K, Konno S, Nishiyama K, Olmarker K, Kikuchi S. Presence and distribution of antigen–antibody complexes in the herniated nucleus pulposus. Spine ; : –. Carragee EJ, Han MY, Yang B, Kim DH, Kraemer H, Billys J. Activity restrictions after posterior lumbar discectomy. Spine ; : –. O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylosis or spondylolisthesis. Spine ; : –. Indahl A. Low back pain — a functional disturbance. Thesis. University of Oslo, Norway, . Roy SH, DeLuca CJ, Snyder-Mackler L, Emley MS, Crenshaw RL, Lyons JP. Fatigue, recovery, and low back pain in varsity rowers. Med Sci Sports Exerc ; : –. Brox JI, Storheim K, Juel NG, Hagen KB. Har treningsterapi og manipulasjon effekt ved korsryggsmerter? Tidsskrift for Den Norske Laegeforening ; : –. Coste J, Delecoeuillerie G, Cohen DL, Le PJ, Paolaggi JB. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. Br Med J ; : –. Mannion AF, Müntener M, Taimela S, Dvorak J. A randomised clinical trial of three active therapies for chronic low back pain. Spine ; : –. Turner JA, Deyo RA, Loeser JD, Von Korff M, Fordyce WE. The importance of placebo effects in pain treatment and research. J Am Med Assoc ; : –.
Spangford EV. The lumbar disc herniation: a computeraided analysis of operations. Acta Orthop Scand ; (Suppl): –. McQuay H, Moore A. An Evidence-Based Source for Pain Relief. Oxford: Oxford University Press, . Moore N, van Ganse E, Le Parc J-M et·al. The PAIN study: paracetamol, aspirin and ibuprofen new tolerability study. Clin Drug Invest ; : –. Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on pain and dysfunction of lateral epicondyalgia. Pain ; : –. Fordyce WE, Fowler R, Lehman J, DeLateur B, Sand PL, Trieshmann RB. Operant conditioning in the treatment of chronic clinical pain. Arch Phys Med Rehab ; : –. Lindstrom I, Öhlund C, Eek C, Wallin L, Peterson L-E, Nachemson A. Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain. Spine ; : –. Richardson CA, Jull GA, Hodges PW, Hides JA. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. Edinburgh: Churchill Livingstone, . Videman T, Battie M, Gill K, Manninen H, Gibbons L, Fischer LD. Magnetic resonance imaging findings and their relationship in the thoracic and lumbar spine. Spine ; : –. Hamanishi C, Kawabata T, Yosii T, Tanaka S. Schmorl’s nodes on magnetic resonance imaging: their incidence and clinical relevance. Spine ; : –.
Chapter 6.6 Shoulder MICHAEL R. KROGS GAA RD, RI CHARD E . DE B S KI , ROLF NORLI N & L E NA RYDQVI ST
Classical reference Bankart AS. Recurrent or habitual dislocation of the shoulder joint. Br Med J ; : –. (Reprinted in Clin Orth Rel Res ; : –.) Bankart AS. The pathology and treatment of recurrent dislocation of the shoulder joint. Br J Surg ; : –. Sir A.S. Blundell Bankart was the first to recognize the pathology of the shoulder after traumatic, anterior dislocations. In his first article from he described four cases he had operated on. They all had a typical lesion, which now bears his name. He wrote: ‘The head of the humerus is forced out of the joint, not by leverage, but by a direct drive from behind forewards. In its passage foreward the head shears off the fibrous capsule of the joint from its attachment to the fibrocartilaginous glenoid ligament. The detachment occurs over practically the whole of the anterior half of the glenoid rim. The reason why the dislocation recurs after reduction is that, whereas a rent in the fibrous capsule heals rapidly and soundly, there is no tendency whatever for the detached capsule to unite spontaneously with the fibro-cartilage’. Bankart was also aware that recurrent dislocation is closely connected to forceful motion and activity, and he stated that it ‘may almost be said to be peculiar to athletes and epileptics — a rather curious association, which, as I shall show, is not without etiological significance’.
He presented his classic open operation to repair this condition (Fig. ..). His operation differed basically from standard operations of the time in two ways. First, by osteotomizing the coracoid process and de-
Fig. .. A thin shaving of bone has been raised from the anterior margin of the glenoid cavity and the neck of the scapula. Three holes have been made in the glenoid margin, and a pair of vulsellum forceps is seen in the act of making a fourth hole. A suture has been passed through the two holes in the lower half of the glenoid margin, and the two ends of this suture are seen emerging from the raw surface on the front of the neck of the scapula. Original drawing from Bankart AS [].
Shoulder taching it, and dividing the subscapularis tendon he gained very good access to the anterior portion of the glenoid, which enabled him to recognize the typical lesion. Second, he reattached the stripped-off capsule and ligaments to the glenoid with sutures (Fig. ..). His first article from reported patients and his second . All recovered full range of motion after the operation, and there were no re-dislocations. Bankart’s operation is still widely used, and it has even been adapted as an arthroscopic procedure.
Introduction: shoulder problems in sports Shoulder problems are common in sports, and are the result of either relative overuse or trauma. The spectrum of problems is broad, because the shoulder more than any other joint is dependent on the soft tissues and a very precise neuromuscular coordination during movement. The risk of developing shoulder problems among athletes is closely connected to the sport, the activity level and the age of the athlete. Even though shoulder problems are common in overhead activities, they are rare in other sports, and the overall risk of shoulder problems in athletes is –% [,]. Up to % of athletes performing overhead throwing sports or swimming have experienced significant shoulder problems which have influenced their sporting activity []. Overhead activities are performed repetitively and with great force, mainly by younger athletes, and put enormous demands on shoulder stability and muscle coordination. These athletes are therefore at high risk of overusing tendons and muscles, of stretching or deteriorating soft tissues and bone and of being involved in traumatic episodes. It is well documented that the frequency of shoulder problems — in particular shoulder pain — increases with increasing activity level [–], competitive athletes having most problems. Pain, muscle fatigue, stiffness and reduced range of motion because of degenerative disease of bone, joint cartilage, tendons and ligaments are results of either age-related changes in the tissues, repeated episodes of minor trauma, or long-term overuse. They are rare among young athletes and mainly seen in older athletes who have performed forceful or repetitive motions for longer periods.
The understanding of normal function and pathologic conditions in the shoulder has increased dramatically during the past years. In the s, arthroscopy revealed pathologies such as the superior labrum anterior to posterior (SLAP) lesion [], and arthroscopy and MRI have refined the diagnostic process to much greater detail. Intensive studies of the coordination of muscle activity during shoulder movements have shed some light on muscular imbalance and the symptoms this elicits in the athlete. Several conditions are recognized in clinical experience but not fully explained scientifically yet, such as secondary impingement and scapular instability. Many treatments still lack solid documentation. So, just as this chapter would have been very different (and much shorter) if written years ago, it will probably end up very different if revised years from now. That is what makes the shoulder complicated, but also extremely interesting.
Anatomy, dynamic function and neuromuscular coordination Anatomy A large range of mobility is essential at the shoulder to enable the prehensile hand to be placed in all of the positions required for everyday life. As a consequence, the shoulder has less bony stability than other diarthrodial joints. The shoulder complex has evolved such that mechanisms exist to guide and limit joint motion. Normal function of the shoulder requires the coordinated function of four joints and over muscles as well as the contributions of the joint capsules, ligaments and tendons comprising the shoulder complex [].
Glenoid and humeral version The geometric relationship between the humeral head and glenoid articular surface allows for the large range of motion at the normal glenohumeral joint. Radiographic, computed tomographic [,] and anthropometric studies have been used to characterize this relationship but its relative importance to glenohumeral stability still remains controversial. With the arm at the side, the scapula faces ° anteriorly on the chest wall and is tilted ° upward relative to the transverse plane and ° forward relative to the sagittal
Chapter . 130–150°
5°
20–30° retroversion
(a)
5° retroversion
(b)
(c)
Fig. .. Glenoid and humeral version. (a) ° superior tilt of the glenoid; (b) –° retroversion of the humeral head relative to the axis between the humeral condyles. Version of the glenoid is widely variable between ° retroversion and ° anteversion. (c) –° angle between humeral neck and shaft.
plane []. In general the glenoid has a superior tilt of ° [] and a range of version in the transverse plane from ° retroversion to ° anteversion []; however, a wide range of variability exists. The humeral head articular surface is inclined dorsally and retroverted relative to the humeral shaft []. The angle between the neck and shaft ranges from to ° [] while the humeral head is retroverted approximately ° relative to the axis determined by the humeral condyles [] (Fig. ..).
Articular conformity
(a)
(b)
Fig. .. Geometric relationships of the humeral head and glenoid which provide joint stability. (a) Anterior view of a right glenohumeral joint. (b) Superior view of a left glenohumeral joint showing the comparison between the humeral head– glenoid and a golf ball sitting on a tee.
The surface area mismatch between the humeral head and glenoid, expressed as a ratio of the maximum glenoid diameter to the maximum humeral head diameter (glenohumeral index), has been determined by Saha and others [,] and found to be . and . in the sagittal and transverse planes, respectively. The traditional comparison to this mismatch has been a golf ball sitting on a tee (Fig. ..), but it has been shown that the articular surfaces of the glenoid and humeral head are almost perfectly congruent, within mm, when the cartilage layer is included in the analysis [].
anisms. First, it acts as a fibrocartilaginous ring around the glenoid to which the capsuloligamentous structures are secured [,,]. The labrum also deepens the concavity of the glenoid socket approximately mm in the superior–inferior plane and mm in the anterior–posterior plane [–]. Finally, the labrum increases the surface area of contact for the humeral head, thereby enhancing joint stability [–].
Labrum
Capsuloligamentous structures
The glenoid labrum has been studied extensively [,] and its contribution to stability of the glenohumeral joint can be described in terms of three mech-
The glenohumeral joint capsule is composed of a variably thick layer of tissue with discrete thickenings that constitute the glenohumeral ligaments [,].
Shoulder Cadaver dissections [,] and observations during surgery [–] have been the tools used to elucidate the anatomy of these structures. DePalma and coworkers [] described the marked variability of the capsuloligamentous components and noted six types of anatomic arrangements which they believed could be correlated with the risk for joint instability. More recently, arthroscopy has confirmed the high variability in size and appearance of the glenohumeral ligaments [].
Superior glenohumeral, coracohumeral, middle glenohumeral and inferior glenohumeral ligaments and the posterior capsule (Fig. 6.6.4) The superior glenohumeral (SGHL) and coracohumeral (CHL) ligaments are usually described together because their anatomic courses are parallel. These ligaments form the region of the glenohumeral capsule referred to as the ‘rotator interval’ which constitutes the triangular space between the anterior Shoulder complex
Glenohumeral joint
5 1
2
4
3
Fig. .. Capsuloligamentous anatomy viewed from the side with the anterior aspect to the right and the posterior aspect to the left. The humeral head has been removed, leaving the glenoid. : SGHL, superior glenohumeral ligament; : MGHL, middle glenohumeral ligament; : AB-IGHL, anterior band of the inferior glenohumeral ligament; : PB-IGHL, posterior band of the inferior glenohumeral ligament; : LBT, long head of the biceps tendon.
border of the supraspinatus tendon and the superior border of the subscapularis tendon [,,–]. The SGHL originates from the superior glenoid rim, just inferior to the long head of the biceps tendon, and inserts into the lesser tuberosity of the humerus just medial to the bicipital groove. Although quite variable in size, it is the most consistently present of the glenohumeral ligaments and found in more than % of individuals [,,,]. The CHL courses from the lateral surface of the coracoid process to the lesser and greater tuberosities of the humerus. Patel and associates [] described the CHL as consisting of two bands, anterior and posterior, with the anterior band inserting on the lesser tuberosity and the posterior band inserting on the greater tuberosity. Gross and histologic work by Cooper and associates [] demonstrated that the CHL is usually a thin capsular fold which does not demonstrate the typical ligamentous form. Boardman and coworkers [] established that the CHL’s crosssectional area at the midsubstance was approximately four times greater than that of the SGHL. The middle glenohumeral ligament (MGHL) is the most variable of the glenohumeral ligaments, being found in only –% of individuals and poorly defined in % of the joints where it was found [,,]. It originates from the superior glenoid just below the SGHL, slightly medial to the glenoid labrum, and above the anterior band (AB) of the inferior glenohumeral ligament (IGHL) complex. The MGHL usually manifests itself in two morphologic variations: (i) sheet-like and confluent with the ABIGHL; or (ii) cord-like, with a foraminal separation between it and the AB-IGHL. The IGHL was originally described by Depalma and coworkers [] as a triangular-shaped structure running from the labrum to the neck of the humerus between the subscapularis and triceps. This anatomic description was then modified by Turkel and associates [] who found a thickening in its anterior edge termed the superior band. Others have confirmed that this structure appears consistently from specimen to specimen []. O’Brien and coworkers [], using arthroscopy and gross and histologic dissection, redefined this component as the IGHL complex which has three distinct components. Discrete anterior (ABIGHL) and posterior (PB-IGHL) bands bounded a
Chapter . thin axillary pouch. Bigliani and associates [] also found the superior or AB-IGHL to be consistently present and to represent the thickest portion of the complex (~ . mm); however, they did not find any posterior ligamentous bands. The region of the capsule located posteriorly and superiorly to the PB-IGHL [,] is called the posterior capsule (PC). There is little anatomic information available on this region, although many people have described it as the thinnest portion of the joint capsule [,].
Ligament dynamization The glenohumeral ligaments and capsule are relatively lax in the midranges of joint rotation and seem to function only at the end ranges to limit excessive translations and prevent further rotation of the humerus with respect to the scapula [,,,]. Studies have demonstrated that the rotator cuff tendons attach directly to the various capsuloligamentous components []. Therefore, it is possible that the glenohumeral capsule and ligaments may be loaded during contraction of the rotator cuff muscles.
Dynamic function Rotator cuff muscles (Fig. 6.6.5) Four muscles comprise the rotator cuff: the supraspinatus, subscapularis, infraspinatus and teres minor. The supraspinatus has its origin on the posterior/superior scapula, superior to the scapular spine. It passes under the acromion, through the supraspinatus fossa, and inserts on the greater tuberosity. The supraspinatus is active during the entire range of scapular plane abduction, and a suprascapular nerve block results in a loss of abduction torque of approximately % [,]. The supraspinatus muscle can abduct the joint without the action of the deltoid. The infraspinatus and teres minor muscles originate on the posterior scapula, inferior to the scapular spine, and insert on the posterior aspect of the greater tuberosity. Their tendinous insertions are not separate from each other or from the insertion of the supraspinatus tendon. These muscles function together to externally rotate and extend the humerus [].
Infraspinatus
Supraspinatus
1
2
3
4
Teres minor
Subscapularis
Fig. .. Rotator cuff muscles viewed from the side with the anterior aspect to the right. The humeral head has been removed.
The subscapularis muscle arises from the anterior scapula and is the only muscle to insert on the lesser tuberosity. It is the sole component of the anterior rotator cuff and functions to internally rotate and flex the humerus [,]. The tendinous insertion of the subscapularis tendon is continuous with the anterior capsule; therefore it is considered to be responsible for anterior stability []. The deltoid is the largest of the glenohumeral muscles and covers the proximal humerus on a path from its tripennate origin at the clavicle, acromion and scapular spine to its insertion midway down the humerus at the deltoid tubercle. Each of the three sections of the deltoid has a different function. The anterior portion is primarily a forward flexor of the glenohumeral joint, the middle portion is an abductor, and the posterior portion extends the joint []. The deltoid is active throughout the entire arc of glenohumeral abduction and an axillary nerve block results in a loss of abduction torque of % [].
Long head of the biceps tendon The long head of the biceps has its origin just superior to the articular margin of the glenoid and has been labeled a depressor of the humeral head, especially with external rotation of the humerus []. In this position the tendon lies directly over the top of the
Shoulder humeral head. After exiting the joint through a capsule defect, the biceps tendon enters the bicipital groove where it is retained by the transverse humeral ligament.
Scapulothoracic motion Overhead activities require an optimal balance between mobility and stability of the shoulder, and normal scapulothoracic muscle function is required for coordinated arm elevation. The serratus anterior and the trapezius are the most important muscles for scapular stabilization during arm elevation [,], and are more prone to fatigue during repetitive overhead activities such as swimming and throwing []. The motion that occurs between the scapulothoracic and the glenohumeral joint during abduction is the most extensively studied shoulder motion and has been termed the ‘scapulothoracic rhythm’ [,]. For the first ° of abduction glenohumeral motion is much greater than scapulothoracic motion. This ratio has been reported to range between : and : . Afterwards, both joints move approximately the same amount.
Neuromuscular coordination The normal shoulder is dependent on the muscles and capsuloligamentous structures that comprise this complex. Since it is usually lax and functions at the extremes of motion, the glenohumeral capsule may provide feedback information regarding joint position sense and provide reflex muscle stabilization around the joint. Studies have suggested that sensory afferent feedback systems exist that transmit information from receptors in the skin, joint and muscles to the brain and spinal pathways to produce motion that is appropriate for a given situation []. Proprioception has been defined as a specialized variation of the sensory modality of touch that includes the sensation of joint motion (kinesthesia) and joint position (sense). Relatively little information has been published on proprioception at the glenohumeral joint, with a vast majority of the concepts extrapolated from basic science and clinical studies performed at the knee. Some authors believe that a neurologic feedback mechanism exists that coordinates the actions of the shoulder muscles and protects the glenohumeral capsule from excessive strain []. In animals a ligamento-
muscular reflex has been demonstrated [], and in humans an inhibition of the shoulder muscles is elicited when the anterior capsule is electrically stimulated []. Therefore, the risk for joint injury is increased whenever a proprioceptive deficit exists and disrupts this feedback mechanism. Shoulder proprioception is mediated by peripheral receptors in articular, muscular and cutaneous structures []. The glenoid labrum and the glenohumeral ligaments have been found to contain nociceptive free nerve endings and mechanoreceptors such as Ruffini endings, Pacinian corpuscles and Golgi tendon endings. Muscle and joint receptors are probably complementary to each other as they play a role in shoulder stability. The ligaments, capsule and synovial membrane of the shoulder are innervated by the axillary, suprascapular and musculocutaneous nerves as they cross the joint []. Clinically proprioception is measured by determining the threshold for detection of passive motion (kinesthesia) and joint position sense. At slow angular velocities (.–°/s) the threshold to detection of passive motion, as well as the reproduction of passive positioning, is thought to selectively stimulate Ruffini or Golgi-type mechanoreceptors in the articular structures []. Reproduction of active positioning is believed to involve the stimulation of both joint and muscle receptors and provides a more functional assessment of the afferent pathways. A number of studies have been performed using a proprioception testing device developed at the University of Pittsburgh [,]. In college-age individuals without any history of shoulder injury, no differences were found between dominant and nondominant shoulders, with a minimal variation in proprioception. Groups containing subjects with anterior instability as well as those who had received surgical stabilization procedures were also examined. Significant differences were found between the stable and involved shoulders for subjects with instability. However, no differences could be demonstrated between the surgically reconstructed and contralateral shoulders for any given test.
Proprioception and joint kinematics A number of biomechanical and electromyographic studies suggest that coordination and synergism of the
Chapter . rotator cuff and biceps muscles are required for normal shoulder function. According to Gowan and his associates [], two groups of muscles control the shoulder during the pitching motion in professional baseball pitchers. The first group of muscles demonstrates increased electromyographic activity during the early and late co*cking phase and decreased activity during the acceleration phase. This group of muscles positions the arm for the delivery of the pitch. The second group of muscles demonstrates increased electromyographic activity during the acceleration phase of the pitch. Using the same measurement technique, Glousman and coworkers [] showed changes in the electromyographic pattern in baseball pitchers with chronic anterior instability of the glenohumeral joint. Alteration of the normal neuromuscular balance in patients with anterior instability can cause changes in joint kinematics that can lead to repetitive microtrauma of the glenohumeral joint.
History and physical examination History When a shoulder patient steps into the consulting room for the first time, it is always exciting to wonder whether this is going to be an easy case or one that will cause a headache. Shoulder problems can be just as difficult to diagnose as abdominal problems, and therefore a thorough patient history is mandatory and can save many speculations and investigations. Start at the beginning: Is this a traumatic or a non-traumatic disorder? If traumatic, how did it happen? A precise description of the incident should follow, including the direction and magnitude of the external force that was transferred to the arm and the position and motion of the arm. What were the immediate consequences (pain, fatigue, dislocation, none)? Was it possible to continue activity? What did the patient do then — which treatment was given? If non-traumatic, how did it start: suddenly or gradually? Were there any changes in normal activities, including sport and work, right before the onset of symptoms (change of technique, increase in the amount of training or workload, etc.)? Next, how has the course of the disease been? Are symptoms increasing, decreasing, constant or inter-
mittent? Has the disease influenced work or athletic activities? What is the complaint? Pain, tenderness, fatigue, loss of motion, instability? If there is pain: where is it located? Pain from the subacromial space is projected to the lateral upper arm, and pain from the infraspinatus is projected to the posterior upper arm. Bankart lesions cause pain anteriorly in the shoulder. Acromioclavicular pain is located to the joint and is only projected if the joint impinges on the supraspinatus tendon. Pain from the thoracoscapular bursa is located posteriorly around the upper half of scapula. As pain from the cervical spine can project to the shoulder girdle and arm, any history of trauma to the cervical spine and pain in the neck itself must be described. In that case the location of pain is often much more diffuse than pain from the shoulder, and in the case of cervical root compression, there will often be neurologic symptoms (numbness, paresthesia, etc.). If such symptoms are present, a detailed description of the nature of the symptoms, any variation and provocative factors, the precise location and information about fatigue of the arm are essential (see pp. –, Chapter .). Some patients with longstanding shoulder problems have diffuse feelings of intermittent numbness in the arm and hand without any pattern specific for a cervical root. These problems are often secondary to muscular tension in the shoulder girdle and will disappear when the primary shoulder problem is solved. Shoulder dislocation is the ultimate degree of instability, and often it is well documented whether it is anterior or posterior. Subluxations and feelings of instability following traumatic dislocations or multidirectional instability can usually be described by the patient: When does it happen? And how often? On the other hand, anterior instability without a primary dislocation is often unrecognized by the patient but becomes symptomatic because of secondary impingement. Clicks and lockings are indicative of labral lesions.
Physical examination A basic examination should always be performed. Additional tests can be added depending on the patient history. Both shoulders must be exposed during examination.
Shoulder Basic examination The general impression of the shoulder contours gives valuable information: Is this a muscular or a slight individual? Is there atrophy on the affected side of the deltoid (as in axillary nerve palsy), the supraspinatus (as in rotator cuff rupture) or the infraspinatus muscles (as in suprascapular nerve palsy in volleyball players)? Is the humeral head in joint? (An epulet shoulder is characteristic of acute dislocation.) Is the acromioclavicular joint intact or is the clavicle protruding? Ask the patient to perform active motions: flexion, abduction in the thoracal and scapular planes (the latter ° anterior to the thoracal plane), outwards rotation with the elbows fixed to the side, inwards rotation in horizontal abduction, hand to neck and hand to the back (optimally reaching as high as the opposite scapula). If any of the motions are reduced compared to the other side (or to normal range of motion), the passive motion is tested by the examiner. With supraspinatus/infraspinatus rupture the active abduction and outward rotation is usually greatly reduced, while passive motion is normal. In joint stiffness both active and passive motion is
Fig. .. Test of abduction power in and ° of abduction.
reduced. The true motion of the humeroscapular joint can be measured when the scapula is fixed by the examiner’s hand on top of the shoulder. Test strength of the rotator cuff muscles: abduction (in the scapular plane) (Fig. ..), inwards and outwards rotation (Fig. ..). A reduced strength can be due to either rotator cuff rupture, muscle fatigue (as in suprascapular nerve palsy with infraspinatus atrophy) or pain (which can eventually be eliminated by injection of local analgetics). The movements of the scapula are visualized by watching the patient from behind. Asymmetric movements of scapula during the first sequences of abduction, flexion and outwards rotation are indicative of tightness (reduced motion) of the humeroscapular joint or severe dysfunction of the rotator cuff, due to either tendon rupture or very painful conditions. Increased motion of the scapula may indicate muscle pathology in serratus and rhomboid muscles. Dysfunction of the rotator cuff may not show in scapular movement until a load is applied to the arm in abduction, flexion and rotation (Figs .. & ..), but will of course be demonstrated with the normal
Chapter .
Fig. .. Power test for infraspinatus muscle: outwards rotation without abduction.
rotator cuff power tests. Dysfunction of the scapular stabilizers can be demonstrated by asking the patient to perform repeated arm abductions. Fatigue in scapular stabilizers, in particular the anterior serratus and lower trapezius muscles, will show after , or more abductions as asymmetric movements or winging of the scapula. Examination for tenderness is performed in the shoulder muscles, the acromioclavicular joint, the biceptical groove and immediately subacromially. Bilateral sulcus signs are indicative of multidirectional laxity, and a unilateral sulcus sign for acquired, inferior instability. It is tested for by pulling down on the relaxed arm, and it is positive when a sulcus appears between the acromion and the humeral head (Fig. ..). The anterior/posterior stability can be graded by holding the humeral head with one hand and moving it anterior–posterior while fixing the glenoid (scapula) with the other hand (drawer test), or using the humerus as a lever for the same maneuver (axial load test, Fig. ..). Instability of the acromioclavicular joint can be tested by holding the clavicle down with one hand while applying longitudinal pressure upwards in the
Fig. .. Sulcus test for inferior instability.
Shoulder
Fig. .. Axial load test for anterior–posterior instability.
humerus with the other (grabbing around the elbow). If the joint is very loose, moving the arm into the hurra position and back to neutral will often result in painful clicking and locking. In athletes, it will always be relevant in addition to this basic examination to test for impingement and apprehension, described below.
Fig. .. Neer’s test. The examiner uses one hand to prevent rotation of the scapula and the other to passively raise the patient’s arm in a position between flexion and abduction, thereby reducing the space between the anteroinferior acromion and the greater tuberosity and provoking impingement. The test is positive if the patient — usually when the arm is approximately horizontal — experiences the well-known pain [].
be quite unsatisfactory [–]. The tests should therefore be used as an aid in the diagnostic process and not as gold standards for the diagnosis.
How good is a shoulder test? Shoulder tests are tools used to obtain the correct diagnosis and to quantify the results of treatments. Ideally, each test should be specific for one pathologic condition, i.e. precise and specific, and also be sufficiently easy to perform that it leads to the same result when performed by many examiners. For a number of tests the results have been compared to the diagnoses which were made during arthroscopy. Tests with nearly % specificity and sensitivity are reported (the active compression test) [], but most have a much lower validity [,]. Unfortunately the intra- and interobserver variation of many tests — i.e. the degree of agreement regarding the results of a test between several examiners or by repeated testings by the same examiner — seems to
Shoulder tests There are a large number of tests available in shoulder examination, but not all can be described here, and some are overlapping. The following is a selection of those most commonly used. Tests for primary impingement Neer’s and Hawkins’ tests (Figs .. & ..) were designed for primary impingement, for which both have a high sensitivity (nearly %) and a reasonably good specificity [,], but can also be used for secondary impingement. If any of the tests come out positive, an impingement release test can be performed as follows: while flexing the patient’s arm with one hand, the examiner puts a downward pressure on the upper
Chapter .
(a)
(b)
arm with the other hand, so that the humeral head is moved down. The release test is positive if it reduces the pain elicited by the impingement test. Further confirmation of a subacromial reason for the pain can be produced if a local analgesic is injected subacromially and the test can be repeated without pain.
Fig. .. (a) Apprehension test for anterior instability of the humeral head is performed with the patient supine and the shoulder just beyond the edge of the examination table. The examiner moves the patient’s arm in ° abduction and lets gravity help to externally rotate the arm as much as possible (often with the patient’s hand under the level of the examination table). The test is positive if the patient feels pain or great discomfort (fear of dislocation) in this position. The examiner can eventually augment the test by pushing the humeral head anteriorly from behind []. The degree of abduction can be varied, if the examiner wishes to stress different parts of the anterior capsule. (b) Relocation test. If the apprehension test is positive, the examiner applies an anterior force with the free hand to the humeral head, reducing the stress on the anterior structures. The test is positive if the patient is relieved from the discomfort of the apprehension test [].
Tests for instability Anterior instability is demonstrated with the apprehension test, which is most easily performed with the patient lying on the examination table (Fig. ..a). If positive, it should be followed by a relocation test (Fig. ..b). The anterior slide test is a reversed apprehension test, as it starts with relocation (the examiner applies backwards pressure on the humeral head with the arm in the hurra position) and is positive if the
patient feels pain or discomfort when the pressure is suddenly relieved. Anterior–posterior instability can be demonstrated with a drawer test or the load-and-shift test (Fig. ..). Inferior instability is demonstrated with the sulcus test (Fig. ..). Many individuals have bilateral sulcus signs without any symptoms from the shoulders.
