Women and Exercise - Physiology and Sports Medicine

Gynecologic Concerns in Exercise and Training 227 variable and perception of pain as the de- istered by nasal spray. These agents usually pendent variable makes double-blinding im- lead to significant pain relief. Major side ef- possible. Theories proposed to explain the fects include hot flushes, decreased libido, apparent reduction of pain by exercise and vaginal dryness, headaches, emotional la- training include an exercise-induced in- bility, acne, myalgia, and reduced breast crease in pain-preventing endorphins, an size. Synarel side effects also include nasal exercise-induced increase in vasodilating irritation. Because these drugs produce a prostaglandins, and exercise-induced vaso- pseudomenopausal state with low estrogen dilatation. The truth remains to be eluci- levels, their most serious side effect is bone dated. loss. Treatment with GnRH analogs may be continued for a maximumof 6 months, dur- Athletes who experience dysmenorrhea ing which time significant bone loss is un- should be treated with prostaglandin inhib- likely. itors. Exercise-induced relief from dysmen- orrhea should not be expected, since re- Danazol is a derivative of testosterone, sponses are variable and unpredictable. and it has expected androgenic and anabolic Prostaglandin inhibitors often cause re- properties. Within 6 months of danazol ther- duced menstrual blood loss as an additional apy, women have a significant loss of adi- benefit, due to the vasoconstriction caused pose tissue and a significant increase in lean by the inhibition of vasodilating prostaglan- body mass.18 These changes persist longer dins. than 6 months after discontinuing therapy.18 Other major side effects include hot flushes, ENDOMETRIOSIS headaches, emotional lability, acne, re- duced breast size, edema, seborrhea, and Endometriosis is a condition in which weight gain. Danazol does not lead to bone functioning endometrial tissue exists out- loss. Although the changes in body compo- side the endometrial cavity. Its most com- sition during danazol use are desirable for mon symptoms are pain and infertility, al- an athlete, muscle cramps may potentially though it may produce no symptoms. In a impair athletic training. Anecdotally, ath- multicenter study, Cramer and associates17 letes treated with danazol for endometriosis reported that women who had exercised have noticed improved performance, but regularly since age 25 or younger and for this has not been investigated scientifically. more than 2 hours weekly had a decreased Drug testing would detect danazol use. risk of developing endometriosis. Condi- tioning exercises such as jogging seemed Although reduced distal radial bone mass most associated with this decreased risk. has been reported in untreated women with endometriosis,19 the bone mineraldensityof Women who have endometriosis may be the lumbar spine has been found to be nor- treated medically or surgically. Surgical mal in a population-based cross-sectional treatment depends on the severity of dis- study of untreated women with endometri- ease and may include fulguration of endo- osis.20 metriotic implants, resection of endometri- otic tissue or cysts, or hysterectomy with PREMENSTRUAL SYNDROME bilateral salpingo-oophorectomy. Premenstrual syndrome (PMS) is a con- Medical treatment is most effective with a dition in which women experience emo- gonadotropin-releasing hormone (GnRH) tional and/or physical symptoms during the analog or danazol. Several synthetic GnRH 3 to 5 days prior to the onset of menstrua- analogs are available today, includingleu- tion. In some cases, it may last even longer. prolide acetate (Lupron), which is adminis- Symptoms may include anxiety, depression, tered by daily or monthly injections, and mood swings, increased appetite, head- nafarelin acetate (Synarel), which is admin-

228 Special Issues and Concerns aches, mastalgia, and edema and may vary symptoms, only a few of these have been in severity as well as in duration. The mul- shown to be more effective than placebo. titude and variability of symptoms in this The high placebo response in this entity syndrome have made it difficult to define makes it difficult to evaluate the effective- this entity precisely, and this problem has ness of all treatments. Spironolactone has led Magos and Studd21 to propose the follow- been shown to be more effective than ing working definition for investigators and placebo23 and is associated with very few clinicians: \"distressing physical, psycholog- side effects. Although pharmacologic doses ical, and behavioral symptoms, not caused of progesterone are prescribed by many cli- by organic disease, which regularly recur nicians to treat PMS, there is no evidence during the same phase of the menstrual/ that PMS is caused by a progesterone defi- ovarian cycle, and which disappear or sig- ciency or that progesterone therapy in nificantly regress during the remainder of physiologic doses is more effective than pla- the cycle.\" cebo in treatingit. Luteal phase deficiency is not associated with a more severe PMS than Although the cause of PMSremains to be a normal luteal phase.24 Progesterone in elucidated, it is probably related to hor- pharmacologic doses has been shown in mone levels and/or changes at that timeof only one study to be more effective than pla- the menstrual cycle. No laboratory tests can cebo;25 other studies have found this agent diagnose this condition,since no laboratory to be no more effective than placebo.26,27 measurements have been shown to corre- late with symptomatology during any given A few studies showed bromocriptine to be cycle or to vary between affected and unaf- more effective than placebo in relieving fected individuals. The diagnosis of PMSis a some PMS symptoms, particularly mas- historic one, made solely by reviewing a cal- todynia28; but other studies have failed to endar record of when symptoms and men- confirm this.28 Danazol has been reported to struation occur. Those women whose symp- relieve PMS symptoms,29,30but this has been toms occur solely premenstruallyhave PMS, tested in only one double-blind, controlled and those whose symptoms occur randomly study to date.30 (The side effects associated throughout the cycle do not. Thisseemingly with danazol are listed in the preceding sec- clear picture is confused somewhat by the tion.) A GnRH agonist (Lupron) has been fact that some women who have symptoms shown to relieve PMS symptoms while in- throughout the cycle note a premenstrual ducing amenorrhea.31 Since this drug and exacerbation of symptomatology. other analogs and antagonists of GnRH pro- mote bone loss as a result of the hypoestro- It has been reported that women who ex- genic state they induce,32 these agents alone ercise are less likely to experience PMS and may not be promising for long-term use in that women are less likely to experience this condition. Alprazolam has also been PMS when exercising regularly.Prior,Vigna, shown to be more effective than placebo in and Alojado22 have shown thatconditioning relieving the severity of several symptoms exercise decreases premenstrual symp- of PMS; its reported low incidenceof side ef- toms. However, it is difficult to design con- fects may make it a good choice for many trolled studies in which women are blinded women unresponsive to other therapies.33 It to the fact that they are exercising. Thus, it remains to be shown whether any of these remains difficult to isolate exercise as a vari- medications will affect athletic perfor- able and difficult to confirm that exercise mance. prevents or relieves PMS symptoms. It is probable that the mood elevation and gen- Despite claimsto the contrary, there is no eral feeling of well-being associated with ex- evidence that PMSis caused by any dietary ercise may play a role. deficiency or excess, or that dietary manip- ulation will consistently relieve symptoms. Optimal treatment of PMS remains to be However, salt restriction may alleviate determined. Although several drugs relieve

Gynecologic Concerns in Exercise and Training 229 symptoms in some PMS sufferers and mendation. Hypothalamic-pituitary-ovarian certainly will harm no one. Furthermore, dysfunction can resolve spontaneously, and Wurtman and co-workers34 have shown im- ovulation can occur prior to the first subse- provement in mood when PMS sufferers quent menstrual period. The cause of the consumed a high carbohydrate diet. amenorrhea in such cases changes from hy- pothalamic-pituitary-ovarian dysfunction to At the present time, athletes who are in- pregnancy, but the symptom of amenorrhea convenienced by significant PMS symptoms continues. Thus, the amenorrheic athlete probably should be treated with spironolac- may not detect an unplanned, unwanted tone (25 to 100mg daily). It may be reassur- pregnancy until it is advanced enough to ing for some of them to know that 75%of all produce a significant increase in abdominal women experience at least some premen- girth. strual symptoms, probably due to hormonal changes that reflect normal reproductive Infertile athletes and their partners function (i.e., regular ovulation). Studies should undergo the same comprehensive now in progress may help us to understand evaluation that would be recommended for the etiology of PMS and lead us to optimal any infertile couple. Rarely should treat- therapy. ment be modified because of exercise or training. FERTILITY STRESS URINARY INCONTINENCE No studies to date have shown that infer- tility is more prevalent among athletes than Many women experience stress urinary among the general population. It is true that incontinence during exercise.35 Involuntary luteal phase deficiency, oligomenorrhea, urine leakage results when intravesical and amenorrhea are more prevalent among pressure is higher than intraurethral pres- athletes, and infertility is more prevalent sure. among women who have these conditions. However, the definition of infertility in- Although stress incontinence is most cludes a desire for pregnancy. Since many likely to occur in women who have an ana- athletes are not actively seeking pregnan- tomic defect in the posterior urethrovesical cies at the time of intensive training, when angle, even women with normal anatomy they are most likelyto experience menstrual can experience stress urinary incontinence dysfunction, these women technically are when intravesical pressure increases not infertile, even though their fertility, if enough. Physical activity involving a Val- tested, might be impaired. Many of these salva maneuver increases intra-abdominal women resume having regular ovulatory pressure. Because changes in intra-abdom- menses when they decrease intensive train- inal pressure are not always transmitted ing. It is probable that transient infertility is equally to both bladder and urethra, physi- associated with intensive training, but this cal activities like running and jumping may has not been documented to date.2 raise intravesical pressure above intraure- thral pressure, leading to urine leakage dur- Even if temporary infertility is associated ing exercise.36 Although stress urinary in- with training, athletes who do not desire continence is more common during exercise pregnancy should not presume that concep- than during rest, exercise-induced in- tion is impossible. As discussed in Chapter creases in intra-abdominal pressure are 9, reliable contraception should be used by transient and do not produce chronic pres- even amenorrheic athletes who do not want sure alterations or anatomic abnormalities. a pregnancy. Many anecdotal reports of amenorrheic athletes with unsuspected and Genital prolapse includes several ana- unwanted pregnancies support this recom- tomic abnormalities marked by loss of sup-