Fig. .. Hawkins’ test. To provoke subacromial impingement, the arm is passively flexed to horizontal with the elbow in ° flexion, followed by maximum inwards rotation, reducing the space between the greater tuberosity and the anteroinferior undersurface of the acromion. The test is positive if the well-known pain is provoked [a].
Shoulder
Test for internal impingement Pain from internal impingement can be elicited with the patient in the upright position by bringing the arm into maximal external rotation and abduction (hurra position), while the examiner’s thumb exerts an anterior pressure on the humeral head at the posterior joint line. Pain is felt posteriorly in the shoulder, and there is soreness where the thumb presses on the joint line. The maneuver resembles the apprehension test, but in the latter pain and discomfort is felt anteriorly. Tests for labral lesions The anterior slide test is one of many tests for labral lesions. The basic principle is to apply pressure on the labrum while moving the humeral head. The patient positions the hands on the hips with the thumbs pointing backwards. The examiner is behind the patient and places one hand across the top of the shoulder with the index finger resting on the anterior glenohumeral joint line. The other hand is placed under the elbow, and the examiner applies a forward and superior force to the elbow and upper arm. The patient must push back against this force. An anterior–superior slide of the humeral head appears, which is usually resisted by the superior labrum. The test is positive if it results in pain or clicking in the anterior upper part of the shoulder (under the examiner’s index finger), or if it reproduces the patient’s symptoms []. A sensitivity of % and a specificity of % for detection of superior labral lesions has been reported for the anterior slide test compared to the result of arthroscopy []. A very high sensitivity and specificity for labral lesion has been reported for a recent modification of the active compression test which was originally described in for detection of biceps tendon problems. The test provokes pain or clicking inside the shoulder in the case of labral lesions [] (Fig. ..). Test of the biceps tendon A quite specific test for biceps tendon problems (tendinitis, partial tears and instability) is the supination test [] (Fig. ..). Tests for rotator cuff tears In addition to abduction strength tests (Fig. ..), an indication of a supraspinatus tear is the lag sign, i.e. the
Fig. .. Active compression test. This consists of two steps. First the patient flexes the arm to horizontal with the elbow extended, adducts the arm ° and inwardly rotates it so the thumb points downward. The examiner then applies a downward force to the arm, which the patient must resist. During step , the arm is in the same position, but the hand is fully supinated. The examiner again applies a downward force to the arm. The test is positive if pain is elicited during step and reduced or eliminated during step . If pain (or painful clicking) is localized inside the shoulder joint, the test indicates labral abnormality. If pain is localized to the acromioclavicular joint or on top of the shoulder, it indicates abnormality of the acromioclavicular joint [].
Chapter .
Fig. .. Yergason’s test. The patient flexes the elbow ° and pronates the forearm. The examiner holds the patient’s wrist to block rotation. The patient then supinates the forearm with maximal power against resistance. The test is positive if the patient feels pain in the bicipital groove.
Fig. .. Lift-off test. The subscapularis is the only muscle used for this maneuver, which if positive indicates a significant subscapularis tear. The patient internally rotates the arm and rests the dorsum of the hand on the lower back. The patient actively lifts the hand away from the back, eventually against resistance. The test is positive if the hand cannot be lifted from the back, or if power in doing so is reduced [a].
inability to hold the arm when the examiner has brought it into horizontal abduction []. Neer’s dropping sign is a very specific and sensitive test for tears of the infraspinatus: with the arm along the body and the elbow flexed °, the arm is outwards rotated by the examiner. The patient is unable to hold the arm in outwards rotation when the examiner lets go []. A positive lift-off test is indicative of a subscapularis tear (Fig. ..). Teres minor is also an external rotator, but mainly when the arm is in ° abduction. The hornblower’s sign is the inability to actively outwards rotate the arm when it is brought into ° abduction by the examiner, and is very specific and sensitive for teres minor tears (Fig. ..) []. Tests for acromioclavicular disease Pain can be provoked by compression of the joint, i.e. when the flexed, inwards rotated arm is brought into maximum adduction by the examiner. The active compression test has been reported to
Fig. .. Hornblower’s sign. The teres minor is the muscle used for this movement. With the arm passively abducted to horizontal, the patient is unable to outwardly rotate the arm [].
Shoulder be very specific and sensitive for acromioclavicular joint disease, when the pain provoked by the test is located at the joint on top of the shoulder (Fig. ..) [].
Imaging of the shoulder Shoulder imaging is valuable in the diagnostic process, which in many cases can be refined in detail. The accuracy of MRI and ultrasonography is, however, very dependent on the technical equipment and the examiner. The decision as to which modalities the examiner should use in shoulder diagnostics is therefore often dependent more on the local possibilities than on scientifically based guidelines.
X-ray A number of projections are available. The physician must select the projections which are most informative in each case. The two standard projections of the glenohumeral joint are the anteroposterior (AP) and lateral oblique views. As the scapula with the glenoid is rotated ° anterior, the joint space is not visible on a true AP view. Therefore, in the standard AP projection the body of the patient is rotated ° toward the involved side. This projection shows the glenohumeral joint space and the subacromial space. A reduction of the subacromial space is indicative of a large supraspinatus tear. The AP view is usually shot with the arm in slight internal rotation. Additional X-rays with the arm externally rotated highlight the greater tuberosity and can show e.g. cystic changes at the insertion of the supraspinatus tendon and calcifications in the tendon. The lateral view is usually also shot with ° rotation toward the affected side, and is indispensable for the diagnosis of shoulder dislocations and humeral head fractures. The arch formed by the inferior rim of the scapular neck and the posterior aspect of the humerus is usually unbroken — when it is broken, there is a dislocation of the humeral head, either anteriorly or posteriorly. This may be the only indication of a posterior dislocation, as this is often not visible on the AP view. The axillary view, which is a true inferosuperior Xray of the glenohumeral joint, is valuable in shoulder instability, where it will show the size of a Hill–Sachs lesion of the humeral head and the amount of bone loss from the anterior rim of the glenoid. This information
is necessary for preoperative planning. In humeral head fractures and in glenoid fractures it gives information about the bone fragments. The shape of the acromial arch can be revealed with the supraspinatus outlet view. The X-ray beam is tangential to the scapular body and is directed –° caudally. It reveals subacromial and acromioclavicular spurring and is used to characterize the shape of the acromion as flat, curved or hooked. A curved or hooked acromion is related to rotator cuff disease, but the outlet view is technically difficult to reproduce, and the information about acromial shape obtained from this projection is not very valid []. Anterior spurs of the acromion can be revealed with an AP projection with a ° caudal tilt. The acromioclavicular joint is visualized in an AP view with a ° cephalic tilt of the X-ray beam. With this projection spurs from the undersurface of the joint as well as degenerative changes of the acromioclavicular joint and the distal clavicle can be visualized. If the patient is standing up, stress can be applied to the joint, either from gravity or a weight, pulling the arm down, revealing dislocation of the acromioclavicular joint.
Computed tomography scan Computed tomography (CT) is useful for visualizing the bony structures of the shoulder. Defects of the glenoid in traumatic dislocations of the humeroscapular joint can be measured precisely, which is valuable in preoperative planing; a soft tissue reconstruction of the anterior capsule and ligament attachment to the glenoid is not able to prevent dislocations if a substantial portion of the anterior glenoid is missing. This is also the case if there is a large Hill–Sachs lesion (Fig. ..). In these situations an Eden–Hybbinette type of operation with a bone block transplanted to the anterior glenoid rim may be preferred. Coracoid impingement can be demonstrated with CT, either as a protrusion of the coracoid process or as an anterior subluxation of the humeral head []. Os acromiale (an unfused epiphysis of the acromion) is demonstrated excellently []. Reconstruction in three dimensions can visualize fracture fragments, osteophytes and spurs. The anteversion of the glenoid and the retroversion of the humeral head can be
Chapter .
Fig. .. CT scan of an anteriorly dislocated shoulder with a huge Hill–Sachs lesion on the posterior aspect of the humerus.
measured precisely with CT, which may be of value in the decision as to treatment of internal impingement in individual cases []. Bony spurs in the scapulothoracic space can be demonstrated with CT. In many cases of incongruity between scapula and the thoracic wall, this can only be demonstrated with three-dimensional CT reconstruction [].
Magnetic resonance imaging The technical development of magnetic resonance imaging (MRI) is still ongoing, and the introduction of cine MRI has brought about great expectations as to shoulder diagnostics in the future. As there are so many sequences to choose from in MRI, the value of shoulder MRI is very dependent on the available scanner and the expertise employed in operating it and interpreting the pictures.
Subacromial impingement may not be directly visible on MRI, as the arm is usually in few degrees of abduction and slight external rotation during scanning — and this is not the position in which the humeral head impinges on the coracoacromial arch, but the causes of subacromial impingement are detected with great accuracy: osteophytes on the acromion, hypertrophy of the acromioclavicular joint bulging into the supraspinatus muscle, degenerative disease of the acromioclavicular joint, and the type of acromion (flat, curved or hooked) (Fig. ..). The consequences of impingement are also visible: degenerative or inflammatory changes of the supraspinatus tendon with edema, subacromial bursitis, and fluid around the tendon and in the bursa. With cine MRI the changes in the width of the subacromial space can be measured during motion, and the impingement can be directly visualized []. Internal impingement is characteristic on MRI: degenerative changes in the supraspinatus near the insertion on the greater tuberosity, often small cysts in the greater tuberosity, hypertrophy and degeneration of the superior and posterior labrum, and sometimes bone bruise in the greater tuberosity and the superior glenoid []. Rotator cuff tears show as disruption and sometimes retraction of the tendon fibers. Full-thickness tears are detected with high accuracy []. Partialthickness tears show as disruptions in the tendon fibers on the bursal or the articular surface of the cuff. Fibrotic or inflammatory changes within the tendon show as abnormal signal inside the tendon with a normal signal on the bursal and articular sides. The accuracy of MRI for partial tears is lower than for fullthickness tears (Fig. ..). With MRI it is possible to image the degree of atrophy, fatty degeneration and fibrosis of the rotator cuff muscles, which is useful in the planning of repair of older complete rotator cuff tears. If more than % of the matching muscle is fat degenerated or fibrotic, the likelihood of an increase in active motion after repair of the tendon is very small, and the risk for retearing is increased []. The labrum and the glenohumeral ligaments are normally clearly visible on MRI, including the biceps tendon anchoring on the superior glenoid. In most persons the superior and middle glenohumeral ligaments
Shoulder
(a)
Fig. .. MR scan of a complete supraspinatus tear, showing as a light area in the dark tendon (arrow). (From Department of Radiology and MRI, Bispebjerg University Hospital, Copenhagen, Denmark.)
(b) Fig. .. Causes of primary subacromial impingement. (a) X-ray of a huge calcification in the supraspinatus. (b) MRI of a protruding lateral clavicle, impinging the subacromial fat pad and the supraspinatus (arrow). (From Department of Radiology and MRI, Bispebjerg University Hospital, Copenhagen, Denmark.)
are well defined on MRI, whereas the inferior ligament is not regularly seen. Tears of these structures are best seen if there is fluid in the joint, or if contrast is injected intra-articularly. Under optimal conditions SLAP lesions may be detected. With cine MRI the anterior labrum is normally very mobile, whereas the posterior labrum hardly moves during abduction [].
Biceps tendon inflammation is easily spotted because there is fluid around the tendon. Dislocation of the tendon from the sulcus and disruption is also easily demonstrated, while partial tears are seen with less accuracy. The suprascapular fossa with the suprascapular nerve and artery is clearly visible, and cysts or ganglia compressing the nerve will be seen (Fig. ..). In the bony structures intraosseous changes in the form of bone bruise or compression fractures are easily seen. These may be the result of heavy overload to the bone, e.g. during sports, or trauma. If MRI were used generally in acute shoulder trauma, a lot of changes would show, but for many of these findings, e.g. bone bruise, the clinical implications are unknown. MRI is not only able to show acute changes in muscles like disruption, hemorrhage and edema, but in conditions with muscular atrophy, it can distinguish between primary muscular changes and atrophy caused by denervation of the muscle []. Theoretically, scapulothoracic bursitis should show on MRI, but this has not been reported.
Chapter . Table .. Characteristics of the three types of impingement.
Pain Impingement tests Apprehension/relocation test Hurra test X-ray findings Ultrasound/MRI findings Subacromial corticosteroid effective
Primary subacromial impingement
Secondary impingement
Internal impingement
Subacromial and lateral upper arm + – – + + +
Subacromial and lateral upper arm (+) + – – – (+)
Posterior and posterolateral upper arm – (+) + + + –
is recognized with high accuracy, whereas full or partial rupture of the long head of the biceps is diagnosed with less sensitivity [] and the SLAP lesion is usually invisible with ultrasound. Subacromial fibrosis, edema of the rotator cuff and impingement are diagnosed with reasonably high accuracy. Anterior or posterior labral tears and Bankart lesions are best diagnosed during motion, showing a plump, hypermobile labrum []. In many cases the choice between MRI and ultrasonography in the diagnostic process depends on the availability of expertise and the technical standard.
Shoulder impingement
Fig. .. MR scan of the glenoid neck with the suprascapular fossa containing the suprascapular nerve and artery. (From Department of Radiology and MRI, Bispebjerg University Hospital, Copenhagen, Denmark.)
Ultrasound Ultrasonography is non-invasive and fast, and can be performed under dynamic circ*mstances, allowing visualization of the structures in the shoulder during motion. If experience in shoulder ultrasound investigation is available, it is a very sensitive and specific method for diagnosis of full-thickness tears of the rotator cuff [,] (Fig. ..). Partial tears, in which the pathologic changes extend to only one surface of the tendon, are more difficult to diagnose. With regard to biceps tendon pathology, dislocation of the tendon
Impingement means collision. Basically there are three forms of impingement in the shoulder: primary impingement, in which the subacromial space is overcrowded and there is too little space for the supraspinatus and biceps tendons; secondary impingement, in which the rotator cuff is subject to microtrauma or overuse during motion, because of glenohumeral instability; and internal impingement, in which the undersurface of the rotator cuff collides with the superior rim of the glenoid. This is probably a natural phenomenon, but becomes symptomatic in the athlete, because the collision happens repetitively and with great force. Primary impingement occurs mainly in athletes over years of age, whereas secondary impingement is common in younger athletes. These three forms of shoulder impingement all involve the supraspinatus tendon, but differ in pathophysiology and in the way in which they are diagnosed and treated (Table ..).
Shoulder Primary impingement Pathophysiology A breakthrough in understanding the pathophysiology of the primary, subacromial impingement came in , when Neer published his article about acromioplasty as treatment of this condition []. He recognized that many cases of primary impingement are caused by compression of the supraspinatus tendon between the anterior undersurface of the acromion, the coracoacromial ligament and the acromioclavicular joint on one side, and the humeral head and the greater tuberosity on the other. It is important to realize that the symptoms of primary impingement originate from the rotator cuff, in particular the supraspinatus tendon, even though in most cases it is caused by structures next to the tendon. Neer’s classification of primary impingement depends primarily on the condition of the rotator cuff (Table ..) []. There are several reasons why the anterior part of the subacromial space can get overcrowded. Neer divided these into outlet and non-outlet causes, the first being changes in the coracoacromial arch impinging on the rotator cuff, and the latter being changes in the subacromial bursa or the tendon itself. The acromion can be anteriorly hooked. The acromion can be divided into three categories according to shape: flat, bent and hooked (Fig. ..). Persons with a hooked acromion have a much higher risk than persons with a flat acromion for developing impingement, simply because the hook reduces the subacromial space. Instead of a hook, the acromion can host an osteophyte on the anterior undersurface. In rare cases the distal acromial epiphysis (in the anterolateral corner of acromion) does not fuse, giving rise to
an os acromiale, which can be dragged into the subacromial space by the coracoacromial ligament if the epiphysis is mobile. In some persons, the coracoacromial ligament is degenerated and calcified or has a sharp lateral edge []. The ligament is subject to some anatomic variation, and can be in three parts, of which one extends very medially from the acromion and can give rise to impingement []. The ligament normally stretches when the greater tuberosity passes under it [], so a decrease in elasticity may result in a reduction of the subacromial space during motion. After trauma or repetitive overload (e.g. from swimming) or as a result of degenerative disease, the acromioclavicular joint can be thickened, with either an osteophyte or soft tissue, bulging into the subacromial space and compressing the supraspinatus. Enlargement of the greater tuberosity after trauma (fracture) is another reason for impingement. Acute inflammation of the subacromial bursa is very painful and the most dramatic form of primary impingement. This can be a result of either increase in activity (e.g. the number of training hours) or a change — sometimes only a small change — in the nature of the activity (e.g. introduction of a new technique). If the inflammation becomes chronic, the bursa turns into fibrotic tissue, which occupies the subacromial space. The bursa can eventually calcify. Finally, the supraspinatus tendon and muscle itself can be subject to exercise-induced hypertrophy, degenerative disease, chronic tendinosis or a partial or full-thickness rupture, and calcium deposits can also develop in the tendon (Fig. ..a). A rare form of primary impingement — coracoid impingement — was described as early as . The pathophysiology can be a lateral projection of the coracoid process, a subscapular ganglion, calcification of the
Table .. Neer’s staging of primary impingement (from []). Stage
Pathology
Age of patient
Clinical course
Treatment
1 2
Edema and hemorrhage Fibrosis and tendinitis
< 25 years 25–40 years
Reversible Recurrent
3
Bone spurs and tendon rupture
> 40 years
Progressive
Conservative Bursectomy, resection of coracoacromial ligament Acromioplasty, cuff repair
Chapter . bursa in front of the subscapularis or bony projections from humeral head fractures. It can also result from anterior instability of the humeral head. Any of these factors will reduce the space between the coracoid and the subscapularis/rotator interval, introducing compression on the latter [].
In coracoid impingement, flexion combined with adduction and inwards rotation is painful. X-rays, including an axillary view, or CT scan may show protrusion of the coracoid process or bony projections from the humeral head, and MRI will show reduced space between the tip of the coracoid and the rotator cuff [].
Symptoms — clinical picture The primary symptom is pain with gradual onset. Pain spreads from the anterior and lateral part of the subacromion to the lateral part of the upper arm, but never below the elbow. Sometimes there is an intermittent feeling of numbness in the radial part of the forearm and the radial fingers. In the early stages of the disease, pain is induced only when the arm is in the horizontal position and particularly in inwards rotation, and the symptoms decrease or disappear during rest. If the cause of the impingement is not treated and the athlete continues activities unrestricted, pain may progress so that it is induced by all movements of the shoulder and present during rest and at night. When the disease becomes chronic there is often restriction in motion, particularly flexion, inwards rotation and abduction. At examination, Neer’s and Hawkins’ impingement tests are usually positive, with a significant reduction in pain when the tests are repeated after injection of a local analgesic in the subacromial space, or during the impingement release test. The joint is stable. Often there is tenderness of the subacromion anteriorly and laterally, and the acromioclavicular joint may be tender. There may be a reduction in supraspinatus strength caused by pain, but strength is normalized after subacromial injection of a local analgesic. X-rays, including an outlet view, will very often be normal, but may show a curved or hooked acromion, spurs at the anterior acromion or under the acromioclavicular joint and calcifications of the subacromial bursa or the supraspinatus tendon. MRI will typically show a reduction of the subacromial fat layer, fluid over the supraspinatus tendon, a compression in the supraspinatus tendon/muscle from spurs, acromion or a hypertrophic acromioclavicular joint, and degenerative changes in the supraspinatus tendon. Ultrasound investigation will typically show subacromial fluid and fibrosis and a slightly inhom*ogeneous supraspinatus tendon.
Treatment and prognosis There are only few randomized studies as to which treatment option is the best. Stage I impingement — which is the most common form among athletes — is usually reversible during conservative treatment, and rarely requires arthroscopy. Stage II and III are rare in younger athletes, but operative treatment is frequently necessary. Conservative treatment includes reduction of sports activities, a non-specific anti-inflammatory drug (NSAID) or subacromial injections of corticosteroid [], and a rehabilitation program which in most cases will include muscle strengthening exercises (primarily of the scapular stabilizers until pain has decreased, and then of the rotator cuff muscles) and range-of-motion exercises to avoid loss of motion and reduce tightness of the posterior capsule. Conservative treatment for – months has given good or excellent results in –% of patients with stage I–III impingement [,]. Therefore, it is generally agreed that surgical treatment should not be offered before conservative treatment has been given for at least months without satisfactory effect. Six months is somewhat arbitrary, as the proportion of patients with a satisfactory outcome during conservative treatment increases the longer the treatment period is []. In older patients with longstanding impingement, acromioplasty is a more successful treatment option than exercises []. Operative treatment is acromioplasty, which can be performed as an open or arthroscopic procedure. In Neer’s classic description from , the anterior mm of the acromial edge and enough of the anterior undersurface to make the acromion flat is removed in addition to the coracoacromial ligament. If there is protrusion of the acromioclavicular joint, this is flattened as well. The subacromial bursa or fibrous tissue
Shoulder which has replaced it is removed. Frays and tears in the rotator cuff are trimmed. It has been questioned whether this standard procedure should be performed in athletes and younger individuals as resection of the coracoacromial ligament may result in anterosuperior instability of the joint, and resection of the undersurface of the acromioclavicular joint will reduce the stability of that joint. Many surgeons choose not to operate on the acromioclavicular joint unless the main part of the patient’s symptoms can be attributed to it. In some overhead athletes with primary impingement seemingly caused by the coracoacromial ligament, good results have been reported following resection of the ligament without an acromioplasty []. Repair of fullthickness rotator cuff tears seems to give better longterm results than trimming [], and may be preferable in athletes. In athletes, up to % have a satisfactory pain reduction after acromioplasty for impingement stage II–III, but only half are able to return to their previous level of sports []. Undoubtedly, some of the patients with unsatisfactory results have misdiagnosed secondary impingements []. If an os acromiale is present, it should be resected or the epiphysis should be fused, as acromioplasty is not sufficient to relieve symptoms [].
Secondary impingement Pathophysiology In secondary impingement, there is nothing ‘in the way’ in the subacromial space, nothing that the humeral head naturally can collide with. The humeral head is brought into a position where it can collide with the acromion because of hypermobility of the head. The pathogenesis of secondary impingement seems to be glenohumeral instability with insufficiency of both the passive and dynamic stabilizers (lengthening of the glenohumeral ligaments and the anterior capsule, and dyscoordination and fatigue of the rotator cuff muscles), but the interrelationship between these conditions and impingement is poorly understood. The instability, which is usually anterior–inferior, can be either constitutional as a part of hyperlaxity, or acquired. Overhead athletic activities, e.g. swimming
and throwing, put enormous strain on the passive stabilizers of the glenohumeral joint: the glenohumeral ligaments and the joint capsule. As a consequence, these passive stabilizers may be physically stretched by the overhead activities, leading to anterior–inferior instability, in particular if the dynamic stabilizers — of which the rotator cuff muscles are the most important — fail to center the humeral head in the glenoid during motion. There are several hypotheses as to how instability can lead to symptoms from the rotator cuff (impingement). Mechanically the humeral head is subluxed anteriorly and inferiorly to the glenoid during overhead activities in these patients. Because of the anterior glide, the rotator cuff may impinge on the anterior part of the acromion and the coracoacromial ligament. A tight posterior capsule is often found and may increase the anterior glide. The supraspinatus and deltoid muscles apply superior shear force to the humeral head []. In instability, the supraspinatus muscle will be hyperactive during overhead activities, trying to center the humeral head in the glenoid. This may either lead to a superior glide of the head, compressing the supraspinatus tendon against the acromion, or lead to overuse tendinitis in the supraspinatus tendon. Fatigue of the scapular rotator muscles (in particular serratus anterior) has been reported in patients with secondary impingement. This may reduce scapular and thereby acromial rotation during overhead sports and bring the acromion into closer contact with the humeral head []. It is reported that the coordination of muscle activity in the rotator cuff and the scapular stabilizers in swimmers and throwers is different in athletes with shoulder pain compared to asymptomatic athletes [,]. This may be a failure of some muscles to fulfil the demands that the overhead activity places on them. On the other hand, in athletes with pain in only one shoulder, the muscle coordination is also altered in the symptom-free shoulder, indicating that the dyscoordination of muscles may in some cases be constitutional or caused by an inappropriate technique []. In some throwing athletes, signs of instability are found in both shoulders, indicating that laxity of the passive stabilizers in some cases may be constitutional.
Chapter . Symptoms — clinical picture The main symptom is pain, often anteriorly in the glenohumeral joint and subacromially, and sometimes extending to the anterior and lateral part of the upper arm. Onset is gradual — if symptoms started after a trauma, one must suspect a primary traumatic instability (a Bankart lesion) and not a typical secondary impingement. At first symptoms are only present during overhead sports activity, but may progress to a more chronic stage with pain during daily activities and at night. In some cases instability is felt as a glide or a click during overhead activities, in particular during maximal abduction and external rotation. At examination muscular atrophy of the supraspinatus is sometimes seen. Neer’s and Hawkins’ impingement tests may be positive, but this is not optional as in primary impingement, as the secondary impingement only happens during dynamic activity. The apprehension test is positive as either an unpleasant feeling or pain anteriorly in the glenohumeral joint, with relief during relocation. If there is a significant inferior instability component, a sulcus sign can often be provoked. X-rays are usually normal. There are no consistent findings described on MRI, but alternative diagnoses can be verified: a Bankart lesion in primary traumatic instability; changes in the lateral parts of the supraspinatus tendon and the superior labrum in internal impingement, labral tears and instability or inflammation of the biceps tendon. With the patient under anesthesia, the instability can always be demonstrated. During arthroscopy anterior–inferior gliding of the humeral head is present, but there is no avulsion of the anterior capsulolabral complex (including the middle glenohumeral ligament) from the glenoid, as in Bankart instability. There may be frays or tears of the anterior or inferior labrum, due to the gliding of the humeral head over the labrum during overhead activities. It is probably fair to say that some cases can be a mixture of secondary and internal impingement, it being impossible to say which was first.
Treatment and prognosis As with primary impingement, pain and inflammation is reduced by decrease in activity, particularly over-
head activity, rest, NSAIDs and eventually subacromial corticosteroid injections. As anterior–inferior instability is a major cause of secondary instability, rehabilitation concentrates on strengthening the dynamic stabilizers (as the passive stabilizers can not be tightened non-operatively), e.g. the rotator cuff and the scapular stabilizers. When range of motion is full and pain free, the athlete can gradually return to overhead activities. Incorporation of the correct technique is probably very important. On this conservative program, most overhead athletes have been reported to be able to return to their previous level of sports []. Patients who do not respond satisfactorily to the conservative program may be candidates for surgical treatment, which consists of tightening the passive stabilizers. In most cases an arthroscopy will be performed initially to verify the diagnosis and to treat concomitant lesions, such as labral tears. Tightening of the glenohumeral ligaments and the anterior capsule can be performed either as an open capsular shift, originally described by Neer in and modified by Warren, or as an arthroscopic procedure, where the anterior capsule and the glenohumeral ligaments are sewn to the labrum with internal sutures (Fig. ..). Both procedures show good results with % of patients being able to return to sports [,], but the long-term effect of internal suture has not been reported yet. The introduction of capsular shrinkage by burning with laser or electrically was introduced in the early s. Short-term results look promising, but some still regard this procedure as experimental, as the long-term results are unknown.
Prevention Just as hypermobile individuals have a much greater risk for rupture of the anterior cruciate ligament during sports, so they probably also have a much higher risk for secondary impingement of the shoulder, if they perform overhead sports. Hypermobile individuals may therefore be advised not to choose overhead sports. Theoretically, strengthening of the dynamic stabilizers should reduce glenohumeral instability, but there are no clinical reports to support the view that if this program is emphasized generally in overhead
Shoulder
(a)
(c)
(b)
(d)
Fig. .. Arthroscopic tightening of the glenohumeral joint capsule in anteroinferior instability.
athletes, the risk for secondary impingement is reduced.
Internal impingement Pathophysiology Internal or superior glenoid impingement was first described in by Walch []. The collision between the undersurface of the supraspinatus tendon at its insertion and the superior part of the glenoid rim is a
natural phenomenon, responsible for the maximal range of motion in abduction and external rotation in most humans [–]. Most people only occasionally use these extremes of motion (Figs .. & ..). Why this collision becomes symptomatic in some athletes, mainly those performing overhead sports (handball, baseball, volleyball, etc.), has been subject to speculation. Walch suggested that the repetitive, forceful way in which the collision theoretically may occur in overhead sports, and which is unphysiologic,
Chapter .