230 Special Issues and Concerns port, including cystocele, urethrocele, rec- ever, athletes should aim to recover cardio- tocele, and uterine descent. These anatomic vascular fitness as soon as possible, while defects have been reported to be associated avoiding excessive stress on the surgical with prior trauma during vaginal delivery site. As a general rule, postoperative avoid- and with endogenous jointhypermobility.37 ance of pain will lead to avoidance of injury Such joint laxity may also predispose or damage. Those who have greater strength women to joint injury. in muscles far from the operative site can Many women who have stress urinary in- gain mobility early by using those muscles continence may be able to control leakage rather than the muscles near the operative by avoiding fluid ingestion for 3 hours prior site. to exercising and emptying their bladders A surgical wound begins to heal immedi- immediately prior to exercising. However, ately following closure. By the 21st postop- they must be careful to avoid dehydration erative day, the wound has gained nearly as during prolonged exercise sessions lasting much strength as it will ultimately have (al- more than 1 hour. Such women should re- though it will never be as strong as it was place fluid loss immediatelyafter cessation preoperatively). Based on the fact that it of exercise. takes 21 days for a surgical wound to regain Many women who experienceinvoluntary nearly all of its ultimatestrength, it is prob- urine leakage may benefit from practicing ably reasonable for athletes to postpone Kegel exercises. These are done by con- submaximal resistance training that in- tracting the pubococcygeus muscle at any volves the operative site for 21 days follow- time, or specifically during urination, ing a surgical procedure. Lighter work can thereby stopping the urinary stream. probably be done safely prior to this time, Women who lose urine duringexercise may particularly if the wound is not stressed. decrease their discomfort and embarrass- Avoidance of pain remainsa reasonable goal ment by wearing a minipad. No medication for the exercising patient postoperatively, will alleviate this condition.Those who have and exercises that do not cause pain are anatomic defects and who cannot relieve probably safe. Overzealous athletes should their symptoms to a satisfactory degree by be cautioned to use moderation in training practicing Kegel exercises or wearing a postoperatively and to notice subtle body minipad should consider surgical correc- perceptions of discomfort and fatigue. tion of the anatomic defect. Postoperatively, Although there are no studies to indicate such women may be at increased risk of re- when exercise can be safely resumed follow- currence due to the pressure changes dur- ing surgery, I propose the following guide- ing exercise and to persistence of the endog- lines for earliest safe resumption of exer- enous tissue factors that caused the original cise: problem. No studies are available to confirm or disprove this suspicion, but these women • Following a dilatation and curettage or a probably should be cautious when exercis- first-trimester abortion, weighttraining ing postoperatively. and aerobic exercise, except water sports, may be resumed the same or the next day; water sports should be avoided until POSTOPERATIVE TRAINING bleeding has ceased. Tampon use also should be avoided until bleeding has AND RECOVERY ceased. The traditional recovery period following • Following a vaginal delivery or a second- abdominal or other major surgery has been trimester abortion, weighttraining may be 6 to 10 weeks. Recommendations for recov- resumed the same day; aerobic exercise, ery should be site- and sport-specific. How- except water sports, may be resumed in 2

Gynecologic Concerns in Exercise and Training 231 days; water sports may be resumed when published in peer-reviewed journals, but a bleeding has ceased. Tampon use should recent well-designed study by DeSouza and be avoided until bleeding has ceased. colleagues39 concluded that neither men- • Following a diagnostic laparoscopy, aer- strual phase (follicular versus luteal) nor obic exercise in and out of water and menstrual status (eumenorrheic versus weighttraining may be resumed after 1 to amenorrheic) alters or limits exercise per- 2 days. Following operative laparoscopy, formance in female athletes. aerobic exercise in and out of water and weighttraining should be postponed at It is rarely advisable or necessary to ma- least 21 days, depending upon the com- nipulate an athlete's menstrual cycle to en- plexity of the procedure. Avoidance of hance her performance. However, some pain may not provide sufficient limitation women do perform better during the follic- of activity for safety. ular phase than at other times, and others • Following a cesarean delivery or other ab- perceive or believe that they do. If such dominal surgery (requiring an incision), women are elite athletes, it may be appro- light aerobic exercise outside of water and priate to manipulate the menstrual cycle for light weighttraining may be resumed in 7 special events of great importance; I believe days; intense aerobic exercise (speed that such manipulation should be reserved work), submaximal weighttraining, and for world-class athletes (e.g., Olympic com- water sports should be postponed at least petition). 21 days. It must be emphasized that these are the The simplest and least invasive methodof earliest times I recommend resuming exer- manipulating an athlete's menstrual cycle cise postoperatively. Delays may enhance involves administering low-dose oral con- healing despite potential hindrance oftrain- traceptives for several months prior to the ing. Exercise should never be resumed if it competitive event, continuing the hormone- causes pain. All situations should be indi- containing pills until 10 days before the vidualized, and each patient should follow competitive event. The athlete can expect to the advice of her surgeon. have withdrawal bleeding within 3 days after cessation of the pills. She should post- EFFECT OF MENSTRUAL CYCLE pone restarting the pills (if she plans to do ON PERFORMANCE so) until the competitive event has passed. This plan will give her a predictable bleed- Many investigators have studied the effect ing pattern during trainingand will leave her of the menstrual cycle on performance, in- with low levels of both estrogen and proges- cluding specific measurements of strength, terone at the time of the important event. speed, endurance, fatigability, and per- For world-class athletes in their prime, this ceived exertion and cognitive, perceptual, regimen can be repeated every few months and motor skills at different phases of the for the events of great importance. It also menstrual cycle, reflecting different levels provides hormonal protection to those ath- and ratios of estrogen and progesterone. For letes who are deficient in one or both hor- a thorough review of these reports, the mones (estrogen and progesterone) during reader is referred elsewhere.38 The findings training, and it provides contraception to all of these studies have been inconsistent but athletes, regardless of menstrual status. suggest that menstrual cycle phase does not have a significant effect on any of these pa- The only undesirable side effects associ- rameters. Very few such studies have been ated with this plan are the potential risks of breakthrough bleeding during training and of impaired training during oral contracep- tive use, in certain individuals. However, I believe these risks are small and are out- weighed by the benefits of this plan.

232 Special Issues and Concerns An alternative method of management in- causes pain. All situations should be indi- volves administering only a progestogen vidualized and should follow the advice of (e.g., medroxyprogesterone acetate 5 mg) the patient's surgeon. for 5 to 10 days, ending 10 days prior to the important event. This is most likely to be ef- It is rarely advisable or necessary to ma- fective in women with chronic anovulation, nipulate an athlete's menstrual cycle to en- and it may produce undesirable bloating hance her performance. If manipulation is and a sensation of \"heaviness,\" which may considered, it should be reserved for special impair training. This method provides no events of great importance to elite athletes. contraception. As 1 have indicated, I prefer to prescribe low-dose oral contraceptives to REFERENCES athletes in need of menstrual manipulation. 1. Forrest JD, Fordyce RR:U.S. women's contra- SUMMARY ceptive attitudes and practice: How have they changed in the 1980s? Fam Plan Perspect The choice of an optimal contraceptive 20(3):112, 1988. agent should be made on the basis of a pa- tient's lifestyle and medical history but is 2. Shangold MM, and Levine HS: The effect of rarely affected by the fact that a patient is an marathon training upon menstrual function. athlete. Oral contraceptives have not been Am J Obstet Gynecol 143:862, 1982. shown to alter athletic performance. 3. Jarrett JC, and Spellacy WN: Contraceptive Athletes who experience dysmenorrhea practices of female runners. Fertil Steril should be treated with prostaglandin inhib- 39:374, 1983. itors, which often reduce menstrual blood loss as an additional benefit. 4. Plunkett ER:Contraceptive steroids, age, and the cardiovascular system. Am J Obstet Gy- Women who have endometriosis may be necol 142:747, 1982. treated medically or surgically. Some of these treatment modalities may affect ath- 5. Mann JI: Progestogens in cardiovascular dis- letic performance. ease: An introduction to the epidemiologic data. Am J Obstet Gynecol 142:752,1982. Premenstrual syndrome, if severe, may disrupt athletic training. Exercisers are less 6. Kay CR:Progestogens and arterial disease- likely than sedentary women to experience Evidence from the Royal College of General PMS, optimal treatment for which remains Practitioners' study. Am J Obstet Gynecol to be determined. 142:762,1982. Infertile athletes and their partners 7. Wynn V,and Niththyananthan R: The effect of should undergo a thorough evaluation. progestins in combined oral contraceptives Treatment rarely should be modified be- on serum lipids with special reference to cause of exercise or training. high-density lipoproteins. Am J Obstet Gy- necol 142:766,1982. Although stress urinary incontinence is more common during exercise than during 8. Spellacy WN:Carbohydrate metabolism dur- rest, exercise-induced increases in intra-ab- ing treatment with estrogen, progestogen, dominal pressure are transient and do not and low-dose oral contraceptives. Am J Ob- produce chronic alterations in pressure or stet Gynecol 142:732, 1982. anatomy. 9. Mishell DR: Noncontraceptive health bene- Recommendations for postoperative re- fits of oral steroidal contraceptives. Am J Ob- covery following abdominal or pelvic sur- stet Gynecol142:809,1982. gery should be site-specific and sport-spe- cific. Exercise should never be resumed if it 10. Hedlin AM, Milojevic S, and Korey A: Plas- minogen activator levels in plasma and urine during exercise and oral contraceptive use. Thromb Haemost 39:743, 1978. 11. Huisveld IA, Kluft C, Hospers AJH, et al: Effect of exercise and oral contraceptive agents on fibrinolytic potential in trained females. J Appl Physiol 56:906, 1984. 12. Hedlin AM, Milojevic S, and Korey A:Hemo- static changes induced by exercise during oral contraceptive use. Can J Physiol phar- 56:316, 1978., 1978.

Gynecologic Concerns in Exercise and Training 233 13. Powell MG, Hedlin AM, Cerskus I, et al: Ef- double-blind controlled trial of progesterone fects of oral contraceptives on lipoprotein and placebo. Br J Psychiatr 135:209,1979. lipids: A prospective study. Obstet Gynecol 27. Freeman E, Rickels K, Sondheimer SJ, and 63:764, 1984. Polansky M: Ineffectiveness of progesterone suppository treatment for premenstrual syn- 14. Gray DP, Harding E, and Dale E: Effects of oral drome. JAMA 264:349,1990. contraceptives on serum lipid profiles of 28. Andersen B: Bromocriptine and premen- women runners. Fertil Steril 39:510,1983. strual symptoms: A survey of double blind trials. Obstet Gynecol Surv 38:643,1983. 15. Shoupe D, and Mishell DR:Norplant: Subder- 29. Day J: Danazol and the premenstrual syn- mal implant system for long-term contracep- drome. Postgrad Med J 55(Suppl 5):87, 1979. tion. Am J Obstet Gynecol 160:1286, 1989. 30. Sarno AP, Miller EJ, and Lundblad EG: Pre- menstrual syndrome: Beneficial effects of pe- 16. Hatcher RA, Stewart F, Trussell J, et al: Con- riodic, low-dose danazol. Obstet Gynecol traceptive Technology 1990-1992, 15th rev 70:33, 1987. ed. Irvington, New York, 1990, p 134. 31. Muse KN, Cetel NS, Futterman LA,et al: The premenstrual syndrome: Effects of \"medical 17. Cramer DW,Wilson E, Stillman RJ, et al: The ovariectomy.\" N Engl J Med 311:1345,1984. relation of endometriosis to menstrual char- 32. Abbasi R,and Hodgen GD: Predicting the pre- acteristics, smoking, and exercise. JAMA disposition to osteoporosis: Gonadotropin- 255:1904, 1986. releasing hormone antagonist for acute es- trogen deficiency test. JAMA 255:1600, 1986. 18. Bruce R, Lees B, Whitcroft SIJ,et al: Changes 33. Smith S, Rinehart JS, Ruddock VE, et al: in body composition with danazol therapy. Treatment of premenstrual syndrome with Fertil Steril 56:574, 1991. alprazolam: Results of a double-blind cross- over clinical trial. Obstet Gynecol 70:37,1987. 19. Comite F, Delman M, Hutchinson-Williams K, 34. Wurtman JJ, Brzezinski A, Wurtman RJ, and et al: Reduced bone mass in reproductive- Laferrere B: Effect of nutrient intake on pre- aged women with endometriosis. J Clin En- menstrual depression. Am J Obstet Gynecol docrinol Metab 69:837, 1989. 161:1228,1989. 35. Nygaard I, DeLancey JOL, Arnsdorf L, and 20. Lane N, Baptista J, and Orwoll E: Bone min- Murphy E:Exercise and incontinence. Obstet eral density of the lumbar spine in women Gynecol 75:848, 1990. with endometriosis. Fertil Steril 55:537,1991. 36. James ED:The behavior of the bladder dur- ing physical activity. Br J Urol 50:387, 1978. 21. Magos AL,and Studd JWW: The premenstrual 37. Al-Rawi ZS, and Al-Rawi ZT: Joint hypermo- syndrome. In Studd JWW (ed): Progress in bility in women with genital prolapse. Lancet Obstetrics and Gynaecology, Vol 4. Churchill 1:1439,1982. Livingstone, Edinburgh, 1984, p 334. 38. Brooks-Gunn J, Gargiulo J, and Warren MP: The menstrual cycle and athletic perfor- 22. Prior JC, Vigna Y, and Alojado N: Condition- mance. In Puhl JL, and Brown CH (eds): The ing exercise decreases premenstrual symp- Menstrual Cycle and Physical Activity. toms—A prospective controlled three month Human Kinetics, Champaign, IL, 1986, p 13. trial. Eur J Appl Physiol 55:349, 1986. 39. DeSouza MJ, MaguireMS, Rubin KR,and Ma- resh CM: Effects of menstrual phase and 23. O'Brien PMS, Craven D, Selby C, et al: Treat- amenorrhea on exercise performance in run- ment of premenstrual syndrome with spiro- ners. Med Sci Sports Exerc 22:575, 1990. nolactone. Br J Obstet Gynecol 86:142, 1979. 24. Ying Y-K, Soto-Albors CE, Randolph JF, et al: Luteal phase defect and premenstrual syn- drome in an infertile population. Obstet Gy- necol 69:96, 1987. 25. Dennerstein L, Spencer-Gardner C, Gotts G, et al: Progesterone and the premenstrual syndrome: A double-blind crossover trial. Br Med J 290:1617, 1985. 26. Sampson GA: Premenstrual syndrome: A

14CHAPTER Orthopedic Concerns LETHA Y. GRIFFIN, M.D., Ph.D. PATELLA PAIN Ankle Impingement Anatomy of the Patella Wrist Impingement Sources of Pain Shoulder Impingement Evaluating Patella Pain OTHER COMMON CONDITIONS Acute Traumatic Patella Dislocation Achilles Tendinitis Patella Subluxation Shin Splints Patellofemoral Stress Syndrome Stress Fractures Patella Plica Low Back Pain Patella Pain: Summary Bunions Morton's Neuroma IMPINGEMENT SYNDROMES with the growth of women's athletics, many observers predicted an increase in the number and types of injuries occurring as women became more aggressive and competitive in sports.1 Early injury studies of female athletes actually reported that a greater number of injuries were sustained by female than by male athletes.23 However, this reflected a lack of adequate conditioning in women rather than any true physiologic weakness and predisposition to injury. As women became more serious in their sport participation, training and condition- ing techniques improved, and injury rates decreased.4 Recent studies surveying injury rates in conditioned female athletes demonstrate that their injury rates are no higher than those of their male counterparts.5–7 A review of injuries in professional and recreational athletes demonstrated sprains and strains to be the most common injuries and the knee and ankle to be the most frequently traumatized areas in both men and women.8 Injuries are more sport-specific than sex-specific; that is, injury types and rates are similar for men and women in the same sport, but they differ for female athletes partic- ipating in different sports.9 Certain conditions, however, occur more commonly in women—in some cases owing to anatomic differences, in others owing to greater participation in specific sports. Wehave elected to focus in this chapter on those conditions more commonly seen in women (patella pain, impingement syndromes, Achilles ten- dinitis, shin splints, stress fractures, low back pain, bunions, and Morton's neu- roma), and refer the reader to other more general texts on athletic injuries for a 234

Orthopedic Concerns 235 discussion of such injuries as sprains, dis- quadriceps muscles. Since the quadriceps locations, fractures, and inflammation of muscle courses along the long axis of the muscle origins. Table 14-1 briefly lists some femur while the patella tendon inserts into common musculoskeletal injuries and the the tibial tubercle, patella tracking in the women's sports in which they are com- femoral groove is also very much influenced monly seen. by the tibial-femoral angle. This angle(the Q angle) is measured by drawing a line PATELLA PAIN through the center of the quadriceps muscle Anatomy of the Patella and noting its intersection with a line drawn through the center of the tibial tuberosity The patella or kneecap is a sesamoid (Fig. 14-2). Because the gynecoid pelvis of bone, which means it is completely sur- the woman is wider than the narrow android rounded by fascial extensions (retinacu- pelvis of the man, this angle is generally lum) of the four components of the quadri- greater in women than in men and may ex- ceps muscle—the vastus medialis, the plain the increase in patella tracking prob- vastus lateralis, the rectus femoris, and the lems and patella pain in women (Fig. 14-3). vastus intermedius (Fig. 14-1). Fascial ter- In fact, patella pain is one of the most com- minations of these muscles arise just supe- mon complaints of female athletes. rior to the patella, extend over it, and con- tinue inferiorly from the patella to the tibial Although the anterior surface of the pa- tubercle as the patella tendon. The patella tella is flat, the posterior surface is com- lies in the distal femoral groove formed posed of two facets which intersect longitu- where the medial and lateral femoral con- dinally (Fig. 14-4). The medial facet is dyles join at the knee. The patella is guided generally smaller than the lateral. The facets in the femoral groove during knee flexion are lined with hyaline cartilage and articu- and extension by the powerful group of late with the hyaline cartilage-covered su- Table 14-1. SPECIFIC SPORTS COMMONLY ASSOCIATED WITH ORTHOPEDIC INJURIES Injury Sport Shoulder subluxation Swimming Sprains Throwing sports Skiing Thumb Running sports Ankle Uneven ground (field hockey, soccer, Softball, cross-country) Knee Basketball, volleyball (one-foot landings) Tendinitis Ice skating Basketball, volleyball First dorsal compartment Gymnastics (squeezing poles or bars) Achilles tendon Track, basketball, skiing, ice skating, rollerskating Biceps Tennis, other racquet sports, throwing sports Lateral epicondylitis (tennis elbow) Tennis, other racquet sports, throwing sports Shin splints Running Impingements Swimming,* throwing sports, racquet sports Shoulder Gymnastics, ballet, diving, ice skating Ankle Gymnastics, crew, racquet sports Wrist Gymnastics, diving, skating Low back pain Running, gymnastics, ice skating, diving Stress fractures (pars intra-articularis) *In greater numbers than male counterparts.

236 Special Issues and Concerns Figure 14-1. The quadriceps muscles. Note the oblique course of the vastus medialis obliquusmus- cle. (From Scott WN, Nisonson B, Nicholas JA,et al: Principles of Sports Medicine. Williams & Wilkins, Baltimore, 1984, p 274,with permission.) perior extensions of the femoral condyle, across the joint change with increasingflex- forming the patellofemoral joint (Fig. 14-5). ion of the knee (Fig. 14-6), and as previously discussed, are greatly influenced by the Sources of Pain quadriceps pull and the tibial-femoral angle. Forces across the joint have been the sub- Patella tracking in the patellofemoral ject of much investigation, since patellofem- groove may also be influenced by foot strike. oral pain is a common source of discomfort Pronation of the foot increases the knee val- in many activities, especially in sports that gus angle and may lead to an increase or at require multiple flexion-extension maneu- least an alteration in lateral patellofemoral vers (running, kicking, climbing). Forces forces (Fig. 14-7). If the patella does not track anatomically in the femoral groove,

Orthopedic Concerns 237 Figure 14-2. The Q angle is an angle formed by the in- Figure 14-3. Android pelvis and gynecoid pelvis. Note tersection of a line drawn longitudinally through the that the female (gynecoid) pelvis is wider, with a middle of the quadriceps and a line drawn from the greater varus angle of the femoral neck, resulting in a middle of the patella to the center of the tibial tuber- greater valgus angle at the knee when compared with osity. (From O'Donoghue DH:Treatment of Injuries to the typical male (android) pelvis. Athletes, ed 4. WB Saunders, Philadelphia, 1984, p 510, with permission.) forces created during quadriceps contrac- Figure 14-4. Posterior aspect of the patella, illustrating tion may not be adequately dissipated be- the two patellar facets. (From Norkin CCand Levangie tween the two facets, causing abnormally PK: Joint Structure and Function, ed 2. FA Davis, Phila- high forces on a small area of the articular delphia, 1992, p 367, with permission.) surfaces and resulting in patella pain (patel- lofemoral stress syndrome). Athletes who have sustained multiple subluxations or dislocations of their patel- lae may have pain secondary to traumatic loss of the hyaline cartilage during such ep- isodes, that is, chondromalacia. If the carti- lage is thinned or absent or chemically un- able to absorb the forces applied to it, these forces are transferred to the bone beneath, resulting in pain.