(e) (f ) Fig. .. Continued.
degree of external rotation at which the insertion of the supraspinatus tendon collides with the glenoid []. In one series a high percentage of anteroinferior glenohumeral instability among athletes with internal impingement [] was reported, indicating that instability may be a pathophysiologic factor. If the humeral head glides anteriorly and downwards during throwing (when the arm is in abduction and maximal external rotation), the undersurface of the supraspinatus will be brought closer to the superior glenoid rim, which may induce internal impingement. On the other hand, clear MRI signs of internal impingement in asymptomatic, throwing athletes have been reported to be unrelated to instability []. The disease has only been described in overhead athletes []. Fig. .. The pathophysiology of internal impingement. In throwing, the undersurface of the supraspinatus tendon impinges on the superior labrum and glenoid. The inferior glenohumeral ligament is stretched, resulting in anterior–inferior laxity.
explains why these athletes develop clinical symptoms. He also suggested that too small a retroversion of the humeral head will dispose to internal impingement, because the smaller the retroversion, the smaller the
Symptoms — clinical picture Three stages of the internal impingement are described (Table ..). The first symptom is pain in the back of the shoulder, perhaps extending down into the lateral and posterior part of the upper arm. Pain is only present with the arm in maximal abduction and external rotation. As the disease progresses, pain in the acceleration phase of throwing increases and the ability to throw is reduced. Clicking and locking may occur.
Shoulder Table .. The three stages of internal impingement. Stage I Stage II Stage III
Stiffness of the joint during activity, no pain Pain during activity (in particular throwing), but not during rest Irreversible constant pain
Examination usually reveals normal range of motion and normal strength of the rotator cuff muscles. Neer’s and Hawkins’ impingement tests are usually negative. Maximal abduction and external rotation (an extreme apprehension test) results in pain posterior in the glenohumeral joint, not to be confused with a positive apprehension test, in which the discomfort is felt anteriorly. Instability tests may be positive. SLAP tests may be positive. X-rays can show small bone cysts in the top of the greater tuberosity and glenoid [], but are usually normal. MRI will show degeneration of the supraspinatus at the insertion on humerus, often slight bone bruise in the back and top of the greater tuberosity and the superior glenoid, and in some cases also degeneration of the superior labrum []. The subacromial space is usually normal. Ultrasound investigation will show degeneration of the lateral supraspinatus tendon, perhaps small impressions in the greater tuberosity, and sometimes it is possible to see that the posterosuperior labrum is enlarged. Internal impingement has a typical appearance at arthroscopy [] (Fig. ..). There is fraying of the undersurface of the supraspinatus tendon close to the insertion on the humeral head, but usually no inflammation of the tendon. Often there are small lesions in the greater tuberosity just behind the insertion of the supraspinatus. The superior labrum is always frayed and often hypertrophic. The lesion may extend somewhat posteriorly. In some patients, the changes in the superior labrum has the form of a SLAP lesion.
Treatment and prognosis The treatment of internal impingement is still subject to debate. The results after debridement of the frayed tendon and labrum seemed to be satisfactory in one series, as % were able to return to sports []. Riand et al. believe that internal impingement is a
physiologic phenomenon, and that it becomes symptomatic in some people because they are built with less retroversion (that is weeks) can be treated surgically, but the complication rate (radial nerve injury and reduced muscle strength) is higher than after primary operation. Rupture of the distal triceps tendon typically occurs after falling on an outstretched arm and complete tears are easily diagnosed, as triceps is the only elbow extensor. There is a defect just proximal to the tip of the olecranon, and extension of the elbow is impossible or only possible with greatly reduced power. X-rays may show an avulsion from the olecranon. If clinically in doubt, the rupture can be demonstrated on ultrasound or MRI scan. Complete tears should be reinserted by operation, as conservative treatment results in greatly reduced extension power in the elbow, which is very disabling. Results after repair are good, as nearly all patients re-establish full extension strength and normal range of motion. Partial tears are usually located at the muscle– tendon junction and result in pain and reduced strength in extension. The extent of tearing can be
Chapter . evaluated on MRI or ultrasound, and smaller lesions can be treated conservatively.
Nerve entrapment Entrapment of a nerve occurs when it is compressed or when it is stretched over a point of fixation, e.g. a ligamentous structure. Nerve injuries can be divided into three types. Neuropraxia is loss of conduction along an intact nerve, and is the mildest form, being completely reversible. This is the most common type in athletes. Axonotmesis is a more chronic condition with degeneration of the nerve distal to the entrapment, but with intact connecting tissue. The prognosis for recovery is reasonably good. In neuretmesis there is complete disruption of the nerve, and full recovery is never gained. This is only rarely related to sports. The symptoms of nerve entrapment are pain located at the point of affection, and dysfunction of the nerve distally to this. A number of nerve entrapment syndromes are caused by repetitive stress over the elbow.
Musculocutaneous nerve overload The nerve can be compressed between the lateral border of the biceps aponeurosis and the brachial fascia during repetitive elbow extension combined with forearm pronation. Symptoms are burning hyperesthesia in the lateral forearm, and tenderness and weakness of the biceps muscle. Examination reveals atrophy of biceps and reduced sensation on the lateral forearm. Treatment consists of rest and with persisting symptoms decompression with resection of a wedge of the biceps aponeurosis [].
Ulnar nerve (cubital tunnel syndrome and compression) The nerve which is most often affected in the arm is the ulnar nerve. Around the elbow it can be entrapped at three sites: – cm proximal to the elbow at the arcade of Struthers, in the cubital tunnel, and about cm distal to the elbow at the flexor carpi ulnaris and the medial intermuscular septum. Entrapment in the cubital tunnel (posterior to the medial humeral condyle and roofed by the arcuate ligament) is the most common. The ulnar nerve is elongated about mm in the tunnel during normal flexion, and it is further loaded during throwing, when
a valgus stress is applied to the elbow, and a compression force on the nerve of up to six times resting pressure can be measured. If the cubital tunnel is narrowed and the ulnar nerve cannot glide freely, additional entrapment occurs. Narrowing of the tunnel can be caused by hypertrophy of the medial collateral ligament, fibrosis, osteophytes, etc. Entrapment at the arcade of Struthers in the upper arm or the flexor carpi ulnaris muscle in the forearm is seen with muscular hypertrophy. Symptoms are tenderness and pain at the site of entrapment, most often around the medial joint line, and neurologic symptoms, starting with paresthesia and numbness in the fourth and fifth finger, and progressing to decreased strength of the hand muscles. Clinically there is tenderness along the cubital tunnel (or at the arcade of Struthers or the flexor carpi ulnaris muscle) with positive Tinel’s sign (radiating pain when tapping on the nerve), reduced sensation on the volar side of the fifth and ulnar half of the fourth finger, and possibly atrophy of the interosseous muscles. Osteophytes in the cubital tunnel or calcifications of the medial collateral ligament can be demonstrated on X-rays (including axial radiographs), CT scans or MRI scans. Nerve conduction measurements are indicated if there is doubt about the location of entrapment, but usually this is clinically obvious. The primary treatment is conservative: rest and reduction of the activities which stress the nerve, e.g. throwing or body-building (muscular hypertrophy). With persisting symptoms, surgical treatment is necessary. The nerve is decompressed at the site of entrapment. In the cubital tunnel this can be achieved by either in situ decompression or transposition of the nerve anterior to the epicondyle. Osteophytes are removed. If the nerve entrapment is an element of thrower’s elbow (medial instability, posterior impingement, lateral cartilagenous degeneration and ulnar nerve entrapment), the medial instability should be addressed, as decompression alone rarely reduces medial pain [].
Median nerve (pronator syndrome; anterior interosseous nerve palsy) Distal to the elbow, the median nerve runs between the two heads of the pronator teres muscle and continues
Elbow, Wrist and Hand under the fibrous tissue of the flexor digitorum muscle. At the distal edge of the pronator, it gives off the anterior interosseous branch, which is a purely motoric nerve to the pronator quadratus, flexor pollicis longus and flexor digitorum profundus to the index finger. Entrapment of the median nerve (pronator syndrome) can happen with hypertrophy of the pronator teres muscles or by fibrous bands from the pronator or flexor digitorum profundus muscles, but can also be caused by enlarged vessels, a fibroma or other compressing tissues. It is mainly seen in athletes with a very well-developed muscle mass in the upper extremity and provoked by forceful pronation and gripping, e.g. in throwing, weight-lifting, racquet sports, arm wrestling and rowing. Entrapment of the anterior interosseous nerve is usually caused by fibrous bands. Nerve palsy can also be postviral. The pronator syndrome is by far the most commonly seen. The symptom is pain at the anterior upper forearm during repetitive pronation and wrist flexion, e.g. in racquet sports. There can be paresthesias in the first four and the radial half of the fifth fingers, but usually there are no motor nerve symptoms. Examination reveals tenderness - cm distal to the medial epicondyle at the pronator teres. In anterior interosseous nerve palsy there is in addition motor symptoms from the three muscles innervated by the interosseous branch: decreased flexion power in the distal phalanx of the thumb and index fingers, and decreased pronation strength with the elbow maximally flexed []. At examination there is decreased strength in the three muscles in addition to tenderness at the pronator teres muscle. In cases where the compression is caused by a tumor, it may not be felt by examination, and therefore an MRI scan is often performed in cases with motor deficiency. Nearly all cases of pronator syndrome resolve with conservative treatment: rest, NSAIDs and decrease in upper-extremity activities. If symptoms have not disappeared within – months, operative release of the nerve can be performed []. With unresolved entrapment of the motor nerve, operative release of the anterior interosseous branch should be performed.
Radial nerve (high radial palsy, radial tunnel syndrome; posterior interosseous nerve syndrome) High radial palsy is not a specific sports injury, but is seen with trauma or longer compression (e.g. from sleeping on the arm in state of drunkenness). Symptoms are mixed sensory and motoric with numbness on the dorsal side of the hand and reduction of extension force in the wrist and fingers. The triceps muscle may be involved. The radial nerve can be entrapped in the radial tunnel at five sites (Fig. ..) []: fibrous bands anterior to the radial head, vessels to brachioradialis, the tendon of the extensor carpi radialis brevis, Fröhse’s arcade (the fibrous arch at the proximal edge of the supinator muscle) and a fibrous band at the distal edge of the supinator muscle. It may probably also be compressed in the supinator muscle. Entrapment in the radial tunnel or by the supinator muscle is termed radial tunnel syndrome, and if motor symptoms are prominent it is termed posterior interosseous nerve syndrome (PINS), after the branch of the radial nerve which supplies the
Radial nerve
Recurrent radial artery Posterior interosseous nerve Arcade of Fröhse Supinator muscle Extensor carpi radialis brevis muscle (retracted)
Fig. .. Anatomy of the radial tunnel and compression sites of the radial nerve in the proximal forearm.
Chapter . extensor muscles []. The syndrome is seen with repetitive pronation/supinations, as in racquet sports, and in particular with stressed wrist extension, as in weight-lifting, bowling, rowing and golf. Symptoms are pain laterally in the forearm during activity, and in the quite rare cases of PINS also decreased strength of the muscles extending the wrist. On examination there is often pain at the supinator muscle, – cm distally to the elbow, and pain can be provoked by resisted supination with the elbow extended. There is often pain at the proximal part of the extensor muscles, especially with resisted extension of the fingers, in particular the middle finger, but this is also typical of tennis elbow. If there are motor nerve symptoms, extension strength of the fingers and the wrist is decreased. There are no sensory symptoms in this syndrome. Most cases resolve with conservative treatment, and cure after injection of corticosteroid at the tender point of compression has been described. In unresolved cases after – months surgical decompression can be performed with –% successful results.
Compartment syndrome The muscle groups in the forearm are surrounded by fasciae, which are inelastic. A rapid increase in the content of the fasciae, either hematoma, edema or hypertrophy of the musculature, therefore leads to increased compartmental pressure. With small or intermittent increases, a reversible ischemia of the muscle occurs, but the pressure may be so high that it leads to irreversible ischemia and necrosis of the muscle. A compartment pressure of mmHg or more for more than h leads to muscle death. Compartment syndrome of the forearm is in most cases post-traumatic, caused by hematoma or edema, and not particularly a sports injury. Very often the person has been lying on the arm for several hours during intoxication by alcohol or medicine. Direct trauma or muscle tears during sports can lead to edema and intracompartmental bleeding and a fulminant compartment syndrome. The symptoms are constant pain and fatigue of the involved muscle group. Clinically the involved muscle group is swollen, hard and very tender, and active function exerts extreme pain. The person should be admitted to hospital as fast as possible for surgical decompression by splitting the
muscle fascia. It is essential that this is done quickly, as irreversible changes in the muscle are induced after a few hours. Repeated heavy work with the forearm muscles, e.g. in weight-lifting, gradually increases muscle mass, which can cause compartment syndrome, as can acute edema of the muscle after excessive training [,]. In the exertional compartment syndrome symptoms appear during activity, e.g. weight-lifting or racquet sports, and they resolve quickly after activity, leaving tenderness of the muscles for some hours. Examination during activity reveals tenderness and fatigue of the muscle. Measurement of the intracompartmental pressure during activity is useful [], and with increased pressures or strong clinical evidence of compartment syndrome, fasciotomy can be performed with good results.
Wrist Tendon problems Any tendon that crosses the wrist can become inflamed with stress-related sports activities [–]. The cause can be a sudden initiation of motion or a chronic loading mechanism. The symptoms are usually pain which runs along the tendon, and is provoked by resisted activation. Treatment always starts with nonoperative means such as splinting, ice, NSAIDs and avoidance of aggravating activities. Flexibility and strength programs can be initiated after the acute inflammation has resolved. Modifications of techniques such as poor positioning of the hands on a racquet may be helpful and can be directed by a trainer to avoid future injuries.
Intersection syndrome This refers to a condition of pain, crepitus, tenderness and swelling where the abductor pollicis longus and extensor pollicis brevis cross the extensor carpi radialis longus and brevis tendons, approximately – cm proximal to Lister’s tubercle. This condition can be seen in sports which require repetitive wrist flexion and extension against resistance such as rowing or gymnastics [,], and the etiology is secondary to peritendinous inflammation and bursitis []. Non-operative treatment consists of avoiding aggravating activities, splinting of the thumb and
Elbow, Wrist and Hand NSAIDs. This is usually effective []. The addition of a steroid injection may be indicated if initial measures fail. If these measures fail and symptoms warrant it, surgical exploration with decompression of the second dorsal wrist compartment and debridement of the inflamed bursa should be considered.
de Quervain’s tenosynovitis de Quervain’s tenosynovitis is the most common form of stenosing tenosynovitis in the wrist and is seen frequently in racquet-ball players [] (Fig. ..). This condition is secondary to inflammation of the first dorsal compartment tendons (abductor pollicis longus and extensor pollicis brevis) as they pass through a tight fibro-osseous tunnel at the level of the radial styloid []. Clinically, the patient complains of pain about the first dorsal compartment which can radiate along the tendons and is related to activities, particularly thumb use. Examination reveals tenderness to palpation and swelling along the course of the tendon on the dorso-
Fig. .. De Quervain’s anatomy. From Cooney, W. (ed.) The Wrist: Diagnosis and Operative Treatment. Mosby, .
lateral wrist. Confirmation of the diagnosis is by Finkelstein’s test with pain reproduced by ulnar deviation of the hand with the thumb tucked under the fist. Around % of patients respond to non-operative treatment [] of a combination of an injection of steroid into the compartment with attention paid to the superficial radial nerve and immobilization in a thumb spica for weeks. Surgical release can be considered in recalcitrant cases [].
Extensor insertional tenosynovitis Extensor insertional tenosynovitis can occur in any of the extensor tendons. Pain along the tendon is the presenting complaint. The second dorsal compartment (extensor carpi radialis longus and brevis) is the most common of the extensor tendons to be affected. It may be associated with bony thickening at the insertion site which is referred to as carpal bossing [–]. This condition should be distinguished from a dorsal wrist ganglion where the mass is more proximal and transilluminates. Radiographic examination can
Chapter . confirm the osseous nature of this process. The condition frequently responds to non-operative management []. Tenosynovitis of the extensor pollicis longus can occur and is seen after distal radius fractures in squash or tennis players. The tendon is at risk as it crosses around Lister’s tubercle. The patient presents with a history of dorsal radial wrist pain which is elicited with resisted thumb extension. Treatment consists of splinting and NSAIDs. An injection of steroid can be added to the regimen if initial methods fail. In cases resistant to non-operative measures, transposition of the tendon radial to Lister’s tubercle can be considered.
Extensor carpi ulnaris tenosynovitis Extensor carpi ulnaris (ECU) tenosynovitis is an uncommon condition seen typically in racquet sports [,]. The ECU is notable because of its distinct sheath which crosses the wrist (Fig. ..) []. The ECU is believed to contribute to the stability of the wrist. Patients with ECU tenosynovitis typically present with dorsal ulnar wrist pain and swelling. Examination demonstrates tenderness over the ECU at the
wrist with pain provoked by ulnar deviation of the wrist and restricted dorsiflexion in the supinated position []. The treatment consists of a steroid injection combined with immobilization for weeks in a long arm splint in the pronated position. If non-operative measures fail, surgical decompression of the radial side of the subsheath may be performed. The repair of the extensor retinaculum should be done in a meticulous fashion to avoid subluxation of the extensor carpi ulnaris. Recurrent subluxation of the ECU can be caused by a traumatic event in which the ulnar aspect of the ECU fibro-osseous sheath is disrupted []. This is due to a sudden supination, ulnar deviation and palmar flexion force. The condition may be seen in golf, tennis and weight-lifting [–]. The patient presents with complaints of pain associated with a clicking with forearm rotation. This can be elicited on examination although in some cases reproduction may be difficult. If the condition is detected within the first weeks, immobilization in pronation and radial deviation should be successful. Chronic cases require surgical stabilization [].
Fig. .. Extensor carpi ulnaris (ECU) anatomy. From Cooney, W. (ed.) The Wrist: Diagnosis and Operative Treatment. Mosby, .
Elbow, Wrist and Hand Nerve disorders Nerve disorders can be common in certain athletic endeavors such as cycling, baseball, karate, rugby and handball []. Problems in these athletes may include carpal tunnel syndrome, cyclist’s palsy, gymnast palsy and Wartenberg’s syndrome. The cause of these disorders is believed to be mechanical compression secondary to local tissue edema, blunt trauma, adjacent joint synovitis or equipment constraints which results in compression and vascular compromise of the nerve. This mechanical compression causes venous obstruction and subsequent congestion, resulting in anoxia. This anoxia results in greater edema and an inflammatory response, with the end result being fibroblastic proliferation and constriction of the nerve [].
and symptoms have resolved. Splinting and antiinflammatory medications may be used. If these methods fail, decompression of Guyon’s canal can be considered. A return to sports should be avoided until symptoms have been resolved [].
Gymnast’s palsy Gymnast’s palsy is caused by direct compression of or injury to the posterior interosseous nerve secondary to hyperextension of the wrist [,]. On examination wrist extension may cause pain or simply direct compression over the dorsal aspect of the wrist may reproduce symptoms (Fig. ..). Treatment consists of cessation from hyperextension activities as well as splinting for competition. Posterior interosseous nerve neurectomy may be required if these measures fail and symptoms warrant.
Cyclist’s palsy (ulnar nerve Guyon’s canal) Cyclists can develop numbness and paresthesias in the ulnar nerve-innervated digits secondary to compression of the ulnar nerve in and distal to Guyon’s canal. This condition can arise in any sport that involves repeated compression of the ulnar palm. There are three types of compression that have been described []. Type involves motor and sensory branches. The site of compression is proximal to the canal. Type involves the canal to the area of the hook of the hamate and involves the motor branch only. The type lesion involves only the sensory branch and occurs in the distal third of the canal. Patients with this condition present with symptoms of paresthesias in the ulnar two digits. There is often a positive Tinel’s sign and tenderness over Guyon’s canal. Weakness can arise in the chronic cases due to compression of the motor branch []. Weakness can occur in the first dorsal interosseous muscle, the thumb adductor muscle which results in a positive Froment’s sign, or in the third palmar interosseous muscle which may result in a positive Wartenberg sign. Neurologic examination may note a deficit in two-point discrimination. Allen’s test should be performed to rule out vascular injury at the level of the canal []. Causative factors such as poor riding conditions or equipment such as unpadded handlebars which contribute to this condition are noted frequently in the history. Treatment includes avoiding direct pressure over the hypothenar eminence until inflammation
Wartenberg’s syndrome Any sport which requires repetitive forearm rotation and ulnar deviation of the wrist can lead to traction neuropathy of the superficial branch of the radial nerve. This condition is common in non-athletes as well. The nerve can be found located in a subcutaneous position between the extensor carpi radialis longus and the brachioradialis in the mid-distal forearm. As the nerve continues distally to the wrist, the brachioradialis and extensor carpi radialis muscles transition from muscular to tendinous portion and this is where the location of entrapment occurs. Patients complain of pain and numbness over the dorsal radial aspect of the hand and thumb. Physical examination includes Tinel’s sign over the nerve with reproduction of symptoms in wrist flexion and ulnar deviation []. Treatment includes cessation of aggravating activities, ice, and splinting in a co*ck-up wrist splint. If these measures are not successful in alleviating symptoms the nerve can be released over the point of maximal Tinel’s sign [].
Carpal tunnel syndrome Carpal tunnel syndrome is the most common compressive neuropathy at the wrist and may be associated with sporting activities secondary to flexor tenosynovitis or lumbrical muscle hypertrophy as well as an extension injury [,]. The signs and symptoms of carpal tunnel have been well described: the patient presents
Chapter . helpful in confirming the diagnosis and noting the severity of the condition []. It is important to rule out other causes of median nerve compression such as pronator syndrome, anterior interosseous syndrome and cervical radiculopathy. Treatment of carpal tunnel syndrome begins with splinting, especially at night. Causative activities should be avoided and antiinflammatory medication may help decrease the synovitis in the carpal tunnel. Injection of the carpal tunnel may assist in resolution of the symptoms. If non-operative measures fail, surgical decompression is recommended [].
Vascular disorders Hypothenar hammer syndrome
Fig. .. Gymnastic dorsiflexion injury mechanism. From Cooney, W. (ed.) The Wrist: Diagnosis and Operative Treatment. Mosby, .
with pain and paresthesias in the first, second and third digits of the hand, which can radiate along the course of the nerve. Frequently patients complain of nocturnal awakening, pain and paresthesias. Physical examination includes provocative tests such as Phalen’s sign, carpal tunnel compression sign, and Tinel’s sign. Electromyography and nerve conduction velocities are
Thrombosis of the ulnar artery in Guyon’s canal may occur in sports such as judo, karate, basketball, hockey, handball and lacrosse [,,,]. It may occur as a result of a single traumatic event or as a repetitive trauma []. The ulnar nerve and ulnar artery are susceptible to injury in Guyon’s canal. Injury to the ulnar artery may involve only the intima, in which case thrombosis occurs. A true aneurysm results from fusiform swelling of all three areas of the arterial wall, and false aneurysm is the result of a rupture of the vessel with encapsulation of a resulting hematoma []. A pseudoaneurysm results if the outer layers are disrupted, allowing a bulge of the vessel []. Patients present with pain and coldness of the fingers and palm. In advanced cases distal ulcerations of the skin can develop. When examining patients with these symptoms, Tinel’s sign may indicate nerve involvement and if absent, this suggests a primary vascular etiology. Allen’s test is the most important examination to evaluate patency of the vessels []. Differential diagnoses may include thoracic outlet syndrome, subclavian steal, systemic disease such as Raynaud’s or a vasculitis []. Beyond physical examination, Doppler studies or an angiogram may be helpful in diagnosis. Treatment initially involves rest from the offending activity. Baseball players should increase padding over the glove which can be helpful. Surgical options include exploration of the thrombosed ulnar artery with ligation and excision or vein grafting to re-establish flow [].
Elbow, Wrist and Hand Bony injuries and disorders Scaphoid fractures The scaphoid is the most frequently fractured carpal bone in athletes and occurs commonly in sports such as football, basketball, hockey and boxing []. Non-union occurs in approximately –% of patients and key factors in preventing this are early recognition and appropriate management. Most scaphoid fractures heal in an acceptable position with cast treatment []. Diagnosis is made by history and examination. Clues from the history include the mechanism of injury and location of pain, and on examination tenderness and swelling in the anatomic snuff box are noted []. Radiographs may be diagnostic; however, the absence of fracture on plain films does not rule out this injury. High clinical suspicion warrants a bone scan, CT or MRI. These studies have all been used to diagnose scaphoid fractures [,]. Treatment options are determined by displacement and chronicity of the injury. Non-displaced scaphoid fractures can be treated in a long arm thumb spica cast. Displaced fractures should be addressed surgically [].
Capitate fractures Injury to the capitate occurs from direct trauma or extreme dorsiflexion of the wrist and is often associated with high-impact velocity sports []. The mechanism of injury is extreme wrist dorsiflexion and an axial load []. This allows the capitate to come into contact with
the dorsal rim of the radius. Radiographs are often difficult to interpret due to superimposition of the other carpal bones; suspicion is therefore high, and tomograms may be helpful []. There is a high frequency of non-unions and avascular necrosis in capitate fractures therefore anatomic reduction is required []. Rigid anatomic reduction can be accomplished by internal fixation.
Hook of the hamate fractures Hook of the hamate fractures can occur in direct contact sports or racquet-sport injuries as well as golf []. The hamate hook projects into the palm in the area of the hypothenar eminence and is vulnerable at this position. Due to the proximity of Guyon’s canal any hook of the hamate fracture can be associated with neurovascular injury []. Patients present with complaints of pain in the palm aggravated by grasp. There is often loss of grip strength, and symptoms of ulnar nerve paresthesias and weakness of ulnar nerve-innervated muscles in the hand may be present []. On examination there is pain with direct palpation over the hook of the hamate. Standard X-rays should be obtained and if there is a possibility of fracture a CT scan may aid in the diagnosis [] (Figs .. & ..). Prognosis is determined by expedient diagnosis. A short arm cast is the initial treatment of choice. A delayed diagnosis may not allow for return to competition []. If nonunion occurs excision of the hook of the hamate may be done []. Open reduction and internal fixation can
Fig. .. CT scan of the hamate fracture. From Cooney, W. (ed.) The Wrist: Diagnosis and Operative Treatment. Mosby, .
Chapter .
Fig. .. Hook of hamate fracture. From Cooney, W. (ed.) The Wrist: Diagnosis and Operative Treatment. Mosby, .
be considered in both acute or delayed fractures. If the fracture is displaced or diagnosed late (more than weeks) open reduction and internal fixation is recommended [].
Triquetrum impaction fractures Fractures of the triquetrum are seen in athletes; however, there is no consistent association with any particular sport []. They tend to happen as a result of a fall or blunt trauma to the dorsum of the hand. Others have suggested impaction of the triquetrum against the ulnar styloid [,]. Patients present with dorsal ulnar wrist pain. Placement of the wrist in the position of dorsiflexion and ulnar deviation will reproduce the
pain. Another consideration with this injury is associated carpal instability, which should be addressed on examination. The triangular fibrocartilage complex (TFCC) may be injured in association with this mechanism of injury. Diagnoses made on radiographs, however, may be missed. Treatment is with immobilization in a short arm cast [].
Carpometacarpal (CMC) fractures and dislocations Injuries to the CMC joints are relatively rare due to the intrinsic stability of these joints. The most frequent mechanism of injury is axial load applied to a clenched fist. The key to treating this injury is early diagnosis,
Elbow, Wrist and Hand
and a ° pronation oblique view is the most effective method of diagnosis on radiographs []. Recommended treatment is closed reduction and stabilization by percutaneous pin fixation. If closed reduction is unsuccessful, the fracture or dislocation should be opened [,,].
Gymnast’s wrist The popularity of gymnastics has increased over the past two decades. There are often overuse injuries at the level of the wrist associated with gymnastics []. Chronic repetitive compressive forces on the distal radius have adverse effects on enchondral ossification. Repeated microtrauma may disrupt the metaphyseal vascular network. This may result in a wide and irregular physis []. Patients will present with a prolonged history of dorsal wrist pain that is exacerbated by activities and may also have local swelling over the wrist. X-rays in this condition will show widening of the distal radial physis and cystic changes and irregularity of the metaphyseal margin of the physis and palmar radial beaking adjacent to the physis and haziness of the physis [,]. This process is thought to be a result of extreme dorsiflexion. The treatment consists of cessation of aggravating activities and weight-bearing on the affected extremity should not be resumed until the patient is asymptomatic [].
palmar ulnocarpal ligaments []. Patients present with complaints of ill-defined, poorly localized pain in the ulnar aspect of the wrist, and diagnosis by wrist arthroscopy has been recommended by some []. Treatment depends on the classification and involves a combination of wrist arthroscopy with debridement or repair and immobilization [].
Impaction syndromes
Instability
There have been several impaction syndromes associated with repeated hyperextension injuries including ulnar carpal impaction syndrome, scaphoid impaction syndrome and triquetrolunate impaction syndrome. These are all commonly seen in gymnasts but may be seen in other sports []. The general approach to these types of injuries includes rest and splinting (Fig. ..).
Dislocation of the distal radioulnar joint. Distal ulnar dislocation can be either dorsal (in extreme pronation) or volar (in extreme supination by a direct blow on the ulna). Often the TFCC is torn, and rotation is very painful. This condition can be a cause of ulnar pain in athletes. Acute cases can be treated conservatively with a plaster, but in chronic cases operative repair of the TFCC is often necessary.
Triangular fibrocartilage complex (TFCC) injuries
Carpal instability is seen with rupture of the intercarpal ligaments (in most cases between the scaphoid and lunate, but sometimes between lunate and triquetrum) after a trauma to the extended, pronated wrist, e.g. during motor sport or football. The instability can be shown clinically. X-rays may be normal without stress, and the condition is sometimes overlooked. Symptoms are pain and locking. Treatment is often operative.
Injuries to the TFCC can occur in athletes and are a result of a fall on the pronated outstretched hand. They may also occur secondary to a rotational force or traction to the ulnar border of the hand. These lesions may be classified by the Palmer classification []. The TFCC is thought to contribute to the stability of the ulnar side of the wrist as well as serving as an origin for
Fig. .. Ulnar–triquetral impaction. From Cooney, W. (ed.) The Wrist: Diagnosis and Operative Treatment. Mosby, .
Chapter . Hand Fractures Subungual hematomas and tuft fracture Direct trauma to the distal aspect of the fingertip can cause a painful hematoma deep to the nail. This can often be associated with a fracture of the distal phalanx. Evacuation of the hematoma may decrease the symptoms of pain and if the hematoma occupies greater than % of the exposed nail there is a high likelihood of a significant nailbed laceration which should be surgically repaired [].
Fractures of the phalanges and metacarpals Fractures in the hand encountered in sports are often a result of low-energy injuries and are frequently stable []. Diagnosis is often easily made by an X-ray. On physical examination it is important to assess rotation of the ray by asking the patient to flex the fingertips and touch the palm (Fig. ..). Fractures of the distal phalanx may be divided into tuft, shaft and base or physeal fractures in children []. Most closed shaft and tuft fractures are stable and these may be associated with nailbed injuries. Stable fractures may be immobilized with a stack splint. Base fractures of the distal phalanx will be discussed in mallet finger deformities. Proximal and middle phalanx fractures are very common, especially in the index and small fingers []. Fractures are classified according to their anatomic location and include condylar neck and subcondylar shaft and base or epiphyseal fractures [–]. Condylar fractures are either unior bicondylar and displaced fractures should be treated surgically in an attempt to prevent articular incongruity []. Non-displaced fractures treated in cast immobilization should be followed closely due to the inherent instability of the injury. Subcondylar neck fractures are uncommon in adults but can be seen in the proximal phalanx in children []. An important injury to assess for is the fracture of the proximal phalanx that involves ° rotation of the condylar fragment and entrapment of the volar plate in the joint []. These injuries should be treated surgically. Shaft fractures are more common in adults and are stable if not displaced and are amenable to cast immobilization for – weeks. It is important again to note on
Fig. .. Rotational deformity secondary to a metacarpal or phalangeal fracture as best demonstrated with the fingers flexed. The malrotated ring finger overlaps the little finger. From Sports related injuries of the hand and wrist. Clinics in Sports Medicine ; .
examination any rotational displacement of these fractures. Base fractures in adults may be associated with joint dislocations. A significant injury that is sometimes overlooked is one that involves fracture of the volar base of the middle phalanx with dorsal subluxation of the joint []. The subluxation should be reduced and is accomplished by gentle longitudinal traction and flexion of the joint; however, if the patient extends the finger, the joint will tend to resubluxate due to soft tissue disruption. The patient should be immobilized in an extension block splint which prevents extension beyond –°. This fracture should be closely followed due to the possibility of resubluxation []. Surgical treatment has been recommended for treatment of fractures which involve more than % of the articular surface [,,].
Boxer’s fracture Fractures of the neck of the fifth metacarpal are common in sports, especially in boxing. It has been
Elbow, Wrist and Hand
Fig. .. Boxer’s fracture and th metacarpal fracture. From Green’s Operative Hand Surgery, rd edn. Churchill & Livingstone, .
reported that the angulation of a fifth metacarpal fracture up to ° can be accepted; however, ° or less is preferable [,]. These fractures are often easily reduced, but may, however, be unstable and should be followed closely (Fig. ..). As with other fractures in the hand, malrotation should be assessed and corrected. Splinting in a well-molded plaster splint will be helpful in maintaining any reduction. If reduction cannot be maintained with plaster, percutaneous Kwire fixation should be performed [].
Metacarpal shaft fractures Fractures of the metacarpal shaft can be transverse, oblique or comminuted. Non-displaced stable fractures can be treated by cast immobilization; however, any displacement, difficulty with reduction or shortening should be addressed operatively. Transverse fractures may be treated by percutaneous fixation with a K-wire. More rigid internal fixation can be provided with a plate and screws for any type of metacarpal shaft fracture []. Special attention has been paid to the thumb metacarpal fractures and these have been divided into Bennett’s and Rolando fractures as well as epibasal fractures (Fig. ..). Epibasal thumb fractures are extra-articular fractures and are amenable to thumb spica casting. Bennett’s fractures are two-part interarticular fractures at the metacarpal base and the small fragment is held in place by a volar oblique ligament while the larger portion is distracted by the
Fig. .. Rolando fracture. From Campbell’s Operative Orthopedics, th edn. Mosby, .
Chapter .
Fig. .. Mallet finger originating from bone injury. From Rockwood and Green’s Fractures in Adults, th edn. Lippincott-Raven, .
attachment of the abductor pollicis longus []. Closed reduction and cast immobilization has been effective; however, closed reduction and percutaneous pinning for less than mm of fracture displacement and open reduction and fixation for larger displacements has been effective in treating these injuries []. Rolando fractures are three-part interarticular fractures of the thumb metacarpal that should be treated surgically.
(a)
Tendon injuries Mallet finger Mallet finger injuries are a result of disruption of the extensor tendon or a fracture of the distal phalangeal dorsal base which results in extension lag at the distal interphalangeal joint and possibly volar subluxation of the distal phalanx []. In children the fracture occurs through the physis. Open mallet fingers should include surgical debridement as well as a repair of the nailbed. Closed mallet and bony mallet fingers should be splinted for – weeks and large interarticular fragments can be treated with percutaneous pinning [] (Figs .. & ..).
(b) Fig. .. Mallet fractures that are moderately displaced (a) usually heal with reasonably good congruity (b). From Rockwood and Green’s Fractures in Adults, th edn. Lippincott-Raven, .
with the wrist and metacarpophalangeal joints fully flexed []. This injury should be immediately splinted in extension. If initial non-operative treatments fail, surgical repair of the extensor tendon can be considered after adequate range of motion is obtained.
Boutonnière deformity Disruption of the extensor mechanism as it inserts to the base of the middle phalanx may present as a pure ligamentous or a bony avulsion. Boutonnière deformities do not immediately present but develop over the course of – weeks, as the lateral bands migrate volarly producing flexion at the proximal interphalangeal joint (PIP) and extension at the distal interphalangeal joint []. Acutely, the diagnosis can be made with PIP joint tenderness and weak PIP extension against resistance as well as loss of greater than ° of active extension
Avulsions of the flexor digitorum profundus Avulsion of the flexor digitorum profundus tendon is similar to a mallet deformity and is diagnosed as inability to actively flex the distal interphalangeal joint, associated with pain and swelling. Radiographs may show avulsion of the volar base of the distal phalanx. The ring finger is most often involved and is seen in football injuries as the finger is caught in the opponent’s jersey. Surgical treatment of the tendon should be performed within – days to avoid retraction of the flexor tendon.
Elbow, Wrist and Hand Dislocations/sprains Proximal interphalangeal joint (PIP) Dorsal dislocations of the PIP are very common and are typically reduced prior to presentation. Reduction can be accomplished by longitudinal traction of a digit. Dorsal dislocations may involve the volar plate and it is important to differentiate pure dislocation from fracture-dislocations where a fracture fragment or soft tissue is located in the joint space. Treatment of simple dislocations involves buddy taping for weeks []. Complex dislocations may be difficult to reduce by closed methods. Sprain of the collateral ligaments are extremely common in sports, especially basketball. If gross instability is not present, the injury can be managed with buddy taping during activities for approximately month. Resolution of this injury usually takes – months and residual swelling may be present [,].
Metacarpophalangeal joint Dorsal dislocation of the metacarpophalangeal joint can be simple or complex. Simple dislocations often appear to be hyperextended and they are reduced by flexing the first phalangeal base while maintaining dorsal pressure on the metacarpal head. Traction alone should not be used, in order to avoid converting a simple dislocation to a complex dislocation. Complex dislocations involve the flexor tendon and lumbrical muscle as well as an injury to the volar plate which is trapped in the joint. These injuries often require operative treatment if not reduced by closed means []. Simple dislocations can be addressed with reduction and buddy taping and return to activities as tolerated.
Skiier’s thumb Injuries to the ulnar collateral ligament of the thumb are frequent in sporting activities. Occasionally the ulnar collateral ligament is completely avulsed, allow-
ing the adductor epineurosis to become interposed between it and its distal insertion site. This is referred to as a Stenner lesion [,]. This injury can often be palpated on the ulnar aspect of the thumb metacarpophalangeal joint and it prevents normal healing. This results in chronic instability. Stability of the joint to adduction stress is performed with the MP joint held in the extended position as well as flexion at °. Comparison to the non-injured side is mandatory to assess laxity. Injuries with increased laxity of less than ° that have firm or minimally soft end points are considered to be grade I or II sprains and they are best treated in a thumb spica for – weeks. Surgery is indicated for: (i) irreducible injuries due to soft tissue interposition; (ii) interarticular fractures that are displaced or rotated; (iii) grossly unstable injuries; or (iv) the presence of a Stenner lesion [].
Summary Overuse problems in elbow and wrist are very common in sports, but most cases can be treated conservatively with a good outcome. In the elbow, throwing and racquet sports cause epicondylitis, tension overload of the medial ligament, posteromedial impingement and degenerative disease of the lateral compartment. Elbow instability, either from medial overload or after traumatic dislocations, can often be treated surgically. In the wrist, tendon problems are common in golf, racquet sports and cycling. Impaction and impingement problems are common in gymnastics. Nerve entrapment is an overload problem in both elbow, forearm and wrist. Hand problems in sports are mainly traumatic. A precise diagnosis of fractures, ligament or tendon ruptures and dislocations is important for an optimal outcome. This chapter has dealt with the pathogenesis, trauma mechanisms, diagnosis, imaging, treatment, outcome and prevention of these conditions.
Case story 6.7.1 A -year-old-man has played tennis for years. He had never experienced problems until last year, when he had to stop playing months before the end of the season, because of medial pain in the elbow during serving and smashes. Symptoms resolved. Two weeks into the new season he developed medial and lateral elbow pain during serving and slashing. The medial pain resolved after the matches, but the lateral pain is constant, and gets worse during daily activities. With continued playing he now also experiences paresthesia in the ulnar fingers. At examination, there is tenderness laterally, on the epicondyle and on the joint line, as well as medially some cm distal to the joint line. There is a slight extension defect and posteromedial pain with forced extension. Which specific clinical tests should be performed? Which diagnoses are possible? What is the treatment and prognosis?
1–Specific tests Forced extension and flexion of the fingers and wrist to unmask lateral or medial epicondylitis. Palpation of the ulnar nerve in the cubital tunnel and Tinel’s test for entrapment of the ulnar nerve. Test for medial stability, noting if valgus stress elicits medial pain. The valgus extension overload test should be performed for posteromedial impingement.
2–Diagnoses Lateral epicondylitis is the most common problem in middle-aged tennis players, and will also be symptomatic during daily activities. The forced extension test will be positive, and the other specific tests will come out normal. But the history and basic findings (including a small extension deficiency) are suggestive of medial overload syndrome with tearing of the medial collateral ligament, medial instability, posterior impingement, ulnar nerve overload and lateral joint degeneration. The valgus stress test will elicit pain medially, and there may or may not be
instability. The valgus extension over load test will elicit posteromedial pain in posterior impingement, and X-rays may show osteophytes on the olecranon. There may be osteophytes in the cubital tunnel and a positive Tinel’s sign, but entrapment of the ulnar nerve at other locations is of course also possible. Lateral joint degeneration may show on X-rays as decreased joint space and eventually osteophytes or osteochondritis. The history should be supplemented with information about the racquet, playing intensity, and technique. If he has changed to harder strings or a heavier racquet or increased his training hours, it may explain why he gets overload symptoms, and these factors should be corrected. If he uses a one-hand technique, he could reduce the load on the elbow by changing to a two-hand technique.
3–Treatment Primary treatment is conservative: a break from tennis, rest, NSAIDs and if necessary a corticosteroid injection laterally. Gradually as symptoms resolve he can return to tennis. If activities can be modified, the prognosis is good. With recurrent, chronic symptoms despite at least months conservative treatment, surgery can be considered. For lateral epicondylitis the cojoined tendon can be cleaned up. In posterior impingement the osteophyte on the olecranon can be removed, but in the case of medial instability, symptoms will probably develop again. With medial collateral ligament tearing without instability, the ligament can be cleaned up, but the ligament should be visualized by MRI before operation is planned. With instability, reconstruction of the ligament is the ultimate operative option, but it may be reserved for younger athletes. Degenerative changes in the lateral compartment can be cleaned up arthroscopically. Ulnar nerve transposition or cleaning up in the cubital tunnel can be performed in case of nerve entrapment. The chance of returning to recreational tennis after surgical intervention is best in cases of epicondylitis (%) and lower in the other conditions (–%).
Elbow, Wrist and Hand
Cse story 6.7.2 A -year-old telemark skier falls onto his wrist while skiing above the Arctic Circle. He is unable to seek medical attention until many months later. At that time he complains of chronic pain in his wrist. Plain radiographs demonstrate a scaphoid fracture (Fig. ..a). What tests are relevant for a scaphoid fracture? A patient with a scaphoid fracture will complain of pain on the radial aspect of the wrist. Pressure over the volar tubercle on the scaphoid will result in pain. Also, palpation of the snuff box area between the first and third dorsal compartments will result in discomfort. Radiographs will usually demonstrate a displaced fracture, however, many scaphoid fractures are initially non-displaced. Suspicion should be raised if an athlete falls onto the wrist and he presents with chronic wrist pain. A bone scan, tomogram, or CT scan may demonstrate a fracture of the scaphoid, even if the plain radiographs are nor-
mal. MRI is also very sensitive to demonstrate the fracture and the possibility of an avascular proximal segment. Most non-displaced scaphoid fractures respond well to cast immobilization for to weeks. In those athletes who desire greater mobility during the healing period, operative reduction with a screw is possible, using a variety of techniques including a percutaneous approach, arthroscopy, or traditional open exposure. Approximately % of scaphoid fractures may not heal, even with adequate cast immobilization. In such cases, open reduction and internal fixation with a bone graft is required. The bone graft can be obtained from either the iliac crest or as a vascular graft from the distal radius. In the case presented here (Fig. ..b) the young skier underwent a vascularized bone graft from the distal radius with screw fization. His fracture healed at weeks and he was able to return to telemark skiing.
(b) (a) Fig. .. An old scaphoid fracture (a), treated with a bone graft and screw fixation (b).
Chapter . Multiple choice questions Medial elbow pain in throwing athletes: a is usually caused by tennis elbow b can be caused by elbow instability c in most cases develops after a traumatic elbow injury, e.g. dislocation d combined with distinct tenderness of the medial humeral epicondyle and pain during restricted wrist flexion is most likely a golfer’s elbow. e can never be treated surgically, but should be treated with corticosteroid injections. Posterior elbow pain during sports activity: a is often caused by posterolateral rotatory elbow instability b is often seen in athletes with medial elbow instability c is usually caused by collision (impingement) between the ulnar nerve and olecranon d can be treated by arthroscopic operation e often resolves with conservative treatment in active throwing athletes. Lateral elbow pain: a elicited in the late co*cking phase of throwing can be a symptom of posterolateral rotatory elbow instability b elicited in the late co*cking phase of throwing can be a symptom of medial elbow instability c elicited during racquet sports in the middle-aged, recreational athlete is most likely lateral epicondylitis d caused by nerve entrapment is usually not combined with muscle fatigue e caused by tennis elbow usually resolves with rest, NSAIDs and eventually corticosteroid injection.
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Rettig AC. Epidemiology of hand and wrist injuries in sports. Clin Sports Med ; : –. Bergfeld JA, Wieker GG, Andrish JT et·al. Soft plain splint for protection of significant hand and wrist injuries in sports. Am J Sports Med ; : –. Riester JN, Baker BE, Mosher JF et·al. A review of scaphoid fracture healing in competitive athletes. Am J Sports Med ; : –. Rettig AC, Ryan RO, Stone JA. Epidemiology of hand injuries in sports. In: Strickland JW, Rettig AC, eds. Hand Injuries in Athletes. Philadelphia: W.B. Saunders, : –. Caine D, Roy S, Singer KM et·al. Stress changes of the distal radial growth plate: a radiographic survey and review of the literature. Am J Sports Med ; : –. Dobyns JH, Gabel GT. Gymnast’s wrist. Hand Clinics ; : –. Binder AI, Hazleman BL. Lateral humeral epicondylitis — a study of natural history and the effect of conservative therapy. Br J Rheum ; : –. Davidson PA, Pink M, Perry J, Jobe FW. Functional anatomy of the flexor pronator muscle group in relation to the medial collateral ligament of the elbow. Am J Sports Med ; : –. Field LD, Callaway GH, O’Brien SJ, Altcheck DW. Arthroscopic assessment of the medial collateral ligament complex of the elbow. Am J Sports Med ; : –. Morrey BF, An KN. Functional anatomy of the ligaments of the elbow. Clin Orth Rel Res ; : –. Schwab GH, Bennett JB, Woods GW, Tullos HS. Biomechanics of elbow instability: the role of the medial collateral ligament. Clin Orth Rel Res ; : –. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory instability of the elbow. J Bone Joint Surg (Am) ; : –. Edelson G, Kunos CA, Vigder F, Obed E. Bony changes at the lateral epicondyle of possible significance in tennis elbow syndrome. J Shoulder Elbow Surg ; : –. Kang HS, Kindynis P, Brahme SK, Resnick D, Haghighi P, Haller J, Sartoris DJ. Triangular fibrocartilage and intercarpal ligaments of the wrist: MR imaging. Cadaveric study with gross pathologic and histologic correlation. Radiology ; : –. Gruchow HW, Pelletier D. An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention strategies. Am J Sports Med ; : –. Nirschl RP. Tennis elbow. Orthop Clinics N Am ; : –. Kibler WB. Pathophysiology of overload injuries around the elbow. Clin Sports Med ; : –. Froimson AI. Treatment of tennis elbow with forearm support band. J Bone Joint Surg (Am) ; -A: –. Groppel JL, Nirschl RP. A mechanical and electromyographic analysis of the effects of various joint counterforce braces on the tennis player. Am J Sports Med ; : –.
Elbow, Wrist and Hand Ciccotti MG, Lombardo SJ. Lateral and medial epicondylitis of the elbow. In: Jobe FW, ed. Operative Techniques in Upper Extremity Sports Injuries. St. Louis: Mosby, : . Leach RE, Miller JK. Lateral and medial epicondylitis of the elbow. Clin Sports Med ; : –. Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg (Am), ; : –. Vangness CT Jr, Jobe FW. Surgical treatment of medial epicondylitis. Result in elbows. J Bone Joint Surg (Brit) ; -B: –. Slocum DB. Classification of elbow injuries from baseball pitching. Texas Med ; : –. Andrews JR, Timmerman LA. Outcome of elbow surgery in professional baseball players. Am J Sports Med ; : . Andrews JR, Craven WM. Lesions of the posterior compartment of the elbow. Clin Sports Med ; : –. Jobe FW, Kvinte RS. Elbow instability in the athlete. Instruct Course Lect ; : . Glousman RE, Barron J, Jobe FW, Perry J, Pink M. A electromyographic analysis of the elbow in normal and injured pitchers with medial collateral ligament insufficiency. Am J Sports Med ; : –. Andrews JR. Bony injuries about the elbow in the throwing athlete. Instruct Course Lect ; : –. Glousman RE. Ulnar nerve problems in the athlete’s elbow. Clin Sports Med ; : –. Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg (Am) ; : –. Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in the throwing athlete. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg (Am) ; -A: –. Thompson WH, Jobe FW, Yocum LA, Pink MM. Ulnar collateral ligament reconstruction in athletes: Musclesplitting approach without transposition of the ulnar nerve. J Shoulder Elbow Surg ; : –. Jackson DW, Silvino N, Reiman P. Osteochondritis in the female gymnast’s elbow. Arthroscopy ; : –. Tullos HS, King JW. Lesions of the pitching arm in adolescents. J Am Med Assoc ; : –. Baumgarten TE, Andrews JR, Satterwhite YE. The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med ; : –. Takahara M, Shundo M, Kondo M et·al. Early detection of osteochondritis dissecans of the capitellum in young baseball players. Report of three cases. J Bone Joint Surg (Am) ; -A: –. Bauer M, Jonsson K, Josefsson PO, Linden B. Osteochondritis dissecans of the elbow: a long-term follow-up study. Clin Orth Rel Res ; : –. Mitsunaga MM, Adishian DA, Bianco AJ Jr. Osteochon-
dritis dissecans of the capitellum. J Trauma ; : –. Woodward AH, Bianco AJ Jr. Osteochondritis of the elbow. Clin Orth Rel Res ; : –. McManama GB Jr, Micheli LJ, Berry MV, Sohn RS. The surgical treatment of osteochondritis of the capitellum. Am J Sports Med ; : –. Josefsson PO, Johnell O, Gentz CF. Long-term sequelae of simple dislocations of the elbow. J Bone Joint Surg (Am) ; : –. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Surgical versus non-surgical treatment of ligamentous injuries following dislocation of the elbow joint: a prospective randomized study. J Bone Joint Surg (Am) ; : –. Josefsson PO, Gentz CF, Johnell O, Wendeberg B. Dislocations of the elbow and intraarticular fractures. Clin Orth Rel Res ; : –. Cohen MS, Hastings H. Rotatory instability of the elbow: The anatomy and role of the lateral stabilizers. J Bone Joint Surg (Am) ; -A: –. Rayan GM. Recurrent dislocation of the extensor carpi ulnaris in athletes. Am J Sports Med ; : –. Nestor BJ, O’Driscoll SW, Morrey BF. Ligamentous reconstruction for posterolateral rotatory instability of the elbow. J Bone Joint Surg (Am) ; -A: –. Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii. A biomechanical study. J Bone Joint Surg (Am) ; : –. D’Alessandro DF, Shields CL Jr, Tibone JE. Repair of distal biceps tendon ruptures in athletes. Am J Sports Med ; : –. Davidson JJ, Bassett FH, Nunley JA. Musculocutaneous nerve entrapment revisited. J Shoulder Elbow Surg ; : –. Spinner M. The anterior interosseous-nerve syndrome, with special attention to its variations. J Bone Joint Surg (Am) ; -A: –. Sponseller PD, Engber WD. Double-entrapment radial tunnel syndrome. J Hand Surg (Am) ; : –. Potter HG, Weiland AJ, Schatz JA, Paletta GA, Hotchkiss RN. Posterolateral rotatory instability of the elbow. Usefulness of MR imaging in diagnosis. Radiology ; : –. Jawed S, Jawed AS, Padhiar N, Perry JD. Chronic exertional compartment syndrome of the forearms secondary to weight training. Rheumatology (Oxf) ; : –. Søderberg TA. Bilateral chronic compartment syndrome in the forearm and the hand. J Bone Joint Surg (Brit) ; -B: –. Osterman AL, Moskow L, Low DW. Soft tissue injuries of the hand and wrist in racquet sports. Clin Sports Med ; : –. Stern PJ. Tendinitis, overuse syndromes and tendon injuries. Hand Clinics ; : –. Wood MB, Dobyns JH. Sports related extra-articular wrist syndromes. Clin Orth Rel Res ; : –.
Chapter . Wood MB, Linscheid RL. Abductor pollicis longus bursitis. Clin Orth Rel Res ; : –. Linscheid RL, Dobyns JH. Athletic injuries of the wrists. Clin Orth Rel Res ; : –. McCune FC III, Baugher WH, Kuland DN. Hand and wrist injuries in the athlete. Am J Sports Med ; : –. Pettrone FA, Ricciardelli E. Gymnastic injuries: The Virginia experience. Am J Sports Med ; : –. Hajj AA, Wood MB. Stenosing tenosynovitis of the extensive carpi ulnaris. Am J Hand Surg ; : . Spinner M, Kaplan EB. Extensor carpi ulnaris: Its relationship to the stability of the distal radioulnar joint. Clin Orth Rel Res ; : –. Burkhart SS, Wood MB, Linscheid RL. Post-traumatic recurrent subluxation of the extensor carpi ulnaris tendon. Am J Hand Surg ; : –. Plancher KD, Peterson RK, Steichen JB. Compressive neuropathies and tendinopathies in the athletic elbow and wrist. Clin Sports Med ; : –. Rowland SA. Acute traumatic subluxation of the extensor carpi ulnaris at the wrist. Am J Hand Surg ; : –. Shea JD, McClain EJ. Ulnar nerve compression syndromes at and below the wrist. J Bone Joint Surg (Am) ; -A: –. Rettig AC. Neurovascular injuries in the wrists and hands of athletes. Clin Sports Med ; : –. Dellon AL, Seif SS. Anatomic dissections relating the posterior interosseous nerve to the carpus and etiology of dorsal wrist ganglion pain. Am J Hand Surg ; : –. Aulicino PL. Neurovascular injuries in the hands of athletes. Hand Clinics ; : –. Ho PK, Dellon AL, Wilgis EF. True aneurysms of the hand resulting from athletic injuries. Report of two cases. Am J Sports Med ; : –. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orth Rel Res ; : –. Perlik PC, Guilford WB. Magnetic resonance imaging to assess the vascularity of scaphoid nonunions. Am J Hand Surg ; : –. Recht MP, Burk DL Jr, Dalinka MK. Radiology of wrist and hand injuries in athletes. Clin Sports Med ; : –. Stein F, Seigel MW. Naviculocapitate fracture syndrome: A case report. New thoughts on the mechanism of injury. J Bone Joint Surg (Am) ; -A: –. Whalen JL, Bishop AT, Linscheid RL. Nonoperative treatment of acute hamate hook fractures. Am J Hand Surg ; : –. Levy M, Fischel RE, Stern GM et·al. Chip fractures of the os triquetrum: The mechanism of injury. J Bone Joint Surg (Am) ; -B: –.
Garcia-Elias M, Dobyns JH, Cooney WP III et·al. Traumatic axial dislocations of the carpus. Am J Hand Surg ; : –. Garcia-Elias M, Bishop AT, Dobyns JH et·al. Transcarpal carpometacarpal dislocations excluding the thumb. Am J Hand Surg ; : –. Read MT. Stress fractures of the distal radius in adolescent gymnasts. Br J Sports Med ; : –. Cooney WP. Evaluation of chronic wrist pain by arthrography, arthroscopy and arthrotomy. Am J Hand Surg ; : –. Mastey R, Weiss A, Akelma E. Primary care of hand and wrist athletic injuries. Clin Sports Med ; : –. Dixon GL, Loon NF. Rotational supracondylar fractures of the proximal phalanx in children. Clin Orth Rel Res ; : –. Simmons BP, Lavallo JL. Hand and wrist injuries in children. Clin Sports Med ; : –. Jupiter JB, Belsky MR. Fractures and dislocations in the hand. In: Browner BD, Jupiter JB, Levine AM et·al., eds. Skeletal Trauma, third edn. Philadelphia: W.B. Saunders, : –. O’Brien ET. Fractures of the hand and wrist regions. In: Rockwood CA, Wilkins KE, King RE, eds. Fractures in Children, third edn. Philadelphia: J P Lippincott, : –. Palmer AK. Triangular fibrocartilage complex lesions: a classification. Am J Hand Surg ; : –. Culver JE. Sports related fractures of the hand and wrist. Clin Sports Med ; : –. Agee J. Unstable fracture dislocations of the proximal interphalangeal joint of the fingers: a preliminary report of a new technique. Am J Hand Surg ; : –. Schenck RR. Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. Am J Hand Surg ; : –. Smith RJ, Peimer CA. Injuries to the metacarpal bones and joints. Adv Surg ; : –. Pelligrini VD Jr. Fractures at the base of the thumb. Hand Clinics ; : –. Eaton RG, Malerich MM. Volar plate arthroplasty for the proximal interphalangeal joint: a -year review. Am J Hand Surg ; : –. Green DP, Rowland SA. Fractures and dislocations in the hand. In: Rockwood CA, Green DP, Bucholz RW, eds. Fractures in Adults, third edn. Philadelphia: JP Lippincott, : –. Becton JL, Christian JD Jr, Goodwin HN, Jackson JG III. A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg (Am) ; -A: –. Stenner B. Displacement of the ruptured ulnar collateral ligament of the metacarpophalangeal joint of the thumb. A clinical and anatomical study. J Bone Joint Surg (Brit) ; -B: –.