238 Special Issues and Concerns location with spontaneous relocation may not report that her \"kneecap jumped out of joint\" but may perceive only severe knee pain following her twisting injury. Similarly, an athlete who complains of give-way or locking of her joint may not have a mechan- ical lockingof her knee from a torn meniscus or loose body but may have pseudolocking or give-way on the basis of patella pain. Figure 14-5. Patellofemoral joint. (1) Femoral condyle Observation surfaces of the right knee. TL = anteroposterior length of the lateral condyle; TM = length of the medial con- The first step in evaluating the patella is to dyle. The length of the medial condyle (LM) is greater observe the knee: does the patella sit higher than the length of the lateral condyle (LL), because of in the femoral groove than usual (patella its curved surface. (2) Superior surface of the right alta), or is it lower (patella baja)? Athletes tibia. The lateral articular surface is round and the me- whose patellas sit higher in the femoral dial articular surface is oval. (3) The medial tibial artic- groove have a greater tendency to patella ular surface is deeper and more concave than is the lat- subluxation,10 whereas those withlow-lying eral. (4) Side view of the femur showing the flat anterior patellas may have increased forces across surface and the curved posterior surface. The two artic- the patellofemoral joint, especially with re- ulations are illustrated in part 1:the patellar surface, in petitive flexion-extension activities. which the patella articulates with the anterior femur and the tibial surface, which then glides upon the tibia. Does the patella lie centrally in the femo- (From Cailliet R: Knee Pain and Disability, ed 3. FA ral groove, or is it tipped laterally (Fig. 14- Davis, Philadelphia, 1992, p 2, with permission.) 8)? Since an increased Q angle and poorly developed vastus medialis are associated Evaluating Patella Pain with an increased incidence of patella pain, In evaluating the athlete who complainsof the Q angle should be measured, and the quadriceps mechanism assessed, especially a painful knee, one must always consider the its more medial oblique fibers, known as the patella as a potential source of the pain. The vastus medialis obliquus. athlete who sustains a traumatic patella dis- Palpation and Manipulation The retinaculumaround the patella's me- dial, lateral, and superior borders should be palpated to check for tenderness. The ath- lete who has just sustained an acute patella subluxation or dislocation with spontane- ous relocation will have a great deal of ten- derness at the insertion of the vastus medi- alis on the medial border of the patella. In addition, she may have ecchymoses along the fibers of the muscles, from having stretched or disrupted part of the fibers at the time of the subluxation or dislocation. Next, the patella should be tipped medi- ally, and the examiner should feel under the medial facet (Fig. 14-9). Athletes with patel- lofemoral stress syndrome or chondroma-

Orthopedic Concerns 239 Figure 14-6. Patellar contact areas with femoral condyles during knee flexion. (1) Knee flexed 20°: (A) Lateral view of the patellofemoraljoint. Arrows depict site of contact. (B) Area of contact of the patella (shaded area) (L = lateral; M = medial). (C) Superior view showing patella within femoral condyles. At 20° flexion, there is contact symmetrically of the lateral condyle. (2) Knee flexed 45: Pressure upon the patella is in the broader central zone (C). As above, pressure on the medial and lateral patellar facets is symmetrical. (3) Knee flexed 90°: There is broad contact with the superior area of the medial and lateral patellar facets (B). As shown by (C), there is beginning to be more contact of medial facets. (4) Knee flexed 135° (full flexion): The patellar facets contact both femoral condyles, and the patella shifts (C) so that the odd facet contacts the medial condyle more firmly. (From Cailliet R: Knee Pain and Disability, ed 2. FADavis, Philadelphia,1983, pp 88-89, with permis- sion.) lacia will experience pain with this maneu- This action mimics the give-way sensations ver. Then the examiner should place a hand reported by women with these entities. firmly above the patella and ask the patient to contract her quadriceps (Fig. 14-10). In Next, one should palpate the patella ten- this maneuver, called an inhibitiontest, ath- don to check for its intactness and to exam- letes with patellofemoral stress syndrome ine for tenderness at its origin off the infe- or chondrornalacia will have give-way rior surface of the patella or at its symptoms after beginning the contraction. attachment to the tibia. In the very young patient (age 6 to 9 years), inflammation of

24O Special Issues and Concerns Figure 14-7. As the foot goes into pronation, the valgus Figure 14-9. Palpation of the medial patella facet. Pa- angle of the knee and lateral tracking of the patella are tients with patellofemoral stress frequently have ten- accentuated. derness along the medial border of the patella at the retinaculum or under the medial facet of the patella. Figure 14-8. Radiograph of laterally tipped patellas. Note the very short medial condylar flare and the elongated lateral flare, corresponding to the increased width of the lateral patella facet when com- pared with the medial one.

Orthopedic Concerns 241 Figure 14-10. In the inhibition test, the examiner ap- Figure 14-11. (A) The patient with patella tendinitis plies pressure above the patella as the patient contracts will have pain at the origin of the patella tendon. (B) the quadriceps muscle. This maneuver frequently re- The patient with Osgood-Schlatter's disease (seen in produces the pain of the athlete with patellofemoral the teenager with open growth centers) will have irri- stress syndrome. tation at the insertion of the patella tendon into the tib- ial apophysis. (From Andrish JT: Knee injuries in gym- the patella tendon at its origin off the infe- nastics. In Weiker GG (ed): Gymnastics. Clin Sports rior surface of the patella may be associated Med 4:120, 1985, with permission.) with irregularities of the lower patella apophyseal pole (Fig. 14-11). Similarly, ir- joint may indicate that the knee joint has ritation of the attachment of the patella ten- been or is irritated. Patella abnormalities don to the tibial apophysis when it is devel- that can result in an increase in synovial oping (approximately age 11 to 13 years) fluid include patella subluxations or abnor- can result in its inflammation or apophysi- malities of the hyaline cartilage of the retro- tis, a condition termed Osgood-Schlatter's patellar surface (chondromalacia). disease (Fig. 14-11). Aspiration of Fluid Radiographic Evaluation Many different radiographic techniques If there is fluid within the knee joint, it may be aspirated. A hemarthrosis, or blood have been designed to evaluate the patella in the knee, may result from a traumatic pa- and its relationship to the femur in the pa- tella dislocation with spontaneous reloca- tellofemoral groove. The ratio of a line tion. (Remember that the athlete who has drawn longitudinally through the patella to had a spontaneous relocation of her patella a line drawn from the tip of the patella to the may not have perceived her injury as a pa- tibial tubercle measured on a lateral radio- tella dislocation.) Other diagnoses associ- graph, with the knee in 50 degrees of flexion, ated with a hemarthrosis include anterior can be used to estimate patella alta or baja. cruciate ligament tear, peripheral meniscal A ratio greater than 1.2 is indicative of pa- tear, and intra-articular fracture. tella alta (Fig. 14-12), whereas a ratio of less Yellow synovial fluid aspirated from the than 1.0 is associated with patella baja.

242 Special Issues and Concerns thickness of the articular cartilage of the pa- tellofemoral joint. Another helpful study used to assess the intactness of the patellofemoral cartilage and the position of the patella in the femoral groove is computerized axial tomography done following injection of contrast material into the knee joint. The contrast material nicely coats the articular surface for visual- ization (Fig. 14-14). Acute Traumatic Patella Dislocation Diagnosis If spontaneous relocation has not oc- curred, the diagnosis of a dislocation of the patella is obvious from observation. The pa- tella typically lies lateral to the knee joint, and the injured athlete usually will hold her knee partially flexed because of pain. To confirm the diagnosis and make certain there are no fractures, radiographs should be taken. Figure 14-12. Objective confirmation of patella alta is Initial Treatment obtained by using a lateral radiograph and determining First, the intactness of the neurovascular the length of the patella (LP) and the length of the pa- tella tendon (LT). If the tendon length exceeds the pa- structures should be assessed. After medi- tella length by 20%,then patella alta is present (i.e., LP/ cation has been given to decrease pain (giv- LT 0.8). (From Scott WN, Nisonson B, Nicholas JA, et ing intravenous morphine as an analgesic is al: Principles of Sports Medicine. Williams & Wilkins, often extremely helpful), the examiner Baltimore, 1984, p 312, with permission.) should gently extend the patient's legwhile exerting a medial force on the patella. The A view of the patella taken with the knee patella will relocate with an audible sound, flexed to 30 degrees and the cassette held resulting in rapid relief of pain. A dislocated perpendicular to the radiograph tube is patella can sometimes be reduced on the called a skyline view of the patella (Fig. 14- field or court without medication, but it is 13). It is used to assess the patella's position usually wiser to first radiographically docu- in the femoral groove, as well as to detect ment the diagnosis and make certain there the presence of patella spurs and to note the are no associated fractures. Following relocation, one should apply a compressive wrap with lateral pads to hold the patella medially. The knee is then sup- ported in a soft knee immobilizer which keeps the knee extended. The intent of the lateral pad and the immobilization in exten- sion is to bring the patella in close approxi- mation to the vastus medialis fibers so that they can heal securely back to the patella.

Orthopedic Concerns 243 Figure 14-13. Technique for obtaining skyline view of the patella. (From Hunter LY, et al: Common orthopedic problems of femaleathletes. In Frankel VH(ed): Instructional Course Lectures.American Academy of Orthopedic Surgeons, CVMosby, St. Louis, 1982, p 131, with permission.) The physician should instruct the athlete comfort and to decrease stretching of the al- to ice and elevate the extremity and should ready injured medial retinaculum. place her on crutches, so that she bears only partial weight on the affected leg. If she de- Some physicians recommend immediate velops a marked hemarthrosis over the next arthroscopic examination of the joint to several days, it can be aspirated to increase evacuate the hemarthrosis and to check for the presence of a chondral fracture off the Figure 14-14. The patellofemoral joint as viewed by computed axial tomography after injection of contrast material into the knee joint.

244 Special Issues and Concerns posterior surface of the patella or the oppos- mediate arthroscopy feel that if an athlete ing lateral femoral condyle. Cartilage frac- develops loose body symptoms following tures are not recognized on routine radio- patella dislocation, arthroscopy can be per- graphs unless the fracture extends into bone formed at that time. However, performed (an osteochondral fracture). Fracture frag- acutely, such a procedure may merely in- ments, whether cartilage alone or cartilage crease quadriceps atrophy. and bone, need to be removed, because they will become loose bodies that can intermit- Rehabilitation tently catch in the joint, causing severe pain and locking. The knee is kept wrapped with a lateral pad and immobilized in the extended posi- Physicians who do not recommend im- Figure 14-15. Short arc extension exercises increase quadriceps strength following a patella dislo- cation.

Orthopedic Concerns 245 tion for approximately 3 to 6 weeks, to allow Figure 14-16. An example of a patella-stabilizing brace. the torn medial retinaculumto heal. Isomet- Note pad encircling the patella. (From Walsh WM,et al: ric exercises can be done by the athlete Overuse injuries in girls' gymnastics. In Walsh WM while she is in the immobilizer.Some phy- (ed): The Athletic Woman. Clin Sports Med3:841,1984, sicians will use muscle-stimulating units with permission.) during this period to help strengthen the vastus medialis. The athlete who sustains a patella dislo- cation is at greater risk for redislocation. A At the end of this time, short arc extension quadriceps-strengthening program as well exercises, as well as functional strengthen- as brace support may be helpful in minimiz- ing activities such as walking, bike riding, or ing that risk. Athletes with recurrent patella using a stair climber can be started. If an ex- dislocation may require operative proce- ercise bike is used, the seat should be set as dures to help stabilize the patella. (See Sur- high as possible and tension kept on me- gery, under Patella Subluxation.) dium to low. If biking outdoors, a bike that Patella Subluxation has at least 3 gears, but preferably 5 or 10, should be used. The athlete should be in- Athletes whose patellas sit laterally or structed to use low gears (rapid pedaling at who have small, high-riding patellas (pa- low tension) and to avoid hills. Again, seat tella alta) are more predisposed to patella height should be set so the athlete's knee is Subluxation. During an episode of subluxa- completely extended on the downstroke. tion, the patella slides laterallywith twisting Similarly, if a stair climber is used, the ath- movements of the knee (especially lateral lete should set the tension of the machineon twists or valgus stresses) but does not low and perform rapid small steps. frankly dislocate or come completely out of its femoral groove. In principle, the greater Short arc extension exercises are per- the Q angle, the more easily the patella can formed by placinga rolled towel beneath the knee, so that the exercise is begun at ap- proximately 30 degrees of knee flexion. In a rhythmic fashion, the athlete performs mul- tiple extensions from this flexed starting po- sition (Fig. 14-15). Initially, no ankle weights should be used; as the athlete pro- gresses in her exercise program,up to 5 Ib of weight may be added. Usually sets of 10 to 15 repetitions are done at one time and in- corporated into a total strengthening pro- gram for the lower extremities. The partially flexed starting position and use of minimal weights minimize the forces over the patel- lofemoral joint, while the exercises increase quadriceps strength. As rehabilitation proceeds, a lateral pa- tella pad or one of the many braces designed for patella stabilization can be used. The braces typically incorporate a lateral or horseshoe pad to stabilize the patella me- dially (Fig. 14-16). These same braces may be used by the athlete when she returns to her sport. Following acute patella disloca- tion, however, it may be as much as 6 months before an athlete can fully partici- pate in pivotal sports.