Chapter 6.8 Practical Sports Medicine SVERRE MÆHLUM, HE NNI NG LA NGBE RG & INGGARD LE RE I M
The sports medicine team Sports medicine encompasses many different areas of professional specialization, such as exercise physiologists, sports psychologists, coaches, medical doctors and physical therapists. Needless to say each of these areas of specialization make a significant contribution and it is essential to realize that only a team approach that takes maximal advantage of everyone’s talent and expertise can most optimally ensure a rapid and successful return of the athlete to a competition level after injury. Ideally all medical teams should include a medical doctor, a physiotherapist and a sports psychologist. To ensure that the athlete receives the best treatment and care during the rehabilitation process and in the preventive phase it is paramount that medical records be kept, and that all decisions concerning the athlete be communicated to all members of the medical team. The different members of the Sports Medicine team have to conduct assessments at various times after the injury. Such assessments may have distinct purposes: (i) at the time of injury to determine first aid, emergency care measures and transportation needs; (ii) prior to initial treatment to determine the general and specific course for treatment; (iii) during the treatment phase to determine the effectiveness of the treatment and the need for changes in treatment; and (iv) before returning the athlete to full sport participation to assess the athlete’s readiness to return. It is also important that each member of the medical team has detailed knowledge of the physical and psychological demands of the sport and the type of injuries that are likely to occur, and is familiar with the sport-specific training, conditioning and competition so as to be able to formulate prevention strategies and
determine etiology, treatment and the readiness of the athletes to return to play after injury. It is also essential to be familiar with the relevant rules of the sport, including regulations regarding on-field assessment, the use of braces and the doping rules. With respect to assessment and treatment it is important for the sports medical team to have full access to a separate room. An established routine for making appointments and a waiting area is useful. Appropriate medical services will ensure adequate treatment of acute injuries and thus contribute to better and more rapid rehabilitation.
Injury assessment Before an injury is sustained it is important for the sports medicine team to have an emergency plan in place for management and transportation of the injured athlete. The method of transporting the athlete off the field is based on the type of injury and its severity. The sports medicine team must be able to provide assessment and emergency care of injuries instantaneously, and thus be able to be contacted easily by players and officials. In many team sports the obvious location for the medical personnel is on the bench. At the time of injury, it is essential that a member of the medical team immediately perform an on-field assessment to exclude the presence of life-threatening conditions. Hereafter the necessary first aid is carried out and the athlete is safely transported off the field. On the sideline, a second and more detailed sideline assessment can be conducted.
On-field assessment The best handling of an acute injury starts with a good on-field assessment. The purpose of the on-field assessment is to rule out life-threatening and serious in-
Chapter . juries, to determine the severity of the injury, to decide on the mode of transportation of the athlete off the field, to make a quick assessment, and to initially treat the injury in order to minimize any secondary injury. This type of assessment is the most important since an incorrect decision can have dire consequences.
Primary examination The first and foremost aim of any initial on-site examination is to save life, and thereafter to address nonlife-threatening injuries. While most sports-related injuries are not life-threatening it still remains incumbent on the medical staff to ensure that such is the case. Thus, first and foremost it is necessary to conduct a primary assessment for life-threatening conditions by checking airways, breathing and circulation. Thereafter an assessment of neurologic status should be performed, including a Glasgow coma scale, and when appropriate issues of exposure should be addressed, e.g. hypothermia in the case of a skiing accident. If the athlete is unconscious, try to arouse him by speaking loudly, or eliciting a pain response. Remember that athletes with severe injuries or severe pain are most susceptible to shock. When signs or symptoms of shock are observed immediate relevant action must be undertaken. If it is not possible to arouse the athlete immediate first aid must be performed. If the injury is not life-threatening an on-field history should be taken, determining the mechanism, location and severity of the injury. A complete history is not needed during on-field assessment. The goal is to gather the critical information necessary to determine the overall nature and extent of the injury and to decide on the best way of transporting the athlete off the field. The rest of the history-taking can be postponed to the sideline evaluation once the athlete has been safely removed from the playing field. If a spinal injury is suspected from the history of the injury the athlete’s head should be stabilized while performing a bilateral peripheral nerve assessment for sensory and motor innervations. For a suspected head injury, proceed by asking questions to find out about the athlete’s orientation with respect to time, place and person. If the injury involves bony structures, palpation for possible fractures or dislocations should be undertaken. In summary, initial screening should give sufficient information to determine the extent and severity
of the injury and thus allow for proceeding with the immediate action plan.
Sideline assessment The sideline assessment either follows an on-field assessment or serves as the initial evaluation of an injured athlete who has been able to walk off the field. If observed, the occurrence of the injury itself often provides information as to the region and type of injury. The purpose of the sideline assessment is to determine more precisely the nature and severity of the injury so that the appropriate initial treatment can be administered. The sideline assessment includes history, observation, palpation, special tests and tests of range of motion and strength, and finally neurologic, circulatory and functional tests depending on the type and severity of the injury. In the following sections the individual parts of the sideline assessment are described in more detail.
History Once off the field the athlete’s subjective impression of the injury should be obtained with regard to the direction and position of the impact, the exact position of the body, the type and timing and location of the pain, whether any sounds were ‘heard’ and whether previous injuries related to the present injury are present.
Observation Observation starts during the transportation of the athlete off the field by observing the loading and the position of the injured area, eventual protection of the injured part, and the reaction during removal of shoes or clothing and inspection of the contour and position of the injured area compared to the noninjured side.
Palpation The goal of palpation is to obtain information regarding the presence or absence of swelling, the texture of the soft tissues, and the contours of the bony structures. In addition, the palpation gives information on pulse and temperature, and the athlete’s sensitivity and level of pain. All this information is essential for determining the severity of the injury and for planning the optimal treatment. It is, however, important that the palpation is performed in a systematic fashion includ-
Practical Sports Medicine ing all relevant structures. Preferably the palpation is performed first on the non-injured side in order to familiarize the athlete with the assessment. The results from the non-injured side serve as ‘the normal reference’ of the athlete. Superficial and outlying structures shoud be palpated first leaving the most painful areas to be palpated last. Remember to obtain the relative severity of the pain by asking the athlete e.g. to rate the pain on a –-point scale.
Special tests, range of motion and strength The history, observation and palpation of the athlete provide a rough idea of the type and severity of the injury. In order to eliminate or confirm a specific diagnosis a range of special tests must be performed. These tests should allow the investigator to stress the structures sufficiently to distinguish between injured or non-injured structures without aggravating the injury. As for palpation of the extremities, the specific tests should first be performed on the non-injured side. The sum of the results from the tests performed should help in narrowing the possibilities of the diagnosis. When testing the range of motion (ROM) it is recommended to start by allowing the athlete to actively move the injured joint, observing the quantity and quality of the movement. Based on the result further information can be obtained by passively moving the injured joint, making an assessment of the end-feel of the joint possible. Following the determination of ROM, strength testing can provide information on the neuromuscular integrity in the activated contractive structures on the injured area. Preferably first isometric strength with the joint in midposition is tested slowly, building up the resistance with respect to the athlete’s pain and the severity of the injury. The result of the strength assessment is strongly influenced by the presence of pain. If no strength can be produced in spite of the absence of pain, nerve injury or musculotendinous rupture may be possible and neurologic examination must be undertaken.
Neurologic, circulatory and functional tests Neurologic tests include both testing of the innervations of the muscles as well as testing of sensation of the skin and reflexes. In all normal assessments of sports-related injuries a screening of the nerves should be included as a standard. Again, systematic
examination is important making the screening quick, easy and reliable. For testing of the circulatory system pulses are palpated in the area of the injury and distally thereafter. The presence, strength and regularity are registered. The color and temperature of the skin also give valuable information on the circulation in the area. If the injury appears to be of minor severity, functional tests related to the specific sport should be performed before permitting the athlete to return to the field. The tests should stress the structures beginning with slow controlled movements progressing in terms of speed and direction towards movements related to the specific sport. These tests make assessment of the quality of the movements possible.
Acute treatment — special emphasis on muscle injury If an acute trauma has occurred involving joints, muscle or soft tissue injury it is essential to use an aggressive approach in order to stop the bleeding within and around the tissue. To this effect (i) local cooling, (ii) external compression to the injured area, and (iii) elevation of the injured limb is widely recommended (the RICE concept) [–]. The pain-relieving effect of cold application is well documented and has also been hypothesized to reduce the activity of inflammatory enzymes [,]. Based more on clinical than on experimental evidence, it has been suggested that application of ice decreases local blood flow and thus reduces the tendency of swelling. The reduction in local blood flow is very dependent on the depth of injury tissue []. In the event of an acute injury with intratissue bleeding, the delayed reaction of cryotherapy on local blood flow means that cold application should not be the primary treatment unless the main concern is solely to relieve the pain associated with the injury [,]. Somewhat in contrast to cold application, external compression has been shown to reduce local blood flow [,,]. Therefore in order to quickly stop intratissue bleeding and effectively reduce the size of the hematoma, instant application of external compression on the injured area should logically be of primary concern []. For elevation of the injured limb to be efficient in reducing the local blood flow an elevation of least cm above heart level is required before significant reduc-
Chapter . tion of blood flow can be expected [,]. Medication administered in the acute phase includes analgesics, anesthetics and relaxants to relieve pain and reduce cramping. Often non-steroidal anti-inflammatory drugs (NSAIDs) are recommended not only to relieve pain but also to prevent swelling and excessive inflammatory reaction [,,]. It is not known, however, whether a reduction of the inflammation has any influence on the recovery after injury or whether the inflammation is essential for the repair of the injured tissue [–]. For further information on the effect of NSAIDs in relation to sports injury treatment please see Chapters . (Recovery) and . (Pharmacology treatment). In relation to acute treatment of any injury it cannot be emphasized enough that pain relief after the initial treatment may not lead to the conclusion that the athlete can resume the activity.
Off-field assessment Often it is not possible to evaluate the injury immediately after it occurs. More often, athletes are seen hours or days after an acute trauma, or after a slowly progressing overuse injury. In these cases the history and the assessment alone has to provide the necessary
General treatment Air splint Cold spray Instant cold packs Heat cream Massage oil Sun cream Lip balm Insect repellent Safety pins, rubber bands Thermometer Scissors Nail clippers Disposable gloves Syringes Sterile cannulas Stethoscope
information concerning the severity, irritability and nature of the injury. You have to bear in mind that the symptoms and thus the picture of the injury will often be less clear, as the profile of the injury changes with time and the findings are no longer the same as immediately after the onset of the injury. The offfield assessment is roughly identically to the sideline assessment although no time pressure is present and the facilities during off-field assessment permit more accurate and specific assessment. In addition the off-field assessment can be assisted by diagnostic tests such as laboratory tests, ultrasound scans, MR and radiographic tests, or even arthroscopy investigations, making specific diagnosis possible (see Chapter .).
Sports medicine kit A list of the most essential equipment and supplies which should be available for assessment and treatment of injuries during training and games is found in the box below. A presence of a large number of the items mentioned for general treatment is not necessarily based on scientific evidence for their effect, but is based on practical experience from team doctors and physiotherapists.
Alcohol swabs Medical supplies Current list of permitted and prohibited medication (doping) Analgesics Oral steroid (glucocortocoid) Antihistamines Antifungal agent Eye drops Ear topical treatment Nasal spray NSAID Motion sickness tablets Antiseptic solution Local anesthetic, local glucocorticoid
Practical Sports Medicine
Bandages Strapping tape mm, mm, mm, mm Waterproof tape mm Elastic adhesive tape mm Elastic compression bandages mm, mm, mm Tubular support bandage
Work during travel Competitive sport is today recognized on a global scale. Thus athletes at many levels from the elite international stars to the recreational runner have the opportunity to compete all over the world. They accordingly often have to travel to distant places, and they must acclimatize to new environments and times of day in order to perform optimally. Such journeys pose many challenges for the medical team traveling with athletic teams. The task is greater when traveling with a large team to World Championships or Olympic Games, but basically the same problems have to be solved for all athletes who are traveling to an international competition. The work that needs to be done can for didactic purposes be divided into the following areas: • Preparatory work prior to departure. • Work during travel. • Work during stay at the competition venue. • Work following the competition and in connection with the return home.
Preparatory work prior to departure Obtaining information about the competitive site When the location of the competition is known — as when an Olympic Games or World Championships is awarded to a city — the first thing that has to be done is to obtain information about the location. This can be done through a precompetition visit or through other channels if the place is well known already. Information regarding climatic conditions (heat or cold, humidity, winds, rain, etc.) should be sought. Usually this information is readily available from the
Underwrap Adhesive spray Bandage clips Triangular bandages Second skin Sterile strips, butterfly closures Splinting and basic orthotic material
organizers. However, it is important to realize that different nations emphasize different aspects of the information given. Scandinavians for instance would be more interested in details regarding heat and humidity than Africans, since the former have to undergo acclimatization to a hot and humid climate. It is also important to find out what the health situation is in the country one is about to visit. Are there any specific diseases that are prevalent at the competition site? What are the local hospitals like? Will it be possible to obtain prescription drugs or get qualified help if deemed necessary? Also one has to check what sort of electric current is available — in case it should be necessary to use electric equipment brought from home. All this information is usually available through the organizers, and in addition it can be obtained through the Internet from, among other sources, the WHO or the Centers for Disease Control (CDC). In some instances vaccination is advocated prior to departure. Thus vaccination against hepatitis A is often recommended for Scandinavians. In addition, vaccination against yellow fever is mandatory upon entering some African countries. It is also necessary to find out whether prophylaxis against malaria is mandated. What needs to be taken will vary from region to region, and information about the drugs of choice can be obtained either through the WHO, through the health authorities at home or sometimes through the ministry of foreign affairs (via an Embassy or Consulate in the region). It is also important to ascertain the level of hygiene both in general and more specifically in the hotels where the teams will stay. Can the water be drunk? What restrictions will have to be applied regarding eat-
Chapter . ing? The team physician must have answers to these questions.
Making the information known to athletes, coaches and leaders When all the details about the competition site are known, it is important to make sure that the athletes, coaches and leaders all are briefed about the details important to them. Most effectively this can be done in meetings with the group that is going. However, it has been shown time and time again that it is often necessary to repeat vital information on a one-to-one basis in order to make sure that everything is understood. Too often athletes and coaches arrive at large competitions not optimally prepared because they did not realize the importance of the information given to them. If vaccination is deemed necessary this has to be timed so that it does not interfere with the athletes’ competitive schedule. Also if acclimatization is necessary either to the climate or to a new time zone, it should be recognized early so that the athletes may organize their competitive and training schedule around this.
Acclimatization to time zones When crossing many time zones travelers face problems that are very different in nature from the ordinary travel fatigue felt after flying north–south. These problems are called ‘jet lag’ and are a familiar experience to the long-distance traveler. It is of particular concern to elite athletes when the competition is to be held at distant places. Thus when there is more than three time zones’ difference from home, acclimatization to the new time of day will be necessary in order to perform optimally. ‘Jet lag’ results from the disruption of a number of physiologic functions in the body which all operate rhythmically during the -h day/night period. The regulation of these functions is controlled in part by external factors such as light/dark, sleep/wake cycle and food intake, and in part by internal factors — among those the hormone melatonin. When we travel across many time zones, the external factors are changed immediately upon arrival since we eat, sleep and are active according to the new time zone. However, the internal regulators take longer to adjust. Therefore the delicately balanced control is disrupted
and ‘jet lag’ occurs. This then results in sleep disturbances, digestive and gastrointestinal problems, general physiologic and mental symptoms of fatigue as well as changes in endocrine secretions and hormone patterns. In general the problems are greater after eastward travel as compared to westward travel. As a rule of thumb the problems associated with jet lag last, in days, about as long as the number of time zones crossed when going east, and about half the number of days when going west. Younger persons as a rule adjust better than older persons. However, when planning travel for a group of athletes it should also be borne in mind that about % adjust much slower than the average. To be sure that everyone is adjusted prior to the competition it is necessary therefore either to know how each individual athlete adjusts, or to travel earlier in order to leave room for even the ‘slow adapters’. Part of the acclimatization to the new time zone (about h) can be performed at home prior to departure. Thus, when traveling in a westward direction, one can ‘change the daily schedule’ by around h, including going to bed and getting up h later in the week preceding the departure. Most people find this easy, and it is therefore feasible. However, when traveling eastbound one has to get up and go to bed up to h earlier. This is, of course, also theoretically possible, but is very rarely done, since most athletes (and leaders) find it hard to get up at or in the morning and go to bed at or at night.
Acclimatization to heat If the competition is to be held in a hot climate, athletes from the more temperate climates (such as the Scandinavians) will have to acclimatize to heat — especially if the event is held in a hot and humid climate. It is generally believed that around – days of acclimatization is required. It is necessary to train about min in the heat every day for days in order to be optimally acclimatized. If the work intensity is very high a shorter daily training period may be sufficient. The acclimatization effect lasts for around weeks. It is therefore possible to acclimatize to the heat at a hot place, and then go back home for a couple of weeks in order to avoid heat overexposure. If one decides to acclimatize just prior to the competition, the departure date will
Practical Sports Medicine have to be about weeks earlier than otherwise necessary. When there is a need to acclimatize both to heat and to a new time zone, these two processes can, of course, run in parallel.
Planning the travel When all the relevant information regarding the need for acclimatization to heat and time zone has been obtained, the travel plans can be finalized. For long travels across many time zones it is an advantage to arrive at the destination at night so that the athletes can go to bed almost immediately upon arrival. This will improve the adjustment to the new time zone. However, such a scheme is often not possible with the flights available with commercial airlines. It is also important to make sure that the aircraft carry enough liquids, especially when travelling far and with a large team. Most airlines will provide more water when asked to do so. The alternative is to ask the athletes to bring water bottles in their carryon luggage. Likewise, a member from the medical team or the dietician should talk to the airlines regarding the food they serve. Often athletes are used to foods other than those provided by most airlines. Sometimes it is possible to make the airlines change their menus when they carry a large athletic team. Again, the alternative is to ask the athletes to bring their own food. One must bear in mind, though, that many countries have very strict rules about what foodstuffs can be imported.
Obtaining equipment If one travels with only a few athletes, bringing an ordinary doctor’s bag will be sufficient. However, when a large team is going, it will be necessary to bring more equipment and in addition more prescription drugs. All of this must be organized prior to departure. When bringing prescription medicines out of the country it will in some countries — as in Scandinavia — be necessary to obtain an export license for the drugs. Also an import license to the destination country may be necessary. Both documents should be in the carryon luggage ready to be presented to the custom official if demanded. However, it has been the experience of the present authors through years of international travel with sports teams that these documents are re-
quired very rarely. However, they should be in order. Otherwise the medical team may be stopped at the border, and will not be able to accompany the team.
Work during the actual travel The duties of the medical team during the actual travel — i.e. during the flight — will basically be to make sure that the athletes optimize the acclimatization procedures. The air on board is very dry. Dehydration is detrimental for acclimatization to both time zones and heat, and should therefore be avoided. This can be done by: • Making sure that the athletes drink enough while on the plane. Also it is important that they do not drink alcohol, tea or coffee since all these beverages have a diuretic effect. They should drink water. As mentioned above either one should have made the airline provide extra water or the athletes should bring their own — or both. • Making sure that the athletes set their watches to the time of the destination immediately upon starting the journey. If possible they should eat and sleep according to the new time. • Making sure that the athletes get some exercise while flying. They should be encouraged to take frequent walks about the cabin.
Work during stay at the competition venue The main work will of course be the diagnosis and treatment of injuries and diseases. This is covered in the rest of the book, and will not be discussed here. However, in addition the medical team will have to perform some other tasks during the competitions.
Control of residential area The food, water and general hygiene of the place where the athletes stay should be controlled. Obviously the physician is not able to perform a complete hygienic check on everything, but he/she should nonetheless inspect the dining hall, the kitchen and the rooms including the bathrooms. This should preferably be done prior to arrival, but sometimes it has to be done upon arrival. If hygiene is found to be below the desired standard, it is the responsibility of the medical team to try to improve it. If this is not possible they must ensure that the athletes take this into consideration. They may for instance have to avoid eating or
Chapter . drinking certain food or drinks or be extremely careful with personal hygiene.
Assistance in doping controls A member of the medical team should accompany any athlete picked for doping controls. He/she should therefore know the doping regulations and ensure that the control is being performed ‘according to the book’.
Ensuring that the regimens for acclimatization are being followed When a team has traveled across more than three time zones or to a hot and humid climate that they are not used to, there are certain regimes to be followed upon arrival. The medical team must make sure that these regimes are followed, including: Acclimatization to a new time zone It is known that acclimatization to a new time zone is more rapid when athletes do it as a group. Also athletes must be prevented from sleeping in the middle of the day and thus prolonging the acclimatization period. During the first couple of days after arrival the athletes should train only lightly. Since concentration is one of the factors which is affected during these first days, athletes should refrain from technical training or training that demands a lot of concentration. They should gradually get back into normal training over a period of – days — all depending upon how many times zones they have crossed.
Work following the competition The medical team should plan the trip home just as they planned the trip to the competition. Usually the athletes still have many important competitions to participate in after the trip, and it is therefore important to be as well rested as possible when one comes home. There is, of course, usually no need for acclimatization to the home climate, but there may be a need for a readjustment to the time zone at home. This should be done the same way as it was done when going to the competition only that the time has to be switched the other way. After very important tournaments/events such as the Olympic Games or World Championships there is always the question as to when the athlete should start competing again. Such large tournaments will — especially for athletes in team events who may have to go through many matches — be a severe stress on key players. If they then go home and start playing in their home series directly without being allowed a short rest, these players often experience a fall in performance as the season progresses. Thus, the medical team should in cooperation with the trainers try to assess the load the athletes have gone through and, on the basis of this advice, the players, the teams and the federation as to when he/she feels that the players may start playing regular games again. This may sometimes be a difficult decision, but the problem should nonetheless be addressed since it could be very important for some players.
References Acclimatization to heat Athletes have to train in the heat to acclimatize to a hot and humid climate. Daily training of about –/ h is sufficient. However, it is important that the total heat exposure is not too great. The medical team must therefore make sure that the athletes do not stay out in the hot sun for hours following training. They should be in the shade or indoors in air conditioning — even though for Scandinavians staying in the sun may seem very attractive. Athletes who have to train and compete many times in the sun — such as for instance football players — have to be particularly careful as to their total heat exposure. Too much heat will in the long run wear the athletes down, and their performance may drop as the tournament proceeds.
Baker BE. Current concepts in the diagnosis and treatment of musculotendinous injuries. Med Sci Sports Exerc ; : –. Garret WE Jr. Muscle strain injuries: clinical and basic aspects. Med Sci Sports Exerc ; : –. Glick JM. Muscle strains: prevention and treatment. Physician Sportsmed ; : –. Herring SA. Rehabilitation of muscle injuries. Med Sci Sports Exerc ; : –. Järvinen TA, Kaariainen M, Järvinen M, Kalimo H. Muscle strain injuries. Curr Opin Rheumatol ; : –. Kellet. J. Acute soft tissue injuries — a review of the literature. Med Sci Sports Exerc ; : –. Swenson C, Swärd L, Karlsson J. Cryotherapy in sports medicine. Scand J Med Sci Sports ; : –. Dorwart BB, Hansell JR, Schumacher HR. Effects of heat, cold and mechanical agitation on crystal-induced arthritis in the dog. Arthritis Rheum ; : –.
Practical Sports Medicine Harris ED Jr, McCroskery PA. The influence of temperature and fibril stability on degradation of cartilage collagen by rheumatoid synovial collagenase. N Engl J Med ; : –. Thorsson O, Hemdal B, Lilja B, Westlin N. Med Sci Sports Exerc ; : –. Thorsson O, Lilja B, Ashgren L, Hemdal B, Westlin N. Med Sci Sports Exerc ; : –. Ashton H. The effect of increased tissue pressure on blood flow. Clin Orth ; : –. Nielsen HV. External pressure–blood flow relations during limb compression in man. Acta Physiol Scand ; : –. Aronen JG, Chronister RD. Quaericeps contusions. Hastening the return to play. Physician Sportsmed ; : –. Nielsen HV. Arterial pressure-blood relations during limb compression in man. Acta Physiol Scand ; : –.
Agerskov Andersen L, Götzshe PC. Naprowen and aspirin in acute musculoskeletal disorders: a double-blind, parallel study in patients with sports injuries. Pharmatherapeutica ; : –. Lehto M, Järvinen MJ. Muscle injuries, their healing process and treatment. Ann Chir Gynaecol ; : –. Almekinders LC, Gilbert JA, Healing of experimental muscle strains and the effects of nonsteroidal antiinflammatory medication. Am J Sports Med ; : –. Almekinders LC. The efficacy of nonsteroidal antiinflammatory drugs in the treatment of ligament injuries. Sports Med ; : –. Järvinen M, Lehto M, Sorvari T, Mikola A. Effects of antiinflammatory agents on the healing of ruptured muscle. An experimental study in rats. J Sports Traumatol ; : –.
Chapter 7.1 Multiple Choice Answers
Chapter 1.1
d and f a, e and f e a, d and e c, a and e
Chapter 1.2
c a c and d b, c and d c and e
Chapter 1.3
c c c c
Chapter 1.4
b e e e a
Chapter 1.5
c a c a b
Chapter 1.6 b a d
d d
Chapter 1.7
b c c a, d and e a, b, d and e a and c b and c
Chapter 1.8
e g e e a
Chapter 2.1
a c a e d and e
Chapter 2.2
e e c e e
Chapter 2.3
b and c a, c and f b, d and f b and e
Multiple Choice Answers b, d and e a, b and e d and e a b, c and d a and d a, c and e c and d a, b, d and e
Chapter 2.4
c and d (d is only correct if energy needs are met.) d (only if energy needs are met) b d
Chapter 2.5
d and e d and e a, b, c and e a, d and e a, b, c, d and e
Chapter 3.1
a e d a b
Chapter 3.2
c d a and b none
Chapter 3.3
d c a c
Chapter 3.4
c none a, b, c and d b and c b
Chapter 3.5
c d b a c
Chapter 4.1
c a, b, c and d c b and d b, c and d
Chapter 4.2
a, b, c, d and e a and c a and c a, b, c and d
Chapter 4.3 b and c c and d
Chapter 4.4
a b b b a
Chapter 4.5
b b a a b c
Chapter 4.6
b a a, b, d and e a, c, d and e a, b and e
Chapter 4.7 c c d
Chapter . a a
Chapter 4.8
c b a, b, d and e a, b, c and e a, b, d and e
Chapter 5.1 b, d and e. Stress fractures can be demonstrated after few days by bone scintigraphy as a point of heavy activity. CT is not very sensitive. Diffuse activity in the tibia is typical of medial stress syndrome and not stress fracture. d. Narrowing of joint space is seen in osteoarthritis and not after cartilage injuries. Cartilage does not show very well on standard MRI sequences, but can be visualized on special cartilage sequences. Bone bruise is closely connected to cartilage injury, but often diffuse injury and not necessarily solitary cartilage defects. MRI is not able to distinguish between fibrocartilage and hyaline cartilage. a, c and e. In healed meniscus lesions MRI will show a compete tear, as scar tissue looks like a lesion. Healing can be demonstrated because there is no inflow of fluid into the scar tissue. There is not necessarily an association between a ligament tear and instability. a, c, d and e. There is not a very good association between the changes in tendons seen by ultrasound and symptoms (pain). d. X-rays can in addition to a Hill–Sachs lesion demonstrate a bony Bankart lesion, but not a soft tissue Bankart lesion (which is the most common injury), and cannot usually discriminate between traumatic and non-traumatic instability. Standard MRI can sometimes demonstrate soft tissue Bankart lesions, but SLAP lesions and labral lesions are best demonstrated by MRI arthrography. CT cannot be used for tendon diagnoses; ultrasound or MRI can demonstrate rotator cuff lesions with good sensitivity. In rotator cuff tendinitis ultrasound can demonstrate intratendinous changes, also visible on MRI. Arthrography is used regularly in shoulder MRI and CT.
Chapter 6.1 d b
b e b
Chapter 6.2 d c c e c a c d b e
Chapter 6.3
c a and e b and e d a and c
Chapter 6.4
c e e e b
Case story 6.4.1 It is essential for his brain to recover from the concussion by taking it easy. If he has a baseline neuropsychological assessment registered, this investigation should be repeated, and he will be ready to return to any sports activity when he has returned to his baseline. In the period following the concussion he should avoid head injuries, as the damage is cumulative and there is a risk of second impact syndrome. If no baseline assessment exists, he can probably return to his sports weeks after he feels subjectively well. A CT scan should be performed immediately. It will probably show an epidural hematoma, which should be acutely evacuated to prevent impingement of the brainstem. If neurologic deficit appears, the prognosis is dubious.
Chapter 6.5 b d
Multiple Choice Answers c e e
Chapter 6.6 a, c and d. With a complete supraspinatus tear active abduction is reduced, but passive abduction is usually normal. In subacromial impingement the reduced abduction is caused by fibrous tissue and is present with active as well as passive abduction. In acute anterior dislocation the humeral head is locked in front of the glenoid and can move only very little. With a complete subscapularis tear the internal rotation force is reduced, but abduction is usually normal. With acromioclavicular joint dislocation the range of motion in the shoulder joint is usually normal. c and d. As shoulder instability is often the reason for the secondary impingement, the apprehension and relocation tests are usually positive. Overhead sporting activities can only be performed with great demands on stability in the shoulder joint. Instability will therefore be symptomatic (secondary impingement) in overhead activities. In addition the enormous strain throwing puts on the anterior– inferior shoulder capsule may stretch the capsule and ligaments and create instability. Secondary impingement is usually not (contrary to primary subacromial impingement) caused by changes to the subacromial arch (osteophytes) but by a dynamic impingement caused by the instability (and not fully understood). As secondary impingement is caused by instability, the dynamic stabilizers should be trained first—which is sufficient in most cases. With persisting symptoms, surgical stabilization of the passive stabilizers (capsule and glenohumeral ligaments) can be performed. There are no typical findings on MRI. a, c and e. The apprehension test can be performed on the standing patient, but the relocation test can only be performed on the supine patient. In addition to the three tests mentioned the lag-test
is sensitive for supraspinatus rupture (the inability to hold the arm over horizontal when the examiner has lifted it passively). It is necessary to rotate the person ° to visualize the glenohumeral joint line, as the glenoid rotates ° anterior (because the scapula rotates). Unfortunately, the interobserver agreement in shoulder testing is quite poor. Ultrasound is very good at visualizing a tear in the rotator cuff, but only MRI can grade the fatty degeneration in the corresponding muscle. This is important in chronic tears, as a fatty degeneration of more than % of the muscle makes it unlikely that the muscle will ever function again, even if the tendon tear is repaired. b and d. During extensive rotator cuff activity, two conditions can elicit subacromial impingement: acute inflammation of the subacromial bursa, and hypertrophy of the supraspinatus muscle. Both will reduce the subacromial space and create overcrowding. In patients with impingement, these two scapular elevators dysfunction. It is not known whether this is the reason for the impingement (as the acromion is not lifted sufficiently during overhead activity and therefore will impinge with the humeral head) or a consequence of the impingement. Strengthening of these muscles is a key point in rehabilitation of impingement patients. Pain from primary subacromial impingement is felt on the lateral side of the upper arm. Pain is felt at the acromioclavicular joint with degenerative disease in that joint (which can of course also create a subacromial impingement if the joint is bulging into the supraspinatus tendon). In wrestling, primary subacromial impingement and acromioclavicular joint degeneration is typical in addition to tendinitis. Internal impingement is only seen in overhead sports with repetitive, forceful abduction and external rotation. As secondary impingement is caused by instability, acromiplasty will have no effect. The surgical treatment of choice is capsular shifting.
Chapter 6.7 a No. Tennis elbow is lateral epicondylitis. Lateral
Chapter . pain caused by degenerative cartilage disease can be seen in combination with medial pain in the case of thrower’s elbow, and will show with tenderness of the lateral joint line and not tenderness at the lateral epicondyle, as typical for tennis elbow. b Yes. Valgus overload of the elbow during throwing applies stress to the medial collateral ligament, at first causing degenerative changes of the ligament and gradually loss of tension and instability. Pain is elicited from the ligament during valgus loading. c No. It is seen as a complication to elbow dislocation with injury to the medial collateral ligament and capsule, but most cases in throwing athletes are caused by repetitive valgus overload during the throwing motion. d Yes. Pain from the medial collateral ligament shows a couple of cm below the epicondyle and is not typically provoked by restricted flexion of the wrist, but by application of valgus stress to the elbow. e No. If medial pain is caused by golfer’s elbow, conservative treatment with rest and eventually corticosteroid injections under the cojoined flexor tendon attatchment at the medial humeral epicondyle is the first choice, but with continuous symptoms, surgical intervention can be necessary. If medial pain is caused by overload of the medial collateral ligament, conservative treatment is also the first choice, but corticosteroid injections should not be used, as they may weaken the ligament further. Continuous medial pain with medial instability should be treated operatively with tensioning or reconstruction of the medial collateral ligament. a No. Symptoms of posterolateral rotatory elbow instability are lateral elbow pain and locking/ clicking. b Yes. It is caused by posteromedial impingement between the olecranon and the humerus and is an element of thrower’s elbow: medial instability, posteromedial impingement, lateral cartilagenous degeneration and eventually ulnar nerve compression. c No. Collision takes place between the tip of olecranon and the olecranon fossa (in cases without
medial instability, e.g. in boxing), or the posteromedial facet of the olecranon and humerus. Pain can also be caused by partial tears of the triceps tendon. d Yes. In posterior or posteromedial impingement an osteophyte in gradually formed on the olecranon, and this as well as fibrous tissue can be removed arthroscopically. e No. Often an osteophyte will have formed on the olecranon as a reaction to the forced extension and valgus stress on the elbow during throwing. Even if the osteophyte is surgically removed, the posterior impingement has a high recurrence rate, as long as the underlying mechanism of injury continues. a Yes, it can, in particular if supination plus extension also elicits clicking or locking. In posterolateral rotatory elbow instability the radial head subluxes or dislocates posterior to the humeral capitulum during extension plus supination. As posterolateral rotatory instability is usually caused by elbow dislocation, it is quite rare compared to medial instability, which can also be a cause of lateral elbow pain. b Yes, it can. Medial elbow instability is most often an overuse injury caused by repeated valgus stress to the elbow, including powerful compressive forces of the lateral compartment, resulting in degenerative cartilagenous changes, which can be painful during throwing. Tenderness is found on the lateral joint line. c Yes. Up to % of recreational racquet athletes experience lateral epicondylitis regularly. d Yes. Radial nerve entrapment causes lateral forearm pain during activity, but only rarely motor symptoms (fatigue of the hand extensors). Median nerve entrapment (pronator syndrome) causes anterior forearm pain (which may also be felt laterally), but only with entrapment of the anterior interosseus branch also motor symptoms (decreased power with flexion of the first and second distal finger joint and pronation during flexion). e Yes, nearly all cases of tennis elbow resolve with conservative treatment. Only about % with continuous symptoms for – months despite conservative treatment are candidates for operative treatment.
Index Page numbers in italics refer to figures; those in bold to tables. Index entries are arranged in letter-by-letter alphabetical order. A-band , Abbreviated Injury Scale (AIS) abdominal cramps – abdominal muscles – acute strains myotendinous (lower abdomen) , abdominal pain during exercise –, abdominal trauma abduction strength test, shoulder , abductor muscles (of thigh) abrasions, in disabled athletes , absorptive state energy sources , – hormonal regulation of metabolism accelerometers – accidents, prevention acclimatization heat , –, high altitude , medical team duties to time zones , acetaminophen see paracetamol acetazolamide, in high-altitude illness acetylcholine receptors , acetyl-CoA Achilles tendon (AT) allografts , blood supply collagen metabolism – force (ATF) measurements –, – injuries – chronic – corticosteroid injections , – management – scintigraphy , ultrasound imaging –, mechanical properties , reflex – repair, rehabilitation rupture – corticosteroid injection treatment – ultrasound imaging tendinitis tendinosis – acid–base balance, PCr breakdown and acidosis, lactic ACL see anterior cruciate ligament acromioclavicular (AC) joint – active compression test , – arthritis dislocations – instability –, – overload injuries
in shoulder impingement X-rays acromion hooked imaging acromioplasty – ACTH see adrenocorticotrophic hormone actin , filaments , – myosin coupling a-actin promoter active compression test , acupuncture, in osteoarthritis acute injuries, in children and adolescents – acute mountain sickness (AMS) , – acute phase reaction , adaptations, training – balance with injury – cardiorespiratory , – adductor longus tenotomy adductor muscles (of thigh) acute strains , common origin adductor-related groin pain clinical presentation – treatment – adenine nucleotides (AN) –, adenylate kinase adhesion molecules, in muscle injury – adiposity see obesity adolescents bone mass accretion exercise health benefits ‒ health benefits in chronic disease risk of exercise – risks of sports participation – hip pain knee instability testing knee pain – low back pain , , physical activity sports injuries , see also children; young people ADP accumulation during exercise fusion – adrenaline see epinephrine adrenal medulla, sports adrenocorticotrophic hormone (ACTH) , in overtraining syndrome b-adrenoreceptors, in overtraining syndrome aerobic capacity – in acute infections aerobic lactate threshold, in overtraining aerobic metabolism , –, aerobic performance, at high altitude – aerobic power –
in elderly –, maximal see VOmax aerobic training , – components in elderly , in type diabetes – afterload age at menarche , onset of puberty age-related changes bone mass , – flexibility VOmax , see also children; elderly aggrecan aging – benefits of exercise effects on body – epidemiology of exercise and health – sports performance and successful see also elderly aids, in osteoarthritis air density, at high altitude pollution/irritants water content, at high altitude air-stirrup air travel alcohol alkaline phosphatase (AP), bone-specific , , Allen’s test , allergy, asthma and – allografts ACL repair ankle ligament reconstruction meniscus osteochondral – PCL repair , posterolateral knee injuries allopurinol altitude see high altitude AMBRI classification, shoulder instability amenorrhea – athletic –, bone mineral content , characteristics classical reference etiology – treatment , – bone metabolism –, , definitions eating disorder , exercise-induced –, , – hypothalamic – idiopathic/functional hypothalamic (FHA) osteoporosis and , primary and secondary , ,
Index American football head injuries , – spinal cord injuries upper extremity injuries ‘American Paradox’ amino acids essential in overtraining syndrome utilization AMP accumulation during exercise deamination – ¢-AMP-activated protein kinase (AMPK) – amphetamines – amputees cartilage changes – prostheses sports participation –, – anabolic steroids , – in children and adolescents detection of use – satellite cell activation side-effects – anaerobic lactate capacity, in overtraining syndrome anaerobic metabolism –, – anaerobic power anaerobic threshold, in overtraining syndrome , anaerobic training , – components – anal fissures analgesics in low back pain for osteoarthritis – see also codeine; non-steroidal antiinflammatory drugs; paracetamol androgens abuse – see also anabolic steroids; testosterone anemia iron-deficiency sports (or runners’) , – angiedema, cold-induced – angina pectoris , angular velocity , ankle – acute ligament injuries (sprains) – classification physical examination – treatment – anterior impingement (footballer’s ankle) , , , arthroscopy braces , , – chronic instability – case story – classical reference clinical evaluation , , , – etiology non-surgical treatment stress radiography , , surgical treatment – anatomic reconstruction – tenodesis – external support – ligamentous laxity , ligaments see also specific ligaments
osteophytes prevention of injuries , – taping , , – ankylosing spondylitis ankylosis, bony annulus fibrosus anorectal disorders anorexia athletica anorexia nervosa , – diagnostic criteria , identification in athletes , medical problems osteoporosis , – prevalence in athletes – antagonist muscles, coactivation – anterior cruciate ligament (ACL) acute injury – cartilage changes – combined with MCL injury , combined with posterolateral knee injury – complete isolated tears – diagnosis incidence joint stability evaluation – magnetic resonance imaging , , , , non-surgical management – osteoarthritis after partial tears – physical examination – prevention in team handball , , biomechanical modeling of loading –, , , functional brace – load–elongation curve – classical reference , electrical muscle stimulation , , knee osteoarthritis and meniscal repair with osteotomy with rehabilitation , , , – surgical technique – transection, cartilage degeneration – anterior inferior iliac spine (AIIS) avulsion fractures – anterior interosseous nerve palsy – anterior slide test anterior superior iliac spine (ASIS) avulsion fractures – anterior talar translation (ATT) , anterior talofibular ligament (ATFL) acute injuries , chronic injuries – reconstruction , – anterior tibial (compartment) syndrome , – anterior tibiofibular ligament (anterior syndesmosis ligament) injuries , antidepressants, in osteoarthritis anti-inflammatory drugs see corticosteroids; non-steroidal anti-inflammatory drugs antioxidants – in diabetes dietary sources in muscle injury – antisense therapy, in ligament injury
anxiety, effects of exercise aortic stenosis apophyseal cartilage, mechanical properties –, apophyses appetite, effect of exercise Apply’s test apprehension test patellar shoulder instability aprotinin arcade of Struthers, ulnar nerve entrapment Aretaeus of Cappadocia , arm – anatomy and biomechanics – elevation, scapulothoracic motion exercise, in spinal cord injury – injuries – case stories – classical reference , clinical examination – epidemiology – imaging – neck pain radiation nerve entrapments , –, – overuse injuries paresthesia, transient neck pain with – see also elbow; forearm; hand; wrist arrhythmias in athletes – in children and adolescents – exercise with – arrhythmogenic right ventricular dysplasia (cardiomyopathy) (ARVD, ARVC) arteriovenous oxygen difference (a-vodiff) , – arthritis corticosteroid injections degenerative see osteoarthritis prevention rheumatoid see rheumatoid arthritis arthrography computed tomography (CT) , knee – magnetic resonance (MR) – arthrometers knee , arthroplasty, in osteoarthritis , , – arthroscopy joint lavage – arthrosis, degenerative see osteoarthritis aspirin asthma – benefits of exercise , beta- agonists , , classical reference , definition – exercise-induced (EIA, EIB) – in children and adolescents in cold conditions –, , – differential diagnosis exercise challenge test – at high altitude prevalence in athletes , risk factors – training type and risks of exercise in sports – treatment –
Index doping and non-pharmacologic measures – pharmacologic atherosclerosis –, , , athlete’s heart (cardiac hypertrophy) –, – ECG findings –, functional adaptations heart dimensions , – historical reference in veteran athletes – athletic pubalgia atlantoaxial joint instability atmospheric pressure, at high altitude atopy, asthma and – ATP generation – aerobic processes amount (capacity) – anaerobic processes – maximum rate (power) – hydrolysis , turnover , , atrial fibrillation , , atrial flutter attitude, and sports injuries autografts ACL repair osteochondral autonomic dysreflexia , – autonomic nervous system (ANS) see also parasympathetic (vagal) activity; sympathetic nervous system autonomic neuropathy, diabetic avascular necrosis see osteonecrosis axial load (load-and-shift) test , , axillary nerve entrapment axillary view axonotmesis back muscles –, contusion flexion/relaxation phenomenon –, rupture stabilizing exercises , back pain, low – acute –, case story – chronic –, classical reference , clinical examination – diagnostic aspects – epidemiology – history and mechanisms – imaging – ligament strain muscle contusion muscle rupture prevention , –, – radiculopathy – red flags rehabilitation – scintigraphy ‒ treatment – unspecific – yellow flags (risk of chronicity) Baker’s (popliteal) cyst , balance in ankle instability
board training tests training, in elderly ballet dancers – amenorrhea , osteoporosis , – Bankart lesion , , – Bankart’s operation , , – arthroscopic standard open basal metabolic rate (BMR) in athletes calculation energy turnover calculation from – factors (MET values) baseball pitchers , basketball injuries , wheelchair , , , bed rest in acute infections bone mass/mineral density changes behavior modification sports Bennett’s fracture – beta- agonists , in asthma in children and adolescents beta-adrenergic agents beta-blockers detection of use as ergogenic aid , bicarbonate , biceps brachii muscle , biceps femoris muscle biceps (femoris) tenodesis procedure biceps tendon (at elbow) rupture , biceps tendon (at shoulder) imaging –, instability (subluxation) –, long head , – ruptures combined with rotator cuff tears isolated in SLAP lesions , tendinitis Yergason’s test , biomechanics – analysis – examples – kinematics kinetics – link-segment models muscle–tendon unit models noise reduction/filtering offline/online digitization simulation – three-dimensional (D) –, classical reference , equipment – head injury , – musculoskeletal flexibility – spine – upper extremity – blindness blisters, disabled athletes , blood altitude-induced changes doping ,
blood flow insulin-stimulated – peak muscle – pulmonary splanchnic , blood pressure (BP) – in children classification in cold environments , effects of exercise – high see hypertension in spinal cord injury – stroke risk and in type diabetes , , blood volume (BV) BMC see bone mineral content BMD see bone mineral density body composition aging effects – amenorrheic athletes in spinal cord injury body fat see fat, body body mass in childhood – lean, effect of dieting body mass index (BMI) body proportions, in childhood body size, in childhood – body surface area, in childhood – body temperature see temperature, body bone – age-related changes – bruise , knee shoulder contusion cysts grafts, in chondral injuries immobilization-induced loss loading –, – bone mass and BMD effects –, bone turnover/remodeling and cellular responses – characteristics of sports – mechanotransduction – remodeling in elderly mechanical strain effects in meniscus injury running training and –, training adaptations turnover in amenorrhea mechanical strain effects see also immobilization; physical inactivity bone-on-bone forces – bone-cartilage transplantation bone–ligament–bone complex, mechanical properties – bone-lining cells, mechanotransduction , bone marrow cells bone mass in elderly , – athletes effects of training , , – in female athletes , – peak , , , athletic amenorrhea and calcium intake and
Index bone mass (cont.) physical activity and –, – in adults – in young –, – see also bone mineral content; bone mineral density bone mineral content (BMC) in amenorrheic athletes , in female athletes , – physical activity and in spinal cord injury bone mineral density (BMD) in athletes –, –, – classical reference , , , in immobilization/inactivity , in osteoporosis diagnosis physical activity and – in adults – in elderly in young – bone scintigraphy see scintigraphy bone tumors computed tomography knee scintigraphy , boosting – borreliosis Boutonnière deformity boxer’s fracture – boxing, head injury , brachialis muscle brachioradialis muscle bradycardia, resting –, , bradykinin brain contusion brain injuries contrecoup diffuse – focal – rotational acceleration theory second impact syndrome translational acceleration theory traumatic (TBI) see also concussion; head injuries breast cancer breathing control – pattern rate bronchoconstriction in cold environments – exercise-induced (EIB) – see also asthma, exercise-induced bronchodilator therapy bruises, in disabled athletes buckle transducer technique –, buffer capacity, muscle altitude-induced changes bulimia nervosa ‒ diagnostic criteria , identification in athletes , medical problems osteoporosis prevalence in athletes bursitis corticosteroid injections hemorrhagic hip region – knee –
shoulder ultrasound imaging
caffeine , – urine levels calcaneal spur – calcaneofibular ligament (CFL) acute injuries chronic injuries reconstruction , – calcaneus, stress fractures – calcium intake supplements calcium channels, in mechanotransduction calcium ions (Ca+) in bone mechanotransduction intracellular in muscle injury in muscle contraction calorimetry direct indirect calpain Calvé–Legg–Perthe’s disease , , – cancer hormone-dependent prevention , risks of sports participation see also tumors; specific types of cancer capacity, energetic see energetic capacity capillaries, muscle , density , number per fiber in spinal cord injury capitate fractures capsaicin, topical capsular shift procedure (Neer) carbohydrate (CHO) dietary intake in diabetes mellitus , during exercise/training , , per day, recommendations – postexercise , , – pre-exercise loading – glycemic index (GI) and metabolism, hormonal regulation – oxidation amount of ATP produced – during exercise , , –, maximum rate (power) , , – at rest – carbohydrate-containing drinks , carbon dioxide (CO) equilibration production (Vco) – ventilatory response (VE/Pco) – carbonic anhydrase III (CA-III), in muscle injury cardiac hypertrophy see athlete’s heart cardiac output ATP generation rate and at high altitude in hot environments – maximal (Qmax) , , , in elderly VOmax and , cardiac transplantation cardiomyopathies –
cardiovascular disease (CVD) – in athletes , contraindicating exercise in diabetes , in hypertension , in obesity , prevention –, , – risk factors , , in childhood and adolescence – in type diabetes – in type diabetes , , cardiovascular system – aging effects – at high altitude classical reference , , in hot environments – recovery from inactivity – in spinal cord injury , training adaptations , , –, – car ownership carpal bones fractures , , – carpal bossing carpal instability carpal tunnel , carpal tunnel syndrome , – in wheelchair athletes carpometacarpal (CMC) joint first fractures and dislocations – cartilage – fissures/cracks , healing immobilization/remobilization studies – injuries see chondral injuries in ligament injuries – loading , – classical reference , cyclic and static – impact – in vitro explants – in vivo studies – long-term effects –, – models loss, in osteoarthritis magnetic resonance imaging mechanical properties ‒ obliterative degeneration running training studies – training adaptations transplantation , ultrasound assessment weight-bearing alterations and – case studies catalase catarrh, nasal catch-like property, skeletal muscle catecholamines regulation of metabolism , in spinal cord injury – see also epinephrine; norepinephrine celecoxib center of pressure central command cerebral contusion cerebral edema, high-altitude (HACE) – cerebral palsy benefits of exercise exercise physiology –
Index sports injuries sports participation – Cerebral Palsy – International Sports and Recreation Association (CP-ISRA) cervicalgia , cervical pain see neck pain cervical radiculopathy , – cervical spine exercises , , injuries , – cervicobrachialgia chest pain children – back pain , benefits of exercise body proportions body size – bone mass and physical activity chronic disease benefits of exercise risks of sports participation – classical reference , corticosteroid injections disabled, sports injuries health benefits of exercise – hip pain knee instability testing knee pain – muscle fiber type muscle mass neuromotor control physical activity risks of exercise – sports injuries , upper extremity injuries cholesterol, blood benefits of exercise chondral injuries elbow – knee – operative treatment – rehabilitation – chondrocytes in joint trauma , , – in loaded cartilage , in osteochondral allografts – transplantation of autogenous – chondroitin -sulfate (CS-)/chondroitin -sulfate (CS-) ratio chondroitin sulfate treatment chondromalacia patellae Chrisman–Snook tenodesis – chromium chromones chronic airways disease – see also asthma chronic disease in athletes in children and adolescents effects of physical training – motive for physical training , chylomicrons , cimetidine cine-film recordings circulatory system testing cirrhosis of liver, in cystic fibrosis citrate synthase (CS) claudication, intermittent – clavicle
displacement lateral osteolysis lateral resection – clenbuterol , climatic conditions, information about clothing, in cold environments – clo unit coaches eating disorders and , , information provision to cocaine – codeine , , cognitive defects, postconcussion cold, common cold environments , – acclimatization children and adolescents clothing – definition exercise-induced asthma –, , – heat loss – heat production performance in – cold injuries – direct – indirect – cold therapy cold urticaria cold water immersion , – colitis, ischemic (hemorrhagic) , , collagen aging changes – a-chains cartilage , cross-links , , age-related increase degradation in ligament healing muscle , – in denervation and reinnervation in elderly –, , functions immobilization effects in muscle injury physical activity and – post-translational processing – tendon, responses to loading – type I propeptide, carboxy-terminal (C-terminal) collar, cervical colon cancer , , effects of exercise redundant – color Doppler imaging (CDI), tendons Comité International des Sports Silencieux (CISS) compartment syndrome forearm lower leg acute anterior tibial , – chronic –, lateral (peroneal) posterior muscle injury and repair competition venues information about – medical team duties at –
return from travel to see travel to competitions compliance compression external – necrosis, articular cartilage compressive stress, cartilage – computed tomography (CT) , – arthrography , groin injuries knee injuries –, low back pain – shoulder problems – upper extremity concentric muscle contraction EMG studies maximal strength , muscle morphologic changes in rehabilitation testing strength training concussion , – biomechanics management – mechanisms repeated , congenital heart disease , conjoined tendon – acute strains connective tissue – age-related changes –, , classical reference – recovery from injury training adaptations – consciousness, traumatic loss of continuous passive motion (CPM), in knee injuries , , contraction band, in muscle injury contrecoup brain contusion Cooper test coordination in acute infections , childhood development coracoacromial ligament (CHL) degeneration resection , coracoclavicular ligament ruptures – coracohumeral ligament (CHL) coracoid impingement , – coronary arteries congenital anomalies increased perfusion increased volume – coronary artery bypass surgery coronary heart disease (CHD) prevention – risk factors , , corset, in spinal injuries corticospinal pathways , corticosteroids inhaled , , injections – in Achilles tendon disorders , – administration adverse effects contraindications in epicondylitis (tennis elbow) , , in groin injuries/pain –, indications –
Index corticosteroids (cont.) in osteoarthritis shoulder impingement , phonophoresis/iontophoresis in radiculopathy , in spinal cord injury systemic therapy cortisol , in athletic amenorrhea , ‒ osteoporosis and , in overtraining syndrome costs, sports injuries countermovement jump coxibs see non-steroidal anti-inflammatory drugs (NSAIDs), COX--selective coxsackie virus infections , creatine shuttle – supplementation , ergogenic effect mechanism of effect , , creatine kinase (CK) , anaerobic training effects in muscle injury muscle-specific isoenzyme (CK-MM) creatine phosphate see phosphocreatine cromoglycate, inhaled cross-country skiing cross-education, eccentric training cruciate ligaments see anterior cruciate ligament; posterior cruciate ligament cryotherapy CT see computed tomography cubital tunnel syndrome cyclists amenorrhea asthma risk cyclist’s palsy cyclooxygenase (COX) isoform (COX-) , isoform (COX-) , , selective inhibitors see non-steroidal anti-inflammatory drugs (NSAIDs), COX--selective isoform (COX-) cyclops lesion cystic fibrosis benefits of exercise risks of exercise – cystitis see urinary tract infections cytokines in acute infections in joint injury in muscle injury in strenuous exercise , in tendon injury , Daito-ryu Aiki Jujutsu Roppokai dance, wheelchair dancers back pain see also ballet dancers dead space, physiological (VD/VT) , deaf decorin, antisense nucleotide defecation, during exercise degenerative arthritis see osteoarthritis dehydration in cystic fibrosis
during air travel during exercise – gastric emptying and in hot environments – in spinal cord injury dehydroepiandrosterone (DHEA) dehydropyridine receptors delayed-onset muscle soreness (DOMS) , deltoid ligament injuries rupture – deltoid muscle , depression effects of exercise – in overtraining syndrome de Quervain’s tenosynovitis desmin , de-training, oxidative enzymes after , developmental aspects – dexamethasone, in high-altitude illness diabetes mellitus , – classical reference complications ligament healing type (insulin-dependent, IDDM) – benefits of exercise , – risks of exercise type – cardiovascular disease in elderly physical inactivity predicting – prevention –, , treatment – Diabetes Prevention Program dial test – diarrhea –, diastolic ventricular filling rate diclofenac diet – -h recall analysis methods – benefits of exercise energy density guidelines while abroad postexercise – stress fractures and – in training camps/competitions – in type diabetes vegetarian , see also food; nutrition dietary history – dietary-induced thermogenesis (DIT) , dietary supplements – complete motivations for using vs. doping , dieting eating disorders and exercise and diffuse axonal injury (DAI) digestive diseases, benefits of exercise dihydrotestosterone disability sports injury causing – see also specific types of disability disabled – classical reference – exercise physiology – sports participation , –
classification systems –, competitive vs. non-competitive doping and boosting – history – injuries – special precautions – technical developments – discography – disease chronic see chronic disease contraindicating exercise , effects of physical training – prevention , – disks, intervertebral see intervertebral disks disodium chromoglycate distance-correlated injury index (DCI) diuretics diving, prevention of injuries dominance doping – agents – classification , legal methods of detection – testing for specific – urinary levels see also ergogenic aids analyses asthma medication and blood , in children and adolescents control –, dietary supplements vs. , by disabled athletes – historical background , medical team duties dorsal radiocarpal ligament dorsal radioulnar ligament Down’s syndrome ,-DPG, at high altitude drawer tests anterior ankle instability , knee instability flexion rotation posterior –, posterolateral shoulder instability , , drop jump drugs for osteoarthritis – traveling with for treatment of sports injuries – use of prohibited see doping duch*enne dystrophy duration, training in anaerobic training older adults dynamometry –, dyspnea , – dystrophin , eating disorders –, – amenorrhea , definitions diagnosis in athletes , , long-term health effects medical problems not otherwise specified (EDNOS) osteoporosis – prevalence in athletes –