246 Special Issues and Concerns slip laterally. Medial patella subluxation In fact, the whole vastus medialis may be theoretically can occur, but practically is poorly developed. rarely found. Women with patella subluxation fre- Symptoms quently have an ectomorphic body type, with slender, poorly muscled lower extrem- Athletes with patella subluxation may ities. The examiner observing active and complain merely of knee pain with kicking, passive knee flexion can see the patella rid- twisting, or running maneuvers. The whip ing laterally and/or sitting high in the fem- kick or frog kick in swimming may be pain- oral groove. ful. Even though both patellas are high-rid- ing, small, and easily subluxable,frequently Palpating the medial retinaculum or the only the dominant knee is symptomatic and medial facet of the patella will frequently so the athlete may not complain of pain in cause discomfort.The athlete generally will both knees. Like the athlete with patellofem- be apprehensive if one moves her patella oral stress syndrome, she may state that she laterally. In fact, this sign is so characteristic has give-way episodes when going down- of the patient whose patella subluxes or dis- stairs (an activity that increasespatellofem- locates that it is believed to be diagnostic of oral forces) or may complain of locking or this condition. Frequently, the examiner catching of her knee. She may not localize may be able to completely dislocate the pa- her pain to the patella and may never have tella by putting a direct lateral force on it experienced an episode of frank patella dis- with the knee in extension. location. Treatment: Conservative The pain experienced by the athlete with chronic patella subluxation may result from Treatment of the athlete with symptom- inflammation of the parapatellar retinacu- atic chronic patella subluxation is difficult. lum as it is stretched when the patella rides Exercise to strengthen the quadriceps, es- laterally, or it may be secondary to abnor- pecially the vastus medialis and particularly mal forces on the hyaline cartilage surface of its oblique fibers, so that the patella will ride the patella. In fact, some women with more mediallyin the patellofemoral groove, chronic subluxable patellas may develop fi- may be helpful. When the athlete is acutely brillation or even fissuring of the hyaline symptomatic with pain, the anti-inflamma- cartilage, eventually have erosion and loss tory agents, such as aspirin (two taken four of the hyaline cartilage surface, and hence times a day) or one of the other nonsteroidal develop patellofemoralarthritis. anti-inflammatory drugs, may be helpful. Family History Intra-articular injection of steroids is not recommended in the young athlete, as this The history from the athlete with sublux- may cause softening of the hyaline cartilage. able patellas may reveal a sister, mother, grandmother, or even a male relative who Treatment: Surgical has had knee problems. The predisposition for patella symptoms is based on anatomic If all conservative measures fail—includ- factors. ing activity modification to avoid rapid piv- otal sports—operative procedures to better Physical Examination centralize the patella can be performed.In- cising (releasing) the lateral retinaculumar- As indicated previously, the patella is fre- throscopically or with a small parapatellar quently small and high-riding. The vastus lateral incision may help the patella to track medialis obliquus may be poorly developed. more medially. Theoretically this weakens the pull of the vastus lateralis muscles on the patella. However, this procedure must

Orthopedic Concerns 247 be linked with a rehabilitation program de- aminer tries to force her patella laterally. signed to strengthen the vastus medialis Moreover, although her patella may sit lat- muscles. erally in the patellofemoral groove, it is sta- ble in its position, and the examiner will not Other operative procedures transfer the have the feeling that it could be dislocated bony attachment of the patella tendon more by being pushed too firmly laterally. medially on the tibia. This decreases the Q angle and should better centralize the pa- The athlete with patellofemoral stress tella, preventing subluxation. Such a proce- syndrome will have a positive patella inhi- dure may be combined with lateral retinac- bition test; that is, she will experience pain ular release. if the examiner puts a hand firmly above the patella and asks the athlete to contract her Care must be taken not to move the patella quadriceps. This test increases patellofem- tendon attachment distally on the tibia, as oral forces, and hence, reproduces the ath- this will increase patellofemoral forces and lete's pain and give-way episodes. lead to patella cartilage softening or chon- dromalacia.11 The examiner should note the degree of vastus medialis development, as frequently Patellofemoral Stress Syndrome athletes with patellofemoral stress syn- Patellofemoral stress syndrome is very drome, like those with patella subluxation or dislocation, have a poorly developed vastus common, particularly in the teenaged fe- medialis. Hamstring tightness has also male athlete. This diagnosis is used to de- been reported to increase patellofemoral scribe a syndrome in which there is patella forces—when the athlete fully extends the pain with activities that load the patellofem- knee, the tight hamstrings create a \"bow- oral joint such as kneeling,kicking, running string\" effect. (especially downhill running), climbing, or sitting for a prolonged period of time with Note should be made of the footstrike in the knee acutely flexed. The syndrome does the athlete with patella pain. Check to see if not include athletes with subluxable or dis- the feet appear to have no arches, due to ex- locatable patellas. cessive inward rolling of the feet at the an- kles. Many people who have \"flat feet\" may Symptoms have normal arches. Their feet may appear flat because they pronate excessively. Such The athlete with patellofemoral stress athletes (overpronators) may be at an in- syndrome may have symptoms similar to creased risk of developing patella pain dur- those of the athlete with patella subluxation. ing running.During running, the foot strikes She may present with increasing aching dis- the ground on the lateral part of the sole and comfort in the knee, with or without associ- rolls medially prior to toeing off. If there is ated effusion, or she may present with an excessive pronation associated with this acute episode of knee pain with locking or medial roll, the patella may be forced later- giving way. Effusions are more typically as- ally in the patellofemoral groove, resulting sociated with patella subluxations or dislo- in abnormal distribution of patellofemoral cations. forces. Physical Examination Treatment On physical examination, although she Alteration of patella tracking is the fun- may have a patella that rides laterally in the damental principle in all treatment pro- patellofemoral groove, with an increased Q grams for patellofemoral stress syndrome. angle, a woman with patellofemoral stress Quadriceps-strengthening exercises, de- syndrome is not apprehensive when the ex- signed to minimize patellofemoral force while increasing quadriceps strength, are

248 Special Issues and Concerns recommended. Short arc extensions and tracking.12 In addition, there are patella biking, as described above, are two ways of straps or bands of material that fasten about achieving this objective. Another is straight the proximal tibia at the level of the patella leg lifts, with minimal weights and maximal tendon. Theoretically, these bands are de- repetitions. A stair-stepper machine can signed to alter the resting length of the also be used, but only with small, rapid steps quadriceps-patella tendon unit, and hence, at low tension settings. decrease the force this unit can generate at the patellofemoral joint, much like tennis Devices that limit pronation are often use- elbow bands are thought to alter the force ful in treating patella pain. Many track shoes generated by the wrist extensor mechanism, have varus wedges (thicker heels medially and hence, decrease the stress placed on the than laterally). Arch supports incorporated lateral epicondyle. into insoles or custom-ordered orthotics to alter foot strike may be helpful. For an or- The symptomatic athlete should be in- thotic to limit pronation effectively, it must structed to avoid prolonged knee flexion; be used in a shoe that has a tight counter to that is, she should not sit \"Indian-style\" for grip the heel and a saddle to keep the foot long periods of time, and she should stretch from slipping over the orthotic. her legs frequently while riding in a car or sitting in the theater or at her desk. Her Icing the parapatellar area following ex- training routines should be reviewed to ercise may help decrease inflammation, and make certain they do not include activities hence, pain. Oral anti-inflammatory agents, that maximally load the patellofemoral joint, either aspirin, ibuprofen, or other prescrip- such as stair climbing (other than discussed tion nonsteroidal drugs, may be useful in the above) or deep squats. If the hamstring mus- patient who is acutely symptomatic. cles are tight, hamstring stretching should be initiated. Slow stretches, as shown in Fig- Braces like those previously described for ure 14-17, are recommended. use in athletes with patella subluxation or dislocation can also help to alter patella Figure 14-17. Hamstring stretch. For stretching the left hamstring and the right side of the back, slowly bend forward from the hips toward the foot of the left leg from a sitting position with the legs spread. Keep the head forward and the back straight. Hold the stretch for 20 seconds. With repeti- tions, the stretch will become easier. Repeat the stretch with the opposite leg.

Orthopedic Concerns 249 Prognosis dible \"pop\" or snap can be felt as the knee actively extends, and this sound is accom- Although the patellofemoral stress syn- panied by pain. Occasionally, the \"pop\" can drome may be associated with significant also be produced by passive knee extension. pain, which temporarily incapacitates the athlete, this overuse syndrome is not typi- Treatment cally associated with any permanentimpair- ment. Unlike chronic patella subluxation or For the acutely symptomatic athlete, hav- multiple patella dislocations, patellofemoral ing her rest the knee in extension in a soft stress syndrome infrequently results in knee immobilizer for 5 to 10 days and pre- chondromalacia or frank patellofemoral ar- scribing a nonsteroidal anti-inflammatory thritis.9 Treatingthe athlete withpatellofem- agent such as aspirin may decrease inflam- oral stress syndrome may be frustrating, mation and resolve the symptoms com- however, as symptoms may initially be quite pletely. refractory. Treatment of the athlete with chronic pain Patella Plica from a symptomatic plica is more difficult. Patella plica (also called synovial plica or Rest and anti-inflammatory agents can be tried. Exercises to alter patella trackingmay patella shelf) is a normal developmental also be helpful. In rare cases, excision of the fold of tissue that sits retropatellarly. It is patella plica must be done to relieve symp- the embryonic remnant of the divisions in toms. the knee.13 Patella Pain: Summary Symptoms Patella pain is one of the most common The remnant is normally thin and filmy, musculoskeletal complaints in female ath- but following multiple episodes of minimal letes. It may result from repeated episodes trauma or one severe acute traumatic epi- of patella dislocation, from multiple patella sode to the patellofemoraljoint, this fold of subluxations, from patellofemoral stress tissue can become thickened. When the pa- syndrome, or from symptomatic patella tella rides over this thickened fold, it can plica. Diagnosis is made on history and cause an audible \"pop\" and associated pain. physical examination.Altering patella track- The pain may be reported by the athlete as ing while decreasing acute inflammation is being diffuse or as being definitely associ- the basis of most treatment programs. ated only with the \"pop\"and localized well along the medial side of the joint. She may IMPINGEMENT SYNDROMES feel a catching sensation as the patella tries to slide under the thickened fold. Impingement syndromes result when soft tissues are repetitively traumatized between Pain can be gradual in onset over days and bony prominences. For example, shoulder weeks, as this tissue slowly thickens with impingement refers to irritation of bursa multiple low levels of trauma, or it can be and rotator cuff tissue, which becomes acute, especially if the athlete has per- trapped between the humeral head and formed a knee-intense activity and the plica acromion with shoulder elevation if the hu- has acutely been irritated and thickened. meral head is not firmly held in the glenoid fossa. Impingement syndromes commonly On physical examination, the athlete may occur about the ankle, the wrist, and the have a small effusion. She will feel tender- shoulder, and they are particularly common ness over the medial parapatellar area over the location of the plica. Moreover, an au-