Index prevention prognosis risk factors – subclinical , treatment – see also anorexia nervosa; bulimia nervosa eccentric muscle contraction EMG studies , – maximal strength – muscle damage –, –, – aging effects – muscle morphologic changes in rehabilitation testing eccentric muscle strength, optimal training eczema, infected education, patient, in osteoarthritis – effort-induced venous thrombosis elastic modulus elbow anatomy and biomechanics – cartilagenous injuries – degenerative joint disease dislocation , imaging injuries – clinical examination epidemiology – lateral instability , ligaments magnetic resonance imaging – muscles overstress (medial) instability –, posterior impingement , , – posterolateral rotatory instability , , testing , , , stability testing , thrower’s –, –, elderly – adaptability to exercise – cross-sectional studies –, – longitudinal studies , – back pain , benefits of exercise bone mass see bone mass, in elderly classical reference , exercise recommendations falls prevention , – motoneuron firing frequency – osteoporosis respiratory muscles strength training , , , – VOmax –, , , see also aging; masters athletes; veteran athletes electrically stimulated leg cycle (ESLC) training – electrical stimulation in rehabilitation , , in spinal cord injuries –, – electrocardiography (ECG), in athletes –, electrogoniometers , electromagnetic fields, in bone electromyography (EMG) adaptations to strength training – compound surface signal amplitude – cross-talk between electrodes evoked spinal responses
integrated intramuscular , in eccentric contraction in movement analysis , –, movement artefacts response to stretching ‒, electron transport chain elite athletes motivation treatment of injuries – EMG see electromyography end-diastolic volume (EDV) endocrine system, in elderly endomysium , b-endorphin endothelial dysfunction, in diabetes , endothelium-dependent dilatation (EDD) , – endotoxins, in heat stroke endurance athletes aging effects – bone mass doping female – iron supplements life expectancy endurance training in asthma cardiovascular adaptation – muscle changes , in neuromuscular disorders respiratory adaptation – in spinal cord injury – energetic capacity – aerobic processes – during exercise – muscle mass effects energetic power – aerobic processes – during exercise – muscle mass effects energy chemically bound deficit, in amenorrhea – density mechanical requirement stores supplements – energy balance assessment – case stories , during exercise in obesity in overweight and obesity , physical activity and – in spinal cord injury energy expenditure – activity-dependent (AEE) aging and classical references during exercise exercise metabolism – in children in overweight and obesity , , total (TEE) energy intake (EI) assessments – basal metabolic rate (EI/BMR) ratio , ,
effect of exercise female athletes – in overweight and obesity , underestimation , energy substrates (sources) – intake during exercise – at rest – utilization during exercise , –, –, in absorptive state – gender differences in postabsorptive state – in trained state energy turnover (ET) – components – in dietary assessments – measurement –, enteroviruses enthesopathies environment – classical reference , exercise-induced asthma and – risks in infections – sports injury prevention measures , thermal , – see also high altitude ephedrine –, epicondylitis – clinical examination imaging –, , lateral (tennis elbow) , – case story corticosteroid injections , , imaging –, surgery medial , , , epidermal growth factor (EGF) , – epidural hematoma – epilepsy , epimysium , epinephrine (adrenaline) in overtraining , regulation of metabolism , response to exercise , , epiphyseal (growth plate) injuries , , epiphyses equipment for disabled athletes – in injury prevention , medical, traveling with ergogenic aids – classical reference , dietary , effect legal see also doping ergometric testing – in overtraining syndrome – rowing running – ERKs (extracellular related kinases) , erythema migrans , erythropoietin (EPO) at high altitude recombinant human (rhEPO) detection of use doping , , ergogenic effect ,
Index esophageal temperature , esophageal varices, in cystic fibrosis esophagus estradiol, in bone estrogen antagonists, doping effects in bone , , in elderly in female athletes replacement therapy see hormone replacement therapy estrogen receptor, in bone Evans tenodesis procedure (ankle) evoked spinal motoneuron responses , – excitation–contraction coupling exercise, definition exercise testing in asthma – post-myocardial infarction explosive muscle strength defined – in elderly training for – extensor carpi muscles extensor carpi ulnaris (ECU) recurrent subluxation tenosynovitis extensor insertional tenosynovitis – extensor muscles of hand/fingers , extensor pollicis longus tenosynovitis extensor tendon sheaths external hip rotator muscles extracellular matrix (ECM) cartilage muscle – effect of loading – in muscle injury and repair – F-isoprostanes Faber test , facet (zygoapophyseal) joints , anesthesia facial injuries falls, prevention in elderly , – falx inguinalis see conjoint tendon fascial defects, lower leg fasciotomy , , fat dietary intake , –, during exercise – osteoporosis and physical activity and oxidation see fatty acids (free fatty acids, FFA), oxidation fat, body distribution, aging and female athletes low, in amenorrheic athletes – mass, effects of exercise in spinal cord injury fatigue muscle , – in overtraining syndrome fatigue fractures see stress fractures fatty acids (free fatty acids, FFA) hormonal regulation of metabolism – oxidation capacity , during exercise , , , –, fat intake and
maximum rate (power) , – at rest , ventilation and feed-forward regulation of circulation female athletes – amenorrhea see amenorrhea anabolic steroid side-effects athlete’s heart , bone mass , – eating disorders , – growth and pubertal development – iron supplements nutrient utilization nutritional disorders – osteoporosis , – reproductive function –, – sports-induced osteoarthritis stress fractures , , see also women female athletic triad see also amenorrhea; eating disorders; osteoporosis femoral epiphysis, slipped capital femoral head, avascular necrosis , , – femoral neck fractures , , stress fractures , femoral nerve , stretch test femur , femur–medial collateral ligament–tibia complex (FMTC) , ferritin, serum – fever exercise guidelines , risks of exercise fibrinolysis fibroblast growth factor, basic (bFGF) , , fibroblasts in ligament healing , muscle , stretch-induced alignment –, tendon – fibronectin in cartilage , , in mechanotransduction in muscle injury , fibula fibular collateral ligament (FCL) avulsion reconstruction fingers fractures – mallet Finkelstein’s test , fitness benefits of exercise , in overweight/obesity testing , – type diabetes and – fitness training – components , methods – physiology – flexibility, musculoskeletal – age-related changes ‒ definition determinants –
mechanisms for improvement – pre-exercise warm-up and stretching training flexion rotation drawer test flexor carpi muscles flexor digitorum profundus tendon avulsions flexor muscles of hand/fingers , flexor tendon sheaths fluid flow, in bone , fluid intake during air travel during exercise –, in hot environments – postexercise pre-exercise flurbiprofen flying focal adhesion kinases follicle-stimulating hormone (FSH) food airline double portion method frequency questionnaires glycemic index (GI) habits – hygiene , – records supplements see dietary supplements food quotient (FQ) foot athlete’s diabetic injuries – ligaments stress fractures – trench (immersion) valgus , football see American football; soccer footballer’s ankle , , , foot pressures in leg length discrepancy in sporting activities , , , , transducers footwear, high ‘heel tab’ force bone-on-bone – ground (external) reaction , in vivo measurements – buckle transducer technique – optic fiber technique – joint reaction moment of peak muscle see muscle force platforms –, forced expiratory volume in s (FEV) , , force–velocity (F–V) relationships , classical reference , muscle power and in normal locomotion – forearm – anatomy and biomechanics – clinical examination compartment syndrome epidemiology of injuries – forward dynamics – c-fos fractures
Index computed tomography hand – knee – osteoporotic see osteoporotic fractures pelvic region – radiography – scintigraphy skull , spine – stress see stress fractures wrist – free body segment method , free radicals antioxidants and – in diabetes in muscle injury – frequency, training, older adults frostbite –, frostnip fruit functional tests Gadd Severity index – gait , galactosylhydroxylysyl glycosyltransferase (GGT) , , gap junctions, in mechanotransduction – gas chromatography/mass spectrometry (GC/MS) , – gas exchange, pulmonary – gastric emptying (GE) – classical reference , fluids , gastritis, hemorrhagic (HG) , gastrocnemius muscle, partial rupture of medial head gastroenteritis , gastroesophageal reflux (GER) gastrointestinal (GI) bleeding – gastrointestinal (GI) disorders – gastrointestinal hormones gastrointestinal (GI) tract – function, effects of exercise – malignancy gender differences age-related bone loss nutrition and exercise – see also female athletes; women gene-chip technology gene transfer technology genital infections genitofemoral nerve entrapment genu varus, posterolateral knee injuries with GH see growth hormone GH- project Gilmore’s groin ginseng glenohumeral index glenohumeral joint anatomy – articular conformity capsular shrinkage procedures , capsuloligamentous structures – capsuloligamentous tightening operations , dislocation see shoulder, dislocation dynamic function –
instability see shoulder, instability posterior capsule (PC) proprioception and kinematics – X-rays glenohumeral ligaments – dynamization imaging – surgical tightening glenoid labrum imaging – SLAP lesions , , , – tests for lesions relations to humeral head version –, – glucagon during exercise –, at rest gluconeogenesis during exercise hormonal regulation at rest – glucosamine glucose blood control see glycemic control in diabetes impaired fasting , ingestion during exercise metabolism, in elderly tolerance, impaired (IGT) transport ‒ insulin-stimulated – in spinal cord injury , – uptake, insulin-stimulated – utilization during exercise , –, rate at rest – glucose -phosphate dehydrogenase (GPD), bone cells , , GLUT- , in spinal cord injury , – in type diabetes – glutathione peroxidase , gluteal muscles glycemic control in type diabetes – in type diabetes – glycemic index (GI) , , glycogen stores , anaerobic training and synthesis (glycogenesis) hormonal regulation postexercise –, , , utilization rate –, water bound by , glycogenolysis control during exercise , , hormonal regulation at rest – glycogen phosphorylase glycogen synthase (GS) in spinal cord injury – in type diabetes , glycolysis , anaerobic training and control
during exercise , maximum rate (power) , glycosaminoglycans (GAGs) cartilage in immobilization in running training , polysulfated golf Golgi organs excitatory feedback from inhibitory feedback from , – gonadotropin-releasing hormone (GnRH) goniometers –, goniometry measurement error in rehabilitation gracilis muscle gracilis tenotomy greater tuberosity, causing impingement groin injuries/pain – acute (muscle strains) –, – clinical presentation – etiology treatment case story chronic , – clinical presentation – etiology – treatment – classical reference history and physical examination – imaging –, – myotendinous (muscles and tendons) – nerve entrapments scintigraphy –, , , tumors groin region see pelvic region ground (external) reaction forces , growth adverse effects of exercise – body proportions and normal growth factors in ligament injuries ‒ in mechanotransduction , in muscle injury and repair growth hormone (GH) , doping , in children and adolescents detection , in elderly in exercise-induced bone changes in overtraining syndrome growth plate (epiphyseal) injuries , , Guyon’s canal ulnar artery thrombosis ulnar nerve entrapment gymnasts amenorrhea and eating disorders growth and puberty –, injuries upper extremity injuries , , , gymnast’s palsy gymnast’s wrist Haddon matrix – crash measures postcrash measures
Index Haddon matrix (cont.) practical application precrash measures – HAGL lesion Haglund’s disease , hallux rigidus hamate, hook fractures – hamstring muscles , assessment of tightness biomechanical analysis , tight, anterior knee pain and hand – anatomy and biomechanics – clinical examination dislocations/sprains epidemiology of injuries – fractures – tendon injuries Hawkin’s test –, hay fever (seasonal allergic rhinoconjunctivitis) – H-band , head injuries – biomechanics , – case story classical reference – closed on-field assessment management – open types – Head Injury Criterion (HIC) health benefits athletic career – physical activity , , – hearing impairment , heart athlete’s see athlete’s heart conduction abnormalities limits to functional capacity structural changes – heartburn heart disease in athletes congenital , valvular see also coronary heart disease heart failure heart rate – in children at high altitude , classical reference , maximal (HRmax) , in elderly at high altitude – in overtraining syndrome resting –, , variability (HRV) , heat acclimatization , –, balance – equation exhaustion illness (injury) , – intolerance, children loss – production see thermogenesis stroke , see also hot (and humid) environments
heat–moisture exchange devices ‘heavy legs’ feeling heel pain , height see stature helmets, protective hemangioma, intra-articular hemarthrosis hematoma intracranial – intramuscular –, subungual hematuria, sports – hemobursa hemoconcentration, cold-induced , hemoglobin concentration ([Hb]) hemophilia hemopure hemorrhagic colitis , , hemorrhagic gastritis (HG) , hemorrhoids heparin injections hepatitis A vaccination hereditary motor and sensory neuropathy hernia diagnosis sports (incipient) – see also inguinal canal-related groin pain herpes infection , hexokinase (HKII), in spinal cord injury – high altitude , –, acclimatization , aerobic performance – illnesses , –, immediate adjustments live high – train low , live low – train high physical changes/implications – simulated , training –, high-altitude cerebral edema (HACE) – high-altitude pulmonary edema (HAPE) , –, , Hill curves see force–velocity (F–V) relationships Hill–Sachs lesion , , hip anatomy – bursitis – flexion testing fractures , , joint disorders nerve entrapment osteoarthritis –, , – pain –, snapping – history-taking HIV infection exercise in , , transmission risks Hoffmann reflex see H-reflex hook of hamate fractures – hopping, in vivo tendon forces – hop test, single-limb hormone replacement therapy (HRT) in athletic amenorrhea , – bone mass changes , muscle strength and power and
hormones – aging changes during exercise – carbohydrate metabolism regulation effect of training fat metabolism regulation dysregulation in overtraining syndrome – regulation of resting metabolism see also specific hormones hornblower’s sign horseback riding by disabled , injuries hot (and humid) environments , – acclimatization , –, cardiovascular effects – children and adolescents in cystic fibrosis dehydration – in spinal cord injury sweating see also heat H-reflex , – in eccentric contraction human chorionic gonadotrophin (hCG) assay methods –, doping humeral head relations to glenoid (retro)version –, –, in secondary impingement humidity exercise-induced asthma and see also hot (and humid) environments Humphrey ligament hyaluronan, intra-articular injection hydrotherapy, in patellofemoral pain syndrome b-hydroxy-CoA-dehydrogenase (HAD) -hydroxyproline (Hyp) , -hydroxytryptamine (serotonin), in overtraining syndrome hygiene, when abroad , –, – hyperextension test (knee) hyperglycemia, exercise-induced hyperosmolality, in hot environments hypertension – benefits of exercise , –, cardiovascular disease risk , in children in diabetes exercise in – in spinal cord injury – hypertriglyceridemia hypertrophic cardiomyopathy , , vs. athlete’s heart , , hypoglycemia, exercise-induced , , hypothalamic–pituitary–ovarian axis hypothalamus body temperature regulation , dysfunction in overtraining , hypothenar hammer syndrome hypothermia – hypoxemia, in cystic fibrosis ‒ hypoxia at high altitude , , acclimatization living in
Index training in ventilatory response , I-band , ice , ice hockey , epidemiology of injuries , , , spinal cord injuries , IgA, salivary IGF see insulin-like growth factor iliofemoral ligament – iliohypogastric nerve ilioinguinal nerve entrapment iliopectineal bursitis iliopsoas muscle , acute strains palpation iliopsoas-related groin pain clinical presentation , treatment , iliopsoas tendon snapping – iliotibial band tears iliotibial tract friction syndrome imaging – classical reference , future prospects in groin injuries –, – indications in knee injuries – in low back pain – in neck pain in shoulder problems – in spinal injuries – upper extremity – see also computed tomography; magnetic resonance imaging; radiography; scintigraphy; ultrasound Immediate Measurement of Performance and Cognitive Testing (IMPACT) immersion foot immobilization – bone mass/mineral density changes , cartilage responses – ligament healing and muscle atrophy muscle collagen changes soft tissue responses – immune system , – benefits of exercise exercise-induced asthma and – infections , – benefits of exercise classical reference , corticosteroid injection and environmental risks – exercise in – management and counselling – metabolic responses/performance effects – risks of exercise – inferior glenohumeral ligament (IGHL) – inflammation in ligament injury in muscle injury – in tendon injury –
inflammatory cells, in muscle injury , , influenza vaccination information about competition venues – in osteoarthritis – prevention of eating disorders infrapatellar bursa, deep infraspinatus muscle power test , inguinal canal-related groin pain – clinical presentation etiology – see also hernia inhibitory (inter)neurons Ia – Ib – injuries, sports – acute treatment – assessment – on-field – off-field sideline , – categories in children and adolescents – costs definitions – development of treatment – in disabled athletes – emergency care epidemiology – absolute numbers –, incidence –, methodologic issues – study design – etiology – conceptual models , risk factors , – history imaging – mechanisms –, – nature observation palpation – pharmacologic treatment – prevention , – crash measures historical reference , model (Haddon matrix) – postcrash measures precrash measures – sequence sports behavior and primary examination rehabilitation see rehabilitation severity – treatment, duration and nature vs. training adaptations – insulin action, effects of exercise cancer risk and carbohydrate loading and – during exercise , in overtraining syndrome resistance at rest secretion – sensitivity , , –, , signaling pathway –
treatment –, in type diabetes insulin-like growth factor I (IGF-I) assay doping , in elderly in mechanotransduction , in muscle injury and repair osteoporosis and insulin-like growth factor II (IGF-II), in mechanotransduction insulin receptor , insulin receptor substrate (IRS-) , integrins –, – intellectual impairment (mental handicap) , –, intensity, exercise in anaerobic training in older adults in specific sports , interdigital neuroma – interleukin , in muscle injury intermittent claudication – International Anti-Doping Arrangement (IADA) International Blind Sports Association (IBSA) , International Coordinating Committee of World Sports Organizations for the Disabled (ICC) International Olympic Committee (IOC) doping control laboratories prohibited doping agents/methods , International Paralympics Committee (IPC) International Sports Federation for Persons with a Mental Handicap (INAS-FMH) , – International Sports Organization for the Disabled (ISOD) , International Stoke Mandeville Games Federation (ISMGF) International Stoke Mandeville Wheelchair Sports Federation (ISMWSF) International Wheelchair Basketball Federation (IWBF) , , interosseous muscles (hand) interphalangeal joints proximal (PIP), dislocations/sprains intersection syndrome – interstitial cell-stimulating hormone (ICSH) interval training in asthma intervertebral disks – herniation , , , surgery intervertebral foramen intestinal absorption intra-articular injections, in osteoarthritis intra-articular injuries, cartilage changes – intracerebral hematoma intracompartmental pressures, elevated – inverse dynamics , , , IREQ index iridocycl*tis
Index iron – deficiency intake supplements , ischemic (hemorrhagic) colitis , , ischial nerve ischial tuberosity avulsion fractures – ischiofemoral ligament – isokinetic dynamometry –, isokinetic exercise isometric muscle contraction maximal strength – in rehabilitation strength training stroke risk and isotonic testing, in rehabilitation jet lag joint angle, anatomic immobilization, cartilage changes – injuries, scintigraphy – lavage – moment, net , position sense range of motion (ROM) –, measurement error measurement techniques passive and active reaction forces replacement (arthroplasty) , , – stability dynamic – evaluation – static – trauma cartilage changes , – osteoarthritis risk Jones fracture jumper’s knee see patellar tendinitis c-Jun N-terminal kinase (JNK) keratan sulfate/chondroitin sulfate ratio , ketoacidosis, diabetic ketoprofen, topical kinematics glenohumeral joint – kinesthesia kinetics , – three-dimensional – kit, sports medicine – knee – anatomy and biomechanics – arthrometers , biomechanical loading –, , bones – brace bursae , , chondral injuries – fractures – injuries –, – case story classical reference ‒, diagnosis differential diagnosis of acute history – imaging – incidence –
magnetic resonance imaging , , –, – mechanism – osteoarthritis and – physical examination – prevention , rehabilitation – return to sport – scintigraphy , treatment – instability , , – anterior translational – medial posterior – posterolateral – jumper’s see patellar tendinitis ligaments – injuries –, – isolated injuries – mechanics – see also specific ligaments osteoarthritis chondral injuries and meniscus injuries and –, , risk factors , – overuse injuries – differential diagnoses – etiology – future directions imaging NSAIDs for treatment – pathologies pain in adolescents – anterior – referred – posterolateral complex see posterolateral complex of the knee replacement , bi- or tricompartmental unicompartmental runner’s tumors KT- arthrometer kyphosis labrum see glenoid, labrum Lachman’s test , , , lactate dehydrogenase (LDH) lactate/lactic acid control of glycolysis formation , plasma after intermittent work at high altitude (‘lactate paradox’) postexercise removal lactate–performance curve, in overtraining syndrome lag sign – lateral collateral ligament (of elbow) rupture , ulnar band rupture lateral cutaneous nerve of thigh sensory mononeuritis lateral patellofemoral ligament lateral patellotibial ligament learning difficulty (mental handicap) , –, Le Fort maxillofacial fractures
left ventricle (LV), dimensions in athlete’s heart , – left ventricular hypertrophy pathological physiological –, – Legg–Calvé–Perthe’s disease , , – leg length differences length–tension curve , , , leptin in athletic amenorrhea osteoporosis and Les Autres , – leukocytes leukotriene receptor antagonists , , life expectancy athletes , physical activity and – lifestyle activity life-threatening injuries lifting – in spinal cord injury – lift-off test ligament injury – cartilage effects – factors affecting healing – mechanical properties ‒ natural history tissue engineering approaches – in vivo force measurements – mechanical properties responses to stress – training adaptations limb elevation – linear transformation, direct linkage concept link-segment models , lipid peroxidation, in diabetes lipid profiles, serum benefits of exercise in children in type diabetes in type diabetes , , a-lipoic acid lipolysis during exercise , hormonal regulation , lipopolysaccharides (LPS), in heat stroke lipoprotein lipase (LPL) , load–elongation curve bone–ligament–bone complex knee ligaments – loading, mechanical bone – cartilage , – knee joint –, , , muscle , – tendon – load-and-shift (axial load) test , , locomotor disability exercise physiology – special precautions – sports participation – long-distance runners gastrointestinal symptoms –, injury prevention stress fractures longevity see life expectancy loose bodies, elbow – lordosis
Index low back pain see back pain, low lower leg – injuries frequency – overuse soft tissue – muscles stress fractures see also ankle; foot Ludloff ’s sign lumbar radiculopathy , , – lumbrical muscles lunate lung function in asthma , , in cerebral palsy luteinizing hormone (LH) lymphocytes lymphokine-activated killer (LAK) cells
macrophages, in muscle injury macrotrauma magnesium – magnetic resonance imaging (MRI) , , – in ankle injuries classical reference , in groin injuries – in knee injuries , , –, – in low back pain principles – in shoulder problems , , –, in soft tissue injury – in spinal injuries strength training-induced changes – upper extremity – magnetic resonance (MR) arthrography – magnetic stimulation, transcutaneous maintenance training malaria prophylaxis mallet finger maltodextrin manual therapy, back pain marathon, wheelchair marathon runners, gastrointestinal symptoms –, march fracture Marfan’s syndrome masters athletes aerobic power – bone changes connective tissue changes performance strength and power see also veteran athletes matrix metalloproteinases (MMPs) , , maxillofacial injuries maximal aerobic power (oxygen uptake) see VOmax maximal voluntary contraction (MVC) maximum achievable ventilation (MAV, maximal breathing capacity, MBC) , M-band , McArdle’s disease McIntosh test McMurray meniscal test meals energy sources after , – hormonal changes after mechanocoupling
mechanotransduction in bone – in muscle medial collateral ligament (MCL) (complex) of the knee – components injuries –, – combined with ACL injuries –, factors affecting healing – magnetic resonance imaging , natural history non-surgical treatment ‒, physical examination , surgical treatment ‒, tissue engineering approaches mechanical properties medial collateral ligament (MCL) of the elbow instability , magnetic resonance imaging , medial patellofemoral ligament medial patellotibial ligament medial suprapatellar plica –, medial tibial stress syndrome , , –, median nerve –, entrapments –, – medical problems, pre-existing – medicines see drugs men, bone mass and physical activity – menarche, age at , meniscal cysts , meniscectomy – knee joint changes , , magnetic resonance imaging after –, – rehabilitation meniscus allografts anatomy discoid injuries –, in adolescents , articular cartilage changes clinical tests diagnosis incidence magnetic resonance imaging , , –, osteoarthritis after –, , repair , rehabilitation scintigraphy , treatment , – ultrasound imaging menopause , see also postmenopausal women menstrual dysfunction in athletes , see also amenorrhea mental handicap , –, mental health – meralgia paresthetica mesenchymal stem cells (MSC), in ligament injury metabolic myopathies metabolic rate basal see basal metabolic rate in cold conditions resting (RMR), in athletic amenorrhea
metabolism , , – aerobic , –, anaerobic –, – classical references effects of infections – energy expenditure and – exercise – in recovery from training – metacarpals boxer’s fracture – fractures shaft fractures – metacarpophalangeal (MP) joints dislocations/sprains stability testing metatarsals fractures stress fractures , , – methylprednisolone MET values MHC see myosin heavy chain microfracture technique microtrauma middle glenohumeral ligament (MGHL) minerals , – excessive intake supplements , – mitochondria proteins and enzymes , , , mitogen-activated protein kinases (MAPKs) mitral valve prolapse modulus, bone–ligament–bone complex moment net joint , support moment of force peak moment–velocity relationship MONICA project mononucleosis, infectious , montelukast , , mood effects of exercise – in overtraining syndrome morphine, detection mortality, physical activity and , Morton’s metatarsalgia – mosaicplasty motion segment, spine –, motivation , , motoneuron diseases motoneurons a- in bilateral vs. unilateral muscle contraction – discharge doublets , , in eccentric contraction – evoked reflex responses , – firing frequency – high-frequency firing pattern inhibitory mechanisms – in muscle injury synchronization in firing motor endplate (neuromuscular junction) , motor nerves , intramuscular rupture, in muscle injury see also motoneurons
Index motor units loss, in elderly see also motoneurons mountain sickness, acute (AMS) , – movement analysis see biomechanics, analysis movement-related cortical potentials (MRCPs) – M-response, maximal , MRI see magnetic resonance imaging mRNA translation efficiency multifidus muscles , , exercises , fatigability, in low back pain multiple sclerosis Mumford procedure muscle – adaptations to training –, , altitude-induced changes architecture – adaptations to strength training , – ATP generation – atrophy inactivity-induced injury-related neurogenic blood flow, peak – capillaries see capillaries, muscle catch-like property cells see muscle fibers classical reference , coactivation of antagonist – in cold temperatures , , contraction , type testing cross-sectional area (CSA) , , –, – in elderly , – denervation , in elderly – electrical stimulation see electrical stimulation endurance, evaluation – energy stores extracellular matrix see extracellular matrix (ECM), muscle fatigue , – function evaluation – in infections , insulin-stimulated glucose uptake – linkage concept loading , – mass in childhood in elderly , energetic power and capacity and in spinal cord injury morphology – adaptations to strength training , – optimizing changes – oxidative enzymes , , , proteins –, catabolism – responses to training –, scintigraphy soreness acute delayed-onset (DOMS) , speed endurance stiffness in elderly ,
short-range elastic (SRES) – strength see strength, muscle training, specific – volume – weakness evaluation in low back pain , , muscle fibers (myofibers, muscle cells) – atrophy cross-sectional area (CSA) –, – development – exercise-induced disruption – hyperplasia , hypertrophy , , – in elderly optimal development – length , nucleus/cytoplasm ratio pennation angle –, , – plasticity – regeneration in muscle injury – size – structure , type I hypertrophy type II – in eccentric contraction hypertrophy type IIa type IIb type IIx types – in children collagen content differentiation – in elderly – ‘explosive’ muscle strength and inactivity-associated changes – in spinal cord injury , training-induced changes , – muscle force development muscle cross-sectional area and – rate of see rate of force development sarcomere length and training-induced changes , in vivo measurements – maximal, estimation – velocity relationships see force–velocity (F–V) relationships muscle injuries – acute treatment – back – classical reference , corticosteroid injections eccentric exercise see eccentric muscle contraction, muscle damage in elderly – grades – inflammation – in situ necrosis type – NSAID treatment , , prevention with NSAIDs – and repair mechanisms – shearing type , – shoulder ultrasound imaging – muscle power , in elderly – cross-sectional studies –
longitudinal studies – evaluation – muscle–tendon unit in vivo force measurements –, – models , stretching , – muscular dystrophy , musculocutaneous nerve overload musculoskeletal disorders, in athletes , myoblasts in muscle injury and repair , , , myocardial infarction during physical activity exercise after – myocarditis , exercise during infections and –, – precautions myocardium, vascularization and perfusion – myoD family of transcription factors , –, myofibers see muscle fibers myofibrils damage by eccentric exercise myogenic precursor cells myoglobin (Mb), in muscle injury myopathies – myosin , , actin coupling filaments , – light chains myosin ATPase histochemistry , myosin heavy chain (MHC) IIb isoform IIx isoform – isoforms , training-induced shifts – myositis ossificans corticosteroid injections imaging , , NSAID treatment – scintigraphy , myotonic dystrophy – myotubes in muscle injury and repair , , N-acetyl-cysteine nailbed injuries nandrolone decanoate narcotic analgesics natural killer (NK) cells, in HIV infection ‘navicular’ fractures , navicular stress fractures – nebulin neck injuries , – neck pain – clinical examination – diagnosis epidemiology history imaging prevention radiating to shoulder/arm , rehabilitation transient, with paresthesia of upper extremity – nedocromil Neer’s test –, ,