250 Special Issues and Concerns in women involved in gymnastics, racquet sports, swimming, throwing sports, ballet, diving, ice skating, and crew (see Table 14- 1). Ankle Impingement Figure 14-18. Beaking of the anterior talar-tibial sur- Impingement of soft tissues about the face, secondary to multiple flexor impingements. ankle may occur with either repetitive Wrist Impingement marked dorsiflexion, such as that seen Impingement of the palmar capsule of the with landings in gymnastics, or repetitive marked plantar flexion, such as occurs in wrist is not as common as that of the dorsal dance, gymnastics, and diving.Athletes with capsule. Dorsal capsular impingement may anterior capsular impingementcomplain of develop acutely if an athlete falls on an out- pain in the region just lateral to the anterior stretched hand or absorbs a sharp impact tibial tendon as it crosses the ankle. The on the dorsiflexed hand, such as might pain is increased with dorsiflexion activi- occur in a tumbling routine in gymnastics, in ties. a poor angle of contact with a volleyball, or in improper baton handoff in track. Posterior capsular pain may be harder to localize. The athlete describes her pain as The athlete with dorsal impingement will posterior in the ankle, deep to the Achilles complain of pain diffusely along the dorsal tendon. The pain is present when she rises wrist structures. The pain is made worse to her toes, and in fact it may prevent her with forced dorsiflexion. A fractureof the ra- from achieving a forced plantar flexed posi- dius or navicular must be considered in the tion. On palpation of her peroneal tendons, differential diagnosis of any athlete present- Achilles tendon, and posterior tibial tendon, ing with a painful wrist. The pain of dorsal no tenderness is found. capsulitis will not be limited to the snuffbox, as with navicular fractures, and the pain is Ankle radiographs of the athlete with soft more distal (centered over the radial-carpal tissue ankle impingement appear normal, junction) than that seen with a nondisplaced but occasionally athletes may demonstrate bony abnormalities (beaking of the tibia and talus anteriorly, and hypertrophy of the talar process posteriorly) (Fig. 14-18). Treatment of most athletes with ankle im- pingement syndromes is conservative. Oral and/or local administration of anti-inflam- matory agents, ice massage, ultrasound, electrical stimulation, and other physical therapy modalities may help diminish the inflammatory response. Use of an anterior ankle pad, for anterior impingement, or a posterior pad to prevent hyperextension with posterior impingement may be helpful. The athlete should review her fundamen- tals, as alteration of technique maydiminish symptoms; for example, \"landing short\" in gymnastics results in a hyperflexed position and may precipitate anterior capsulitis. In the rare athlete with excessive bony hyper- trophy, surgical excision may be required.

Orthopedic Concerns 251 radial fracture. Moreover, with capsular im- mimicking the impingement process that pingement, radiographs are normal. occurs dynamically during sport. This ma- neuver is termed the \"impingement sign\" Analgesic cream applied to the area of (Fig. 14-19). maximum tenderness and ice massage, as well as other physical therapy modalities, No atrophy is generally found. The biceps may be helpful in decreasing symptoms. tendon will be tender if it is involved in the After the acute pain subsides, strengthening impingement process. There is often tender- exercises for the wrist extensors and flexors ness over the acromioclavicular joint, espe- are recommended prior to returning to the cially if arthritis of this joint is present, as in sport. Chronic impingement pain—that is, the older patient who develops the impinge- pain that has been present at a low level of ment syndrome. Acromioclavicular arthritis discomfort for several months—is moredif- is less common in the younger competitive ficult to resolve than the pain of acute im- athlete. Typically, external rotation strength pingement. Similar treatment routines are is diminished over the opposite side, but ab- used, however. Taping the wrist upon return duction is possible. to activity may be beneficial in the athlete with either an acute or a chronic wrist im- Shoulder radiographs are usually normal pingement. in the young athletic individual with shoul- der impingement. In the impingement syn- Shoulder Impingement drome of some athletes, one occasionally Shoulder impingement is commonly seen sees osteophytic spurring of the inferior sur- face of the acromion or sclerosis of the lat- in swimmers and in athletes participating in eral aspect of the humeral head from repet- throwing and racquet sports. It is frequently itive trauma.14 associated with some element of anterior shoulder subluxation in young athletes. In Figure 14-19. To produce the impingement sign of the the impingement syndrome, a weakened ro- shoulder, the examiner holds down the acromiocla- tator cuff allows upward migration of the hu- vicular area while elevating the extremity at the elbow meral head in the glenoid, causing compro- in a pronated, abducted, and forwardly flexed position. mise of the humeral-acromial space. As this If this maneuver reproduces the pain of impingement, space becomes compromised, the tissues it is called a positive impingement sign. contained therein, those of the subacromial bursa, and the rotator cuff itself can become traumatized and inflamed. With greater in- flammation, there is greater mass of tissue, and therefore, a vicious cycle of pain, swell- ing, more pain, and more swelling is estab- lished. Shoulder impingement may be asso- ciated with bicipital tendinitis, since the biceps tendon lies in the subacromial space and can be irritated by the impingement process part of the syndrome. The athlete with shoulder impingement complains of pain at the tip of the acromion or in the proximal arm. Frequently the pain radiates down the external rotators of the shoulder. Tenderness can be elicited if the examiner places one hand on the patient's acromion, holding it down while elevating the arm in either forward or side flexion.

252 Special Issues and Concerns A treatment program for the athlete with agents. After the initial inflammatory re- an impingement syndrome may include sponse subsides, exercises to strengthen temporarily avoiding any activity that re- the rotator cuff muscles, to reinstitute quires the elbow to be raised above shoul- proper mechanics of the shoulder, are ad- der height, combined with physical therapy vised. Many different exercise routines can modalities and oral anti-inflammatory be used to strengthen the rotator cuff. The Figure 14-20. (A) Patient using rubber tubing to strengthen the internal rotators of the shoulder. Note that the elbow is held tightly to the side and the forearm is rotated internallyto the abdomen, as the rubber tubing is affixed to the door. (B) Patient demonstrating use of rubber tubing to strengthen external rotators of the shoulder. Again,the elbow is held tight to the side and the forearm is rotated externally against the resistance of rubber tubing affixed to the door.

Orthopedic Concerns 253 simple exercises using rubber tubing at- ankle or its insertion into the superior pos- tached to a door (Fig. 14-20) were adapted terior tip of the calcaneus. In acute tendini- from the program initiated by the Naval tis, the examiner can feel crepitation over Academy.15 The athlete should be advised to the tendon as the athlete moves her foot review technique with her trainer or coach, from dorsiflexion to plantar flexion. The as frequently impingement is precipitated Achilles tendon may appear swollen when by an alteration in form. For example, in compared with the uninjured tendon. This swimming, an increase in internal rotation swelling may be easier to assess if the pa- of the arm at the shoulder may cause im- tient stands facing away from the examiner pingement of the tissues. or if she lies prone on the examiningtable. Chronic impingement syndromes are Treatment much more difficult to treat. Physical ther- apy modalities and oral anti-inflammatory Rest is essential in the treatment of acute agents can be tried. However,the key to im- Achilles tendinitis. The athlete can substi- provement of symptoms is to reinstitute tute nonimpact load activities that require proper shoulder mechanics through a rota- infrequent ankle motion (e.g., rowing ma- tor-cuff-strengthening exercise program. chine, swimming) to maintain fitness. If The athlete should be advised that such a walking is painful, crutches to assist ambu- program will take anywhere from 4 to 6 lation, heel lifts to relax the Achilles tendon, weeks, so she should not become discour- or in very severe cases, cast immobilization, aged. Controversy exists as to the role of in- may be needed. Rarely, the athlete will re- jected steroids to diminish symptoms. The quire surgical release of the inflamed tendon decision to use these should depend on the sheath. assessment of each individual case. Oral anti-inflammatory agents, local anti- OTHER COMMON CONDITIONS inflammatory creams, ice massage (rubbing the inflamed area with an ice cube), ultra- Achilles Tendinitis sound, iontophoresis, or electrical stimula- Achilles tendinitis is the result of damage tion can all be useful in decreasing acute in- flammation. Steroid injections are not to the fibers of the Achilles tendon or to its recommended because, if injected into the tendon sheath. It can be seen in sports re- tendon itself rather than the tendon sheath, quiring repetitive ankle flexion and exten- they may weaken the tendon. sion (e.g., track, basketball, soccer). It also occurs in athletes who wear boots, such as Stretching an acutely injured tendon can skaters and skiers, from the irritation of the delay healing, but once the acute inflamma- boot on the tendon. tion has subsided, exercises to stretch as well as to strengthen the Achillestendon are Acute Achilles tendinitis is usually char- begun. Stretching can be done by standing acterized by pain that is exacerbated when on a slant board with the heel lower than the the patient actively plantar flexes or resists ball of the foot, by leaning against a wall passive dorsiflexion of the foot. Chronic (facing it) with the feet flat on the floor, or Achilles tendinitis usually results in severe by using a towel under the ball of the foot to pain on first rising in the morning,which pull the foot gently into increasing dorsiflex- lessens with activity. It also generally causes ion. Toe raises are an effective strengthen- considerable pain at the start of a workout, ing exercise. which lessens as the workout progresses, unless the inflammation is severe and then After pain has completely disappeared the pain is persistent. with walking, stretching, and gently jogging, the athlete can gradually resume her run- When asked to localize her pain, the ath- ning sport. Icing following activity for sev- lete will touch either the tendon behind the eral months is recommended, and the ath-

254 Special Issues and Concerns lete should always warm up well and stretch origin of the muscle. Radiographs usually prior to sport. are negative, but occasionally some diffuse periosteal reaction at the posterior tibial Shin Splints muscle origin can be seen. \"Shin splints\" may be used as a general Shin splints must be differentiated from a term to refer to any pain between the tibial stress fracture of the tibia. The pain of a tubercle and the ankle that is not a stress stress fracture increases with activity and is fracture or compartment syndrome. How- relieved with rest. The athlete with a stress ever, many physicians use the term to refer fracture of the tibia will have a very discrete specifically to pain along the anteromedial area of pain on palpation of the tibia (see aspect of the tibia at the origin of the poste- below). rior tibial muscle (Fig. 14-21). As with other overuse syndromes, shin Running on hard surfaces, running in in- splints can be treated with rest, local and/or appropriate shoes, having weak lower leg oral anti-inflammatory agents, physical muscles, and improper stretching have all therapy modalities (e.g., ultrasound and been blamed for causing shin splints. Run- electrical stimulation), and ice massage ning on hard surfaces or in noncushioned (more effective than an ice bag). Stretching shoes may increase stress on the longitudi- and strengthening exercises for the poste- nal arch of the foot and, hence, indirectly on rior tibial muscle, as well as the associated the posterior tibial muscle and tendon that toe flexor muscles, are recommended. Sup- help support this arch. port of the tendons by arch supports or tap- ing may be beneficial. Diagnosis of shin splints is made by his- tory and physical examination. Pain mayini- In patients with chronic shin splints, slow tially increase with activity, usually im- return to sports may be advocated despite proves as the activity proceeds, and may the persistence of mild symptoms, as long as return following activity. The pain of shin the possibility of a stress fracture has been splints is localized to a 2- to 4-inch area on eliminated. The athlete should be very care- the anteromedial aspect of the tibia at the ful to warm up sufficiently and perform ad- equate stretching prior to beginning activ- Figure 14-21. Patient with shin splints demonstrating area of pain.

Orthopedic Concerns 255 ity. If an activity causes severe pain, it lieved with rest. Radiographs are helpful in should be discontinued. The athlete may be diagnosing stress fractures only if the pain able to substitute another activity (e.g., has been present for a minimum of 2 to 3 changing from running to biking) until her weeks. Since stress fractures are really \"mi- symptoms improve sufficiently to permit re- crofractures,\" the fracture line itself is often turn to her preferred sport. not visible on the x-ray film. Radiographs do not demonstrate an abnormality until signif- Stress Fractures icant healing reaction of the periosteum When the rate of bone breakdown from ac- (healing callus) is present. tivity (a normal process) is greater than the To diagnose a stress fracture before a rate of bone formation (repair), a stress frac- healing callus is visible radiographically, a ture may result. Stress fractures have been bone scan can be done. This study will de- reported to occur more often in female than tect increased osteoblastic activity as soon in male athletes.16 The reason for this in- as microfracturesoccur. Bone scans are par- creased incidence may be a lack of condi- ticularly valuable in diagnosing intracapsu- tioning or improper training technique, lar stress fractures, such as those of the fem- rather than a true predisposition to injury. A oral neck. In this location, bone has no woman who fails to condition slowly and periosteum. Hence, radiographs demon- sensibly for her sport does not give her bone strate no abnormality until intracortical ample time to increase in cortical thickness healing takes place, and this takes longer to meet the mechanical demands of the ac- than periostea! healing. tivity. Treatment and Exercise The most common location of stress frac- tures in women is the tibia;17 also common In treating stress fractures, the primary are fractures of the fibula and metatarsals. consideration is to decrease the mechanical Fractures of the pars interarticularis are a stress on the bone to allow healing to occur. special type of stress fracture, as noted in Neither cast immobilization nor operative the section on low back pain. stabilization is generally required. For stress fractures of the lower extremity, the Some investigators have tried to relate the athlete should use a cane or crutch until she low estrogenic secondary amenorrhea seen can bear weight on the extremity without occasionally in competitive female athletes pain. to osteoporosis and a higher incidence of stress fractures.18,19 However, the only area Swimming and bicycling can be started of diminished bone content in these women early in the treatment of stress fractures. has been in the cancellous bone of the ver- These activities will maintain cardiovascu- tebral bodies;20 no change in the density of lar endurance and muscle tone, but are non- cortical bone has been found. (See Chapter weight-bearing activities and therefore do 5.) Most stress fractures occur justproximal not stress bones of the lower extremities in to the metaphysis, in the areas of cortical the same manner as running and walking. bone. Therefore, the relationship of stress Psychologically, the athlete will fare much fractures to low estrogenic secondary amen- better if she can participate in some sporting orrhea is not clearly understood. More in- activity during her treatment course. vestigation needs to be done in this area. Because stress fractures heal at variable Diagnosis rates, it is better to advance activity as pain resolves rather than to establish routine The pain of a stress fracture is typically re- time intervals for activity adjustment. When stricted to a limited anatomic area. It is no pain results from walking long distances made worse with activity and may be re- unassisted by crutches or cane, running can be attempted.

256 Special Issues and Concerns Low Back Pain mal or show a lumbar list (curve) secondary Causes of low back pain have been listed to muscle spasm. as mechanical, neurologic, neoplastic, infec- Most mechanical low back pain runs a 2- tious, and metabolic. Mechanical causes, to 3-week course and is self-limited. If pain the most frequent in athletes, include nerve lasts longer despite the institution of con- root impingement; repetitive microtrauma servative therapy with bed rest, muscle re- resulting in overuse syndromes such as ten- laxants, anti-inflammatoryagents, physical dinitis, fasciitis, and stress fractures; and therapy modalities, and a graded exercise some anatomic abnormalities. Mostana- program, the athlete's symptoms deserve tomic abnormalities, such as asymmetric further evaluation to rule out the possibility lumbar or sacral facets, scoliosis, increased of spondylolysis (a defect in the pars inter- lumbar lordosis, and transitional vertebrae, articularis, as in Fig. 14-22), spondylolisthe- do not usually result in back pain. However, sis (forward slipping of one vertebra on an unequal leg lengths (generally a difference adjacent vertebra, also in Fig. 14-22), large of 1.5 cm or greater) may cause low back disk herniation, infection, neoplasm, or met- pain on a mechanical basis, especially in abolic disease. runners. Spondylolysis Athletes with mechanical low back pain may present with either an acute episodeof Female gymnasts have been found to have severe low back pain, or with pain slowly in- a greater incidence of spondylolysis or de- creasing over several days or months. Pain fects in the pars interarticularis than the associated with numbness or tingling of the general population.21 Defects in the pars in- lower extremities, or pain radiating from the terarticularis in the athletic population back into the leg,implies nerve root im- present an intriguing diagnostic problem: Is pingement (neurologic back pain). this defect a stress fracture resulting from repetitive hyperextension and flexion activ- On physical examination, mild, moderate, ities of the area, or is it a developmental ab- or severe spasm of the paravertebral mus- normality? The youngest reported pars de- cles may be found. Palpation of the low back fect occurred in a 31/2-month-old child. An region usually elicits pain. Reflexes, motor increased incidence of the defect is seen be- function, and sensation are normal in both tween the ages of51/2and 61/2; by age 7, 5% lower extremities. Radiographs may be nor- all white children have been found to have a pars defect.22 A familial predisposition for this defect has been reported. If initial radiographs demonstrate a well- established pars defect indicative of an older injury, return to athletics can follow a period of rest. A strengthening program should be instituted prior to returning to ac- tivity. Bent-knee sit-ups, walking, and swim- ming all help to develop abdominal and paravertebral muscles. Figure 14-22. Spondylolysis and Spondylolisthesis. Stress Fractures (From Norkin CCand Levangie PK:Joint Structure and Function, ed 2. FADavis, Philadelphia, 1992, p 164, with In athletes with normal radiographs and permission.) persistent low back pain, the possibility of stress fracture must be entertained. A bone scan may be required to establish this diag-

Orthopedic Concerns 257 nosis. If this is positive, resting from activi- level. Initial treatment of the athlete with ties for a minimum of 3 to 4 months is rec- suspected disk herniation is similar to that ommended, and many physicians suggest for mechanical low back pain—rest and oral immobilization in a spica or plastic ortho- anti-inflammatory medications, followed by sis.23 Anti-inflammatory and muscle relaxing a program for strengthening paravertebral agents can be useful for symptomatic relief. and abdominal muscles prior to a return to A program of abdominal and back-strength- sport. Muscle relaxing agents and physical ening exercises should be instituted prior to therapy modalities may be helpful in dimin- returning to athletics. ishing pain secondary to muscle spasm. Spondylolisthesis In the athlete whose pain is unresponsive to such treatment over 2 to 3 weeks, or who Spondylolisthesis occurring in associa- has increasing neurologic complaints (in- tion with spondylolysis is most common in creased weakness, muscle atrophy, de- females between the ages of 9 and 13years. creased sensation in the lower extremities, Unlike Spondylolisthesis in the adult, which absent reflexes, etc.), further evaluation by tends to remain stable, Spondylolisthesis in computerized axial tomography (CAT) scan, children can increase in severity during the magnetic resonance imaging, or myelogram years of rapid growth. Children known to should be done. If a ruptured disk iscon- have Spondylolisthesis who complain of firmed by these studies, surgical decom- back pain should be examined carefully to pression of the ruptured disk may need to be note any progression of their slip. done. However, less than 30% of myelo- gram-proven ruptured disks need operative There is disagreement over whether ath- intervention.24 Most improve with conser- letes with mild Spondylolisthesis should re- vative measures. turn to contact sports: some authorities have suggested that they can do so if they Vertebral Apophysitis are protected by a brace. Although this may be acceptable in a football lineman, female Another cause of back pain in the skele- gymnasts would find it difficult to compete tally immature population is vertebral in such a restrictive device. apophysitis, that is, irritation of the growth centers of the vertebral body. Inflammation Rarely, the athlete with Spondylolisthesis is believed to result from traction on the may have persistent significant pain follow- apophysis (the growth center) from the ing a treatment program consisting of rest, anterior longitudinal ligament, as it is anti-inflammatory agents, and using a brace. stretched in repetitive extension maneuvers Fusions are occasionally performed in these that are a part of sports such as gymnastics, recalcitrant cases. A few athletes have even diving, and skating. returned to their sport following fusions for Spondylolisthesis, but contact sports are Rest often relieves symptoms, yet bony generally not recommended in these ath- changes may persist. Prior to returning to letes. sports, these youngsters should begin a strengthening and flexibility program for Herniated Lumbar Disk back and abdominal muscles. Symptoms de- termine when a child may resume full partic- Athletes with nonradicular back pain un- ipation in sports. responsive to conservative measures or with radicular back pain should be evalu- Bunions ated for a possible herniated lumbar disk. In The abnormal prominence of the inner as- the athlete with radicular pain, careful neu- rologic examination may enable localization pect of the first metatarsal head and resul- of the pain to a particular nerve root or disk tant lateral displacement of the great toe is