Index neoplasms see tumors nerve entrapments pelvic region shoulder – upper extremity , –, – nervous system, function in acute infections , neural adaptations to strength training , – antagonist muscle coactivation – bilateral strength deficit – classical reference – eccentric muscle contraction – EMG signal amplitude – ‘explosive’ muscle strength and – inhibitory mechanisms – Ib afferent inflow from Golgi organs – Renshaw inhibition – motoneuron evoked reflex responses – motoneuron firing frequency – motoneuron synchronization optimising – neurapraxia neurologic examination in low back pain –, , , in spinal injuries , neuromotor control, development neuromuscular disorders – neuromuscular junction (NMJ) , neuromuscular stimulation techniques – neuropsychologic tests, in head injury – neurotmesis neutrophils in HIV infection in muscle injury nifedipine in autonomic dysreflexia in high-altitude illness , , , nitric oxide (NO) nitric oxide synthase (NOS) endothelial (eNOS) , , neuronal (nNOS) noise reduction/filtering non-steroidal anti-inflammatory drugs (NSAIDs) – adverse effects , , colon cancer and COX--selective (coxibs) , , in osteoarthritis in tendon overuse injuries – in low back pain in muscle injury , , for osteoarthritis to prevent muscle injury – topical see topical NSAID therapy norepinephrine (noradrenaline) in cold environments , in overtraining , regulation of metabolism , response to exercise , , NS- NSAIDs see non-steroidal anti-inflammatory drugs nucleus pulposus – nutrients adequate intake density vs. energy density essential – optimal intake
recommendations – recommended daily allowances – requirements – vs. energy requirements tolerable upper limit (UL) see also carbohydrate; fatty acids; minerals; protein; vitamins nutrition – in amenorrheic athletes assessment of status – case stories , methods – validation –, benefits of exercise classical reference daily intake/food habits – during exercise/training , – energy vs. nutrient density energy vs. nutrient requirement optimal – osteoporosis/stress fractures and – post-exercise/training – pre-exercise – requirements and recommended daily allowances – specific needs of athletes – gender differences – protein debate see also diet; dietary supplements; food; meals obesity –, – cardiovascular disease risk , in children , classical reference , prevention role of physical inactivity – treatment – observation of athletes obturator nerve occupation, osteoarthritis risk and – oestrogen see estrogen off-field injury assessment Ogden lysis Olympic Movement Anti-Doping code – Olympics for the Disabled , one-leg balance test one-leg hyperextension test , on-field injury assessment – opioids, weak optic fiber method, force measurement – oral contraceptives, in athletic amenorrhea , os acromiale , resection Osgood–Schlatter disease , , – osteitis pubis , , – osteitis pubis-like changes –, osteoarthritis (OA) – after meniscectomy , , altered weight-bearing and – animal models – classical reference in athletes hip –, , – knee see knee, osteoarthritis physical activity and – post-traumatic –, prevention radiography risk factors
running training studies , sports-induced – treatment – non-surgical – surgical – osteoblasts, mechanotransduction –, , – osteocalcin , osteochondral allografts – osteochondral autogenous grafts osteochondral fractures computed tomography knee – operative treatment – osteochondritis dissecans (OCD) computed tomography elbow , knee , , – radiography scintigraphy –, talus – osteoclasts, mechanotransduction , osteocytes, mechanotransduction , –, osteogenesis imperfecta osteoma, osteoid , osteomyelitis , osteonecrosis (avascular necrosis) femoral head , , – imaging osteopenia in athletes definition osteophytes ankle in elbow impingement , pathogenesis , , in shoulder impingement osteopontin , osteoporosis , – in amputees calcium intake and definitions etiology – in female athletes , – prevention , –, risk factors , treatment – osteoporotic fractures prevention , –, risk , osteosarcoma osteotomy in knee , , in osteoarthritis os trigonum ovarian cancer overhead activities – elbow problems rotator cuff lesions , scapulothoracic motion shoulder impingement , , –, shoulder rehabilitation – overhead exercise test overreaching overtraining (syndrome) (OTS) – altered mood profile causes definitions –
Index overtraining (syndrome) (OTS) (cont.) ergometric testing/blood chemistry – parasympathetic (addisonoid) form pathomechanism and hormonal dysregulation – sympathetic (basedowoid) form symptoms – treatment upper respiratory tract infections and vegetative complaints overuse injuries arm in children and adolescents – in disabled athletes , knee – lower leg – pathogenesis – treatment overweight – osteoarthritis and , oxandrolone oxidative enzymes , , , oxidative phosphorylation oxidative stress – in diabetes , oxygen consumption oxygen content, arterial (Cao) oxygen difference, arteriovenous (a-vodiff) , – oxygen diffusion capacity of lung (DLo) oxygen free radicals see free radicals oxygen saturation, arterial (Sao) –, oxygen supplements, in high-altitude illness , oxygen tension (Po) air, at high altitude , alveolar–arterial difference (A–aDo) arterial (Pao) , , ventilatory response oxygen uptake, maximal see VOmax oxyglobin oxymetholone ozone psF pain pharmacologic treatment – rehabilitation and palmar radioulnar ligament palpation – paracetamol (acetaminophen) in neck pain for osteoarthritis Paralympic Games , , doping paraplegia see spinal cord injuries parasympathetic (vagal) activity during exercise gastrointestinal effects training effect – Paromed-system pars interarticularis defect , patella , bipartite chondromalacia dislocation , – subluxation – patellar apprehension test patellar overload syndrome –
patellar tendinitis (jumper’s knee) – in adolescents classification corticosteroid injections , – etiology , imaging , pathology treatment patellar tendon force measurement overuse injury see patellar tendinitis reflex – ultrasound imaging , –, patellar tenotomy patellofemoral joint anatomy – injuries –, – mechanism of injury physical examination – patellofemoral ligaments patellofemoral pain syndrome (PFPS) , – in adolescents – patellomeniscal ligament patellotibial ligaments Patrick (Faber) test , PCL see posterior cruciate ligament PCr see phosphocreatine peak expiratory flow (PEF) , pelvic region – anatomy – avulsion fractures – fractures – imaging – inflammation in joints injuries see groin injuries/pain joints ligaments , muscles – nerve entrapment nerves stress fractures , – tumors performance aging athletes in childhood/adolescence in cold conditions – determinants , effects of infections – at high altitude – in hot environments , – in overtraining syndrome – testing , – choice of test – reasons for periarthropathie sportive pericardium, limits to VOmax perimysium , periosteum peripheral neuropathy, diabetic peripheral vascular system factors limiting VOmax – training adaptations – peripheral vessel disease – peritendinitis corticosteroid injections crepitans peroneal muscle reaction times , , – peroneal tendons, dislocation –
pes anserinus bursitis phalanges fractures Phalen’s sign pharmacologic treatment, sports injuries – phosphate, inorganic (Pi) phosphatidylinositol (PI) -kinase , phosphocreatine (PCr, creatine phosphate, CP) anaerobic training and breakdown –, – capacity , during exercise , maximum rate (power) , – depletion during exercise postexercise resynthesis stores phosphofructokinase (PFK) , deficiency (McArdle’s disease) physical activity assessment – bone mass/mineral density effects – in children/adolescents definition energy balance and – health benefits , lifetime increase osteoarthritis and – strategy for increasing physical activity level (PAL) , – physical inactivity bone mass/BMD effects – cardiovascular disease risk – role in obesity – in spinal cord injuries type diabetes and – piezoelectricity pivot-shift tests elbow , , knee , , plantar aponeurosis (fascia plantaris) plantar fasciitis – corticosteroid injections scintigraphy ultrasound imaging plantar pressures see foot pressures plantar reflex – plasma volume plasminogen-activator inhibitor (PAI-) platelet-derived growth factor (PDGF) plica causing knee pain in adolescents medial suprapatellar –, pneumatists P/O ratio poliomyelitis, exercise and polysulfated glycosaminoglycan popliteal artery aneurysms entrapment syndrome (PAES) – popliteal cysts , popliteal space swellings – popliteal tendinitis popliteofibular ligament injuries popliteus complex popliteus tendon avulsion reconstruction positive predictive value (PPV)
Index postabsorptive state energy sources , – hormonal regulation of metabolism postconcussion syndrome – posterior articular nerve (PAN) posterior cruciate ligament (PCL) assessment of integrity – avulsion fractures reconstruction – double-bundle technique – onlay technique rehabilitation after tears – combined with posterolateral knee injury – posterior drawer test –, posterior humeral circumflex artery compression posterior interosseous nerve injuries syndrome (PINS) – posterior oblique ligament (of knee) posterior sag sign posterior talofibular ligament (PTFL) injuries posterior tibial syndrome posterolateral complex of the knee assessment of integrity – injuries – chronic – non-surgical treatment with other knee ligament ruptures – surgical treatment – posterolateral drawer test postmenopausal women bone mass , , , , muscle strength and power postpolio syndrome posture , power see energetic power; muscle power prednisolone pre-existing medical problems – prepatellar bursitis pressure ulcers, in spinal cord injury presynaptic inhibition –, prevention ankle injuries , – disease , – eating disorders neck problems obesity osteoarthritis re-injury shoulder impingement –, spinal cord injuries sports injuries see injuries, sports, prevention type diabetes –, , procollagens production training progesterone in elderly in female athletes progestins osteoporosis and prolyl -hydroxylase (PH) , in elderly , pronator syndrome , – proprioception evaluation of deficits
shoulder – training , prospective studies prostaglandins (PG) in mechanically loaded bone , in tendon injury – prostate cancer prostheses, for amputees protein dietary intake during exercise excessive postexercise , recommendations dietary needs as energy source , metabolism, postexercise muscle see muscle, proteins nutritional roles supplements protein kinases proteoglycans (PG), cartilage in immobilization in vitro loading studies – in joint trauma , , in running training , weight-bearing alterations and proximal interphalangeal joint (PIP) dislocations/sprains psychological profile benefits of exercise , – in children with chronic disease in disabled in overtraining syndrome psychosocial factors, in back pain puberty adverse effects of exercise – normal pubic pain pubic rami stress fractures pubofemoral ligament – pulmonary blood flow pulmonary edema, high-altitude (HAPE) , –, , pulmonary gas exchange – pyrexia see fever pyridinoline pyruvate , Q q-angle quadratus lumborum muscle quadriceps active test quadriceps muscle , assessment of tone contraction, in rehabilitation , cross-sectional area/volume , electrical stimulation , , rehabilitation, in anterior knee pain quadriceps tendinitis – quadrilateral space syndrome radial nerve , entrapments –, radial palsy, high radial tunnel syndrome – radiculopathy cervical , – lumbar spine , , – radiocarpal joint complex –
radiography (X-rays) – in groin injuries in knee injuries , in low back pain in shoulder problems stress see stress radiography upper extremity radionuclide bone scan see scintigraphy radioulnar joint distal – dislocation proximal radius raloxifene randomized studies, treatment of sports injuries – range of motion (ROM) functional joint see joint, range of motion testing rate of force development (RFD) , determinants in initial phase of contraction – Raynaud’s syndrome reaction forces, ground (external) , reactive oxygen species (ROS) see free radicals recommended daily (dietary) allowances – recovery after training – classical reference , metabolism during – recreational sports benefits and drawbacks motivation treatment of injuries – rectal temperature rectus abdominis sheath – rectus femoris muscle acute strains chronic injuries recurvatum test , red cell mass (RCM) altitude-induced increase high-altitude training reflexes, deep tendon – rehabilitation –, – acute/subacute phase , , classical reference , corticosteroid injections – evaluation during , – knee injuries – in ligament injury low back pain – neck pain phases –, post-myocardial infarction principles – recovery phase , re-evaluation return to sport phase , shoulder problems – in spinal cord injury – relocation test, shoulder instability renin Renshaw cells – Renshaw inhibition – repeated sprint test , repetition of maximum (RM) number of , –,
Index resistance training , older adults in type diabetes –, see also strength training respiratory disease in athletes see also asthma respiratory exchange ratio, in overtraining syndrome respiratory muscles respiratory quotient (RQ) , , respiratory system aging effects – training adaptations , – respiratory tract infections risks of exercise – transmission risks – upper (URTI) , , – in asthma rest periods, in anaerobic training retinopathy, diabetic retrocalcaneal bursitis – return to sport , in knee injuries – reverse pivot-shift test – rheumatoid arthritis benefits of exercise juvenile – risks of sports participation RICE principle ankle sprains , muscle injuries right ventricle enlargement, in athlete’s heart – risks of exercise in childhood and adolescence – in chronic disease – in infections – in specific diseases , rofecoxib Rolando fracture – Roos test rotator cuff muscles , power tests – rehabilitation tears (lesions) – biceps tendon rupture with full-thickness – magnetic resonance imaging , , partial-thickness – tests – ultrasound tendinitis , – rotator interval rowing, performance testing runner’s knee running amenorrhea articular cartilage changes – gastric emptying in vivo tendon forces – lower leg injuries performance tests –, upper respiratory tract infections , Russian root (ginseng) sacroiliac joint sacroiliitis ,
sacrospinal ligaments , sacrotuberal ligament , salbutamol salmeterol sampling, population – sarcomas sarcomere , length–tension curve , , sarcopenia of elderly , sarcoplasm sartorius muscle , acute strains chronic injuries satellite cells in muscle hypertrophy , in muscle injury and repair –, , scalp injuries scaphoid fractures , case story imaging , impaction syndrome scapula instability movements see scapulothoracic motion ptosis , snapping stabilizing muscles , scapulothoracic bursitis scapulothoracic motion assessment – problems – rehabilitation scapulothoracic rhythm scar tissue, in muscle injury and repair , – Scheuermann’s disease – school time, lost through injury scintigraphy (radionuclide bone scan) , , – groin injuries , , , knee injuries method – shin splints , , , upper extremity scoliosis , , – diagnosis , , treatment – seasonal allergic rhinoconjunctivitis – second impact syndrome (SIS) , sedentary lifestyle cancer risk childhood roots energy balance , see also physical inactivity segment angle seizures, epileptic selenium self-efficacy, sports injuries and semimembranosus muscle semitendinosis muscle senescence sensory afferents group I, inhibitory feedback group Ia , group Ib group II, inhibitory feedback sensory nerve fibers sensory testing, in low back pain ,
serotonergic system, in overtraining syndrome serratus anterior muscle , strengthening exercises , testing serum response element sesamoid bone fracture sex differences see gender differences sex hormones in elderly in female athletes intense exercise and , see also estrogen; progesterone; testosterone shin splints – scintigraphy , , , terminology see also specific diagnoses shivering , shock short-range elastic stiffness (SRES) – shoulder – anatomy – bursitis dislocation acute, first-time anterior CT scanning , magnetic resonance imaging , recurrent rehabilitation after voluntary fractures instability – anatomic lesions – anterior post-traumatic – atraumatic classification , directions evaluation , hyperlaxity-induced in internal impingement , multidirectional (MDI) – overuse-induced posterior in secondary impingement , signs – symptoms tests , , traumatic internal rotation, measurement magnetic resonance imaging , , –, multidirectional hyperlaxity (MDH) neck pain radiating to , nerve entrapment syndromes – neuromuscular coordination – pain, assessing athletes with problems –, – case stories – classical reference , in disabled athletes , history imaging – physical examination – rehabilitation – scintigraphy soft tissue injuries – swimmer’s tendon lesions – tests –
Index weight lifter’s see also glenohumeral joint shoulder girdle exercises shoulder impingement – biceps tendinitis imaging –, internal , – clinical features –, pathophysiology – prevention tests treatment and prognosis in multidirectional instability primary , – clinical features Neer’s staging pathophysiology – tests – treatment and prognosis – see also subacromial impingement secondary , – clinical features pathophysiology prevention – treatment and prognosis side-cutting maneuver –, , sideline injury assessment , – Simmonds test simulation (forward dynamics) – Sinding–Larsen–Johansson disease adult form see patellar tendinitis single-limb hop test single photon emission computed tomography (SPECT) , skating skier’s thumb skiing athlete’s heart for disabled –, – injuries spinal injuries ski-jumping, plantar pressures , , , skin blood flow, in hot environments – cold-induced vasoconstriction , infections , skull fractures , SLAP lesions , , , – sleep benefits of exercise disturbances, in overtraining slipped capital femoral epiphysis Slocum test small intestinal submucosa (SIS) scaffolds smoking, cigarette , in children snowboarding, spinal cord injuries , soccer epidemiology of injuries , , , groin injuries injury prevention , , –, neck problems , osteoarthritis risk performance testing , tendon disease social influences, sports injuries sodium intake losses in sweat
sodium channels, in mechanotransduction sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) , sodium/potassium (Na+/K+)-ATPase softball injuries sore throat space flight spasticity, in cerebral palsy – specific muscle training – speed endurance training – speed training spinal cord, inhibitory interneurons , – spinal cord injuries (SCI) – classification ‒ clinical examination , emergency management of suspected , epidemiology – exercise physiology – arm exercise – classical reference – effects of physical inactivity electrically stimulated leg cycle (ESLC) training – prevention sports participation , – doping and boosting – injuries , – special precautions see also wheelchair sports treatment spinal nerves , spinal stenosis spine – acute injuries – clinical examination diagnostic aspects – epidemiology – on-field assessment history ‒ imaging – prevention stable fractures – unstable fractures see also spinal cord injuries anatomy and biomechanics – bone mineral density curves –, motion segment –, muscles see back muscles neural structures , tumors spinous process , fractures – splanchnic blood flow , splenic enlargement spondylolysis/spondylolisthesis – classification , diagnosis , , epidemiology scintigraphy , treatment , sports bone loading characteristics – injury distribution , in physical disability see disabled, sports participation time lost through injury sports hernia –
sports medicine – acute treatment – injury assessment – kit – team travel to competitions – Spurling test –, squat jump , , ‘staleness’ see overtraining Standardized Assessment of Concussion (SAC) stanozolol stature in elderly exercise in childhood and –, Steadman technique stem cell therapy, in ligament injury Stenner lesion steroids see anabolic steroids; corticosteroids; sex hormones stiffness , aging-related increase , loaded cartilage , , muscle–tendon unit after stretching ‒ stimulants, central nervous system (CNS) – in children and adolescents detection methods Stoke Mandeville Games for the Paralyzed stomach – straight-leg raising test , strength, muscle bilateral deficit – in elderly – cross-sectional studies – longitudinal studies – estimation –, –, in knee injuries in rehabilitation – sideline assessment explosive see explosive muscle strength in low back pain , optimal training for – plasticity response to strength training , strength training –, – basic cardiac hypertrophy – in cerebral palsy components in elderly , , , – functional maximal muscle strength changes , neuromuscular adaptations – classical reference – functional aspects – muscle morphology , – neural drive see neural adaptations to strength training optimal development – in neuromuscular disorders – in spinal cord injury – see also resistance training streptococcal tonsillopharyngitis , stress amenorrhea and eating disorders and infections and overtraining and
Index stress fractures , calcium intake and causing spondylolysis in children and adolescents computed tomography in female athletes , , foot – magnetic resonance imaging – pelvic region , – radiography risk factors , – scintigraphy –, , tibia –, , –, stress radiography – in chronic ankle instability , , in elbow instability stress–strain curve, bone–ligament–bone complex stress tests elbow , in knee injuries , , in neck pain – in overtraining syndrome , stretch(ing) , – biomechanical responses – repeated stretches – single static stretch fibroblast alignment –, pre-exercise stretch–shortening cycle (SSC) , stroke , –, exercise training stroke volume (SV) , , subacromial bursitis , subacromial impingement imaging , measurement tests – subchondral drilling subdural hematoma – subscapularis muscle lift-off test subscapularis tendon substrates, energy see energy substrates subtalar instability , subungual hematoma succinate dehydrogenase (SDH) , sudden death in cardiovascular disease , , in children and adolescents in myocarditis suicide , sulcus sign , superior glenohumeral ligament (SGHL) superior labrum anterior to posterior lesions see SLAP lesions superoxide dismutase (SOD) , , support moment suprapatellar plica, medial –, suprascapular artery , suprascapular nerve , entrapment – supraspinatus muscle in impingement , supraspinatus outlet view supraspinatus tendon in impingement , , , tears , supraventricular tachycardias – sweat, evaporation
sweating in cold environments in hot environments water loss due to swimmer’s shoulder swimming amenorrhea for disabled , effects on growth and puberty – exercise-induced asthma , scapulothoracic problems shoulder problems –, sympathetic nervous system in cold environments , , gastrointestinal effects in overtraining syndrome regulation of metabolism , , response to exercise , , in spinal cord injury – sympathomimetics – symphysis pubis osteitis pubis-like changes –, pain – synapsin synaptophysin synovitis hip, in children knee, in adolescents – pigmented villonodular tachycardias, supraventricular – talar tilt (TT) , talus osteochondritis dissecans – stress fractures – tarsal fusion – TCA (tricarboxylic acid) cycle , – team, sports medicine team handball ACL injuries , , epidemiology of injuries , , injury prevention team sports for disabled – injuries , , technetium-m-diphosphonate bone scanning – see also scintigraphy television viewing , temperature, body core during exercise , , , intramuscular measurement regulation see thermoregulation skin surface see also fever; hypothermia temperature, environmental – exercise-induced asthma and – at high altitude lower critical prescriptive (thermoneutral) zone – upper critical see also cold environments; heat; hot (and humid) environments tenascin, in muscle injury tendinitis shoulder – ultrasound imaging ,
tendinopathy corticosteroid injections –, – ultrasound imaging – tendon blood supply – injuries – animal model , corticosteroid injections –, – hand inflammatory reaction – knee – NSAID treatment , shoulder – ultrasound imaging – wrist – in vivo force measurements –, – loading, collagen metabolism and – mechanical properties (strain) – organ culture ‘overloading’ reflexes – regional differences – responses to stress – training adaptations see also muscle–tendon unit tennis – tennis elbow see epicondylitis, lateral tennis leg tenodeses, in chronic ankle instability – tenosynovitis, ultrasound imaging tensile strain ‒ tensile strength ‒ tensile stress terbutaline teres minor muscle testing testicular cancer testosterone doping – detection methods – side-effects – in elderly to epitestosterone (T/E) ratio ligament healing and testosterone/cortisol ratio, in overtraining syndrome tetrahydrobiopterin TGF-b see transforming growth factor-b therapeutic relationship, in eating disorders – thermal environment , – thermogenesis (heat production) – chemical/non-shivering in cold dietary-induced (DIT) , shivering thermoregulation , behavioral in children and adolescents in cold conditions in spinal cord injury thigh circumference Thomas test Thompson’s test thoracic outlet syndrome , , , – thrower’s elbow –, –, throwing athletes elbow problems , – shoulder problems –, , thumb
Index fractures – skier’s thyroid hormone in cold environments , tibia avulsion injuries plateau fractures stress fractures –, –, anterior incidence posteromedial transchondral fracture , tibial collateral ligament (TCL) , tibialis posterior tendon dysfunction/rupture – tibial onlay technique, PCL reconstruction tibial stress syndrome, medial , , –, tibiofemoral joint mechanism of injury – physical examination – anterior translational abnormalities – medial-sided injuries posterior instability – posterolateral instability – tibiofibular joint, proximal – tidal air, during exercise , time zones, acclimatization to , Tinel’s sign , , tissue engineering, in ligament injuries – tissue inhibitors of metalloproteinases (TIMPs) tissue scaffolds, in ligament injury ‒ titin , toe fractures tomography in groin injuries in knee injuries see also computed tomography tonsillopharyngitis , ‘too many toes’ sign topical NSAID therapy , in Achilles tendon disorders in osteoarthritis – torticollis, acute tournament venues see competition venues trace elements – training adaptations see adaptations, training benefits and drawback in chronic disease – exercise-induced asthma and heat acclimatization and motivational aspects , types tramadol transferrin transforming growth factor-b (TGF-b) in degenerative joint changes in ligament injuries in mechanotransduction , in muscle injury and repair transportation, injured athletes transverse process , fractures – transversus abdominis trapezius muscle , , testing
traumatic brain injury (TBI) minor (MTBI) see also concussion travel to competitions – medical team duties during preparation/planning – returning home treadmill trench foot triamcinolone triangular fibrocartilage complex (TFCC) – injuries , tricarboxylic acid (TCA) cycle , – triceps muscle triceps tendon, distal, rupture – triglycerides (TG) , , as energy source during exercise – medium-chain (MCTs) triiodothyronine (T) triple jump, plantar pressures , , triquetrolunate impaction syndrome triquetrum impaction fractures trochanteric bursitis tropomyosin , troponin , , tryptophan, brain, in overtraining syndrome TUBS classification, shoulder instability tuft fracture tumor necrosis factor, in muscle injury tumors computed tomography knee pelvic region spine see also cancer ubiquinone (Q) ulna ulnar artery aneurysms thrombosis in Guyon’s canal ulnar carpal impaction syndrome ulnar collateral ligament elbow instability (overload injury) , – reconstruction rupture thumb injuries testing ulnar nerve , , entrapments , at arcade of Struthers in cubital tunnel in Guyon’s canal (cyclist’s palsy) in thrower’s elbow , , transposition (at elbow) – ‘ulnar splints’ ulnolunate ligament ulnotriquetral ligament ultrasound (US) , , – Achilles tendon disorders –, in ankle injuries beam obliquity artefact future prospects ,
groin injuries , knee injuries –, muscle fiber pennation angle – muscle injury – in shoulder problems tendon changes – uncoupling proteins (UCP) , upper extremity see arm urinary steroid profile urinary tract infections (cystitis) exercise during in spinal cord injury urticaria, cold uterine cancer vaccination vagal activity see parasympathetic (vagal) activity valgus foot , valgus stress test at o knee flexion , elbow , valvular heart disease varus stress test at o knee flexion , elbow instability meniscus injuries vasoactive intestinal polypeptide vasoconstriction, cold-induced , vasodilatation endothelium-dependent (EDD) , – in hot environments vastus lateralis muscle vegetables vegetarian diet , venous thrombosis, effort-induced ventilation – alveolar (VA) capacity maximum , at high altitude maximal voluntary (MMV) maximum achievable (MAV) total (VE) , response to CO production (VE/Pco) – response to hypoxia ventilation–perfusion (V/Q) ratio ventricular arrhythmias ventricular filling rate, diastolic vertebrae , motion segment –, vertebral column see spine vertebral foramen , vertebral fractures classification systems , – emergency management – spinous and transverse process – stable – three column concept , unstable vertebral body vertical jumping , , veteran athletes athlete’s heart – performance see also masters athletes video recording , vinculin
Index viral infections, myocarditis risk , –, viscoelastic behavior, muscle–tendon unit visual impairment sports injuries sports participation , , vitamin C vitamin E in muscle injury – supplements vitamin Q (Q) vitamins , B excessive intake supplements VLDL (very low-density lipoprotein) triglycerides , VOmax (maximal aerobic power) , – aerobic training age-related decline , , – ATP generation rate and blood volume and cardiac output and , in children , in elderly –, , , erythropoietin administration and , at high altitude , limiting factors – in neuromuscular disorders and performance in performance testing in spinal cord injury , training effect , volar plate volar radiocarpal ligament volleyball injuries , , patellar tendinitis , patellar tendon changes sitting vomiting, exercise-induced V-wave , – Waddel signs walking longevity and in osteoporosis in peripheral vessel disease warm-up in asthma
–
in cold environments Wartenberg’s syndrome warts, plantar , water bound by glycogen , cold, immersion , – content of air, at high altitude gastric emptying hygiene , – intake see fluid intake loss during exercise water sports for disabled in epilepsy Watson–Jones tenodesis Wayne State tolerance curve (WSTC) Weaver–Dunn procedure weight, body benefits of exercise , – cycling – effect of exercise – guidance for athletes , loss, role of exercise low, in female athletes – maintenance, role of exercise – osteoarthritis and , osteoporosis and in type diabetes , , see also obesity; overweight weight-bearing altered, effects on cartilage – in different sports weight-class sports – weightlessness weight lifter’s shoulder wheelburns wheelchair sports – basketball , , , doping and boosting – injuries , special precautions – white finger disease wind chill index (WCI) – Wingate test winter sports , clothing – for disabled –, – heat loss recommendations see also skiing
women aging effects benefits of exercise bone mass and physical activity , –, , cardiovascular disease prevention see also female athletes; postmenopausal women working time, loss through injury workload inducing changes in muscle force intermittent vs. continuous World Anti-Doping Agency (WADA) , wrestlers back pain eating disorders – Wrisberg ligament wrist – anatomy and biomechanics – bony injuries and disorders – clinical examination epidemiology of injuries – gymnast’s hyperextension injuries , , impaction syndromes instability nerve disorders – osteoporotic fractures tendon problems – vascular disorders X-rays see radiography yellow fever vaccination Yergason’s (biceps tendon) test , young people back pain , benefits of exercise bone mass and physical activity –, – disabled athletes see also adolescents; children Young’s modulus yo-yo tests endurance test , intermittent endurance test , intermittent recovery test , Z-band (Z-line) , zinc zygoapophyseal joints ,
Plate Satellite cell/myotube isolated from normal biceps muscle of a -week-old human fetus and cultured for weeks. Stain is against a-actinin. A striated band pattern is seen in the myotube to the left. (Photograph courtesy of Jari Ikaheimonen.)
Facing p.
Glucose uptake in skeletal muscle (µmol/kg muscle • min)
Plate Examples of [F] FDG images as determined with PET and callibrated to the same counts pixel level. Cross-sections are shown of thoracic region (upper images) and femoral region (lower images).
200
100
EA
**
**
WL
S
Plate Rate of glucose uptake in skeletal muscle of an endurance athlete (EA), weight lifter (WL) and sedentary person (S) as measured with positron emission tomography (PEG) and -deoxy--[F]fluoro--glucose (F]FDG). **P < . vs. EA.