258 Special Issues and Concerns Figure 14-23. Young girl with bunions on metatarsus primus varus. termed a bunion.Bunions appear to be more Figure 14-24. Runner who has had stress fractures of common in women, and hence, they are the second and third metatarsals following her bun- more common among female athletes than ionectomy procedure. The stress fracture of the second among male athletes. Many women have in- metatarsal is old and has a good healing reaction asso- flammation of the bursa overlying the me- ciated with it, whereas the stress fracture of the third dial prominence or flare of the great toe metatarsal is new, and no healing reaction is yet seen. metatarsal head associated with their meta- tarsus primus varus (Fig. 14-23), but this the middle metatarsals in a long-distance bursal enlargement also occurs without sig- runner following a bunionectomy. Operative nificant lateral displacementof the great toe. procedures should not be done purely for Shoe alteration and protective pads to re- cosmetic reasons; they should be reserved duce pressure over the metatarsal flare are for cases in which pain is unresponsive to often helpful in diminishing symptoms. The conservative care. problem is more difficult when the athlete Morton's Neuroma has not only bursitis but also degenerative changes in the metatarsophalangeal joint, a Pain between the second and third meta- condition seen in athletes involved in kick- tarsal heads, or between the third and fourth ing sports. metatarsal heads, made worse by transverse compression of the forefoot, generally re- The athlete with a bunion must be careful sults from inflammation and scarring about when choosing shoes. She should look for the interdigital nerve (i.e., Morton's neu- shoes with a sufficiently wide forefoot, yet a narrow enough heel to prevent her foot from sliding forward in the shoe. With forward slippage, the first ray is forced into a valgus position and pressure is exerted on the me- dial metatarsal head. If pain persists despite all conservative treatment, bunionectomy can be performed, but great care must be taken to avoid alter- ing foot mechanics disadvantageously by such a surgical procedure. Figure 14-24 demonstrates multiple stress fractures of

Orthopedic Concerns 259 roma). The patient may complain of numb- 2. Anderson J: Women's sports and fitness pro- ness in the toes supplied by the com- grams at the U.S. Military Academy. Phys promised nerve. Swelling between the Sportsmed 7(4):72,1979. metatarsal heads at the site of the neuroma may also be noted. 3. Eisenbert I, and Allen W: Injuries in a women's varsity athletic program. Phys The mechanism of development of this le- Sportsmed 6(3):112, 1978. sion is not clearly understood, but it appears to involve scarring of both the nerve and the 4. ClarkeK,and BuckleyW:Women's injuries in vessel accompanying it.25 It has been theo- collegiate sports. Am J Sports Med 8:187, rized that compression of the adjacent meta- 1980. tarsal heads creates repetitive trauma to these structures, producing the scarring. 5. Whiteside P: Men's and women's injuries in comparable sports. Phys Sportsmed In some cases, a metatarsal pad will alle- 8(3):130,1980. viate symptoms. The athlete should be ad- vised to wear wider shoes and place antiskid 6. Gillette J, and Haycock C: What kinds of in- pads in her shoes to prevent forward migra- juries occur in women's athletics? 18th Con- tion of her foot in the shoe, causing trans- ference on the Medical Aspects of Sports, verse compression of the metatarsal heads. American MedicalAssociation, 1977, p 18. Local injection into this area may be helpful in decreasing or resolving symptoms. 7. Shiveley RA, Grana WA, and Ellis D: High school sports injuries. Phys Sportsmed If all these measures fail, excision of the 9(8):46, 1981. neuroma may be performed, but the athlete should be warned that postoperative swell- 8. DeHaven K:Athleticinjuries: Comparison by ing of the foot can persist for 3 to 4 weeks fol- age, sport, and gender. Am J Sports Med lowing the procedure. She should plan re- 14:218,1986. section of the neuroma for an appropriate time in her competitive season to permit an 9. Hunter L, Andrews J, Clancy W, et al: Com- adequate recovery. mon orthopaedic problems of the female ath- lete. American Academy of Orthopaedic Sur- SUMMARY geons Instructional Course Lecture, Vol 31, 1982, p126. Over the last several decades, there has been an increasing awareness of women's 10. Hunter LY: Women's athletics: The orthope- sports injuries. With the advent of better dic surgeon's viewpoint. Clin Sports Med conditioning programs for women, the rate 3:809,1984. of sports injuries has diminished.When an injury does occur, prompt diagnosis and 11. Turba JE: Formal extensor mechanism re- treatment of the injury is needed to mini- construction. Clin Sports Med 8:297, 1989. mize the time lost from sport. 12. Palumbo PM: Dynamic patellar brace: A new Guidelines for the athlete's return to ex- orthosis in the management of patellofemo- ercise after orthopedic injury or surgery are ral disorder. Am J Sports Med 9:45, 1981. discussed in greater detail in Appendix A. 13. Boland A: Soft tissue injuries of the knee. In REFERENCES Nicholas J, and Hershman E (eds): The Lower Extremity and Spine in Sports Medi- 1. Albohm M: Equal but separate—insuring cine. CVMosby, St Louis, 1986, p938. safety in athletics. JNATA 13:131, 1978. 14. Cone R, Resnick D, and Danzig L: Shoulder impingement syndrome: Radiographic eval- uation. Radiology 150:29,1984. 15. Regan K, and Underwood L: Surgical tubing for rehabilitating the shoulder and ankle. Phys Sportsmed 9(1):144, 1981. 16. Micheli L:Injuries to female athletes. Surgical Rounds2:44,1979. 17. Protzman R, and Griffis C: Stress fractures in men and women undergoing military train- ing. J Bone Joint Surg 59:825, 1977. 18. Caldwell F: Light-boned and lean athletes: Does the penalty outweigh the reward? Phys Sportsmed 12(9):139,1984. 19. Mitchell D: Case presentation. In Bulletin of the Department of Gynecology and Obstet- rics, Emory University School of Medicine, 6:74,1984. 20. Lutter J: Mixed messages about osteoporosis

26O Special Issues and Concerns in female athletes. Phys Sportsmed Differential diagnosis. Am J Sports Med 11(9):154,1983. 7:362,1979. 21. Jackson D, Wiltse L, and Cirincrone R: Spon- 24. Jackson D, and Wiltse L: Low back pain in dylolysis in the female gymnast. Clin Orthop young athletes. Phys Sportsmed 2:53,1974. 117:68, 1976. 25. Bossley C, and Cairney P: The intermetatar- 22. Hoshina H: Spondylolysis in athletes. Phys sophalangeal bursa: Its significance in Mor- Sportsmed 8(8):75,1980. ton's metatarsalgia. J Bone Joint Surg 23. Micheli L: Low back pain in the adolescent: 62B:184,1980.

CHAPTER 15 Medical ConditionsArising during Sports ARTHUR J. SIEGEL, M.D. THE PHYSIOLOGY OF ATHLETES Exercise-Induced Anaphylaxis Exercise-Induced Urticaria CARDIAC CHANGES WITH EXERCISE AND TRAINING: RISKS PSEUDOSYNDROMES IN AND BENEFITS ATHLETES Primary and SecondaryPrevention Pseudoanemia (\"Runner's Anemia\") of Heart Disease Through Exercise \"Athletic Pseudonephritis\" Serum Enzyme Abnormalities: EXERCISE AND CANCER RISK Muscle Injury andPseudohepatitis HAZARDS OF EXERCISE Pseudomyocarditis Heat Stress Hematologic Effects: Iron Status and SCREENING THE ATHLETE FOR MEDICAL CLEARANCE Anemia \"Runner's Diarrhea\" CAUTION: WHEN NOT TO Effects on the Urinary Tract EXERCISE Exercise-Induced Asthma The 1990s promise to be a dynamic step forward in women's health, with rec- ognition of gender disparities in health care1 and a clear mandate from the National Institutes of Health to close the gap through research on women's health.2 A new NIH program is called CHOICES: Cancer Heart disease Osteoporosis Interventions and Community Evaluation Studies This program, committed to improving health outcomes in women, carries a strong mandate to examine the gender-specific health benefits of exercise as endorsed by the U.S.Preventive Services Task Force for the general population.3 261

262 Special Issues and Concerns The purpose of this chapter is to consider megaly without congestive heart failure.The gender-focused medical conditions arising ECG showed a first-degree AV block with during sports and to place these consider- voltage criteria for LVH, ST-segment ations in the forward-looking context of the changes consistent with early repolarization role of exercise in improving women's or acute ischemia. health. This case illustrates the challengingdif- THE PHYSIOLOGY OF ferential that may arise during the acute ATHLETES evaluation of individuals—athletesor oth- erwise—with abnormal clinical examina- Things are not alwayswhat they appear to tions and laboratory data. Although this sce- be. Athletes acquire an altered physiology nario might well fit an individual with an from training, and as a result of those advanced stage of a debilitating illness changes, basic laboratory tests that are ab- (even AIDS), it is also entirely compatible normal for nonathletes may be normal for with a nondisease state and might easily fit athletes. The medical literature is full of de- the description of an elite female marathon scriptions of medical conditions or illnesses runner enjoying a nap after competition! The in athletes that have subsequently been inability to arouse this patient with appro- shown to be physiologic or normal re- priate stimulation, or a marked elevation of sponses to exercise. For example, athletic body temperature, or both, might raise the nephritis and athlete's anemia have been possibility of severe heat injury or even heat appropriately reclassified as pseudosyn- stroke. dromes. A physician who is unfamiliar with laboratory data in athletes may diagnose This sample case illustrates the impor- disease when none exists. tance of a working knowledge of the effects of endurance training on exercise physiol- The following case history illustrates the ogy, to assess specific conditions that may complexities of medical conditions that may arise in athletes during sport, as well as to arise through intense sports activity: differentiate true clinical problems from changes in laboratory data that may not in- A 21-year-old woman was brought to the dicate any underlying illnessor dysfunction. emergency room scantily clad and coma- A number of pseudosyndromes have been tose, having been found, unresponsive, by recognized in athletes, from the athletic the roadside. Her blood pressure was 68/40, heart syndrome to pseudonephritis, pseu- pulse 36 bpm and regular, respirations 8 and doanemia, and pseudohepatitis. These are unlabored, temperature 96°F. Examination examples of abnormal laboratory findings showed no evidence of head injury or other that may result from strenuous training and trauma. The chest was clear. The heart was not be connected to any underlying organ markedly enlarged with an LV lift and pan- dysfunction.4,5 systolic murmur with an S3 gallop. Abdomi- nal examination was unremarkable. The ex- These pseudosyndromes must be differ- tremities showed the appearance of muscle entiated from a range of medical complica- wasting with scant subcutaneous tissue and tions that may arise in the athlete during a height/weight ratio below the fifth percen- prolonged strenuous exercise or competi- tile. Laboratory data included a hematocrit tion, especially due to overexertion states. value of 30%,a urinalysis positive for protein After briefly discussing some medical bene- and trace amounts of blood, and hyaline fits conferred by exercise, this chapter will casts present in the sediment. Serum creat- examine both aspects of medical conditions inine was borderline elevated at 1.7, liver arising during sports: true exercise-related and cardiac enzymes were two to three illnesses, conditions,or risks; and the spec- times normal, with a CPK 10 times normal. trum of pseudosyndromes or apparent dis- Chest radiograph showed marked cardio- orders that may arise as a result of altered physiology through training.

Medical Conditions Arising during Sports 263 CARDIAC CHANGES WITH basic similarities between men and women EXERCISE AND TRAINING: in the characteristics of disease and their re- RISKS AND BENEFITS sponse to preventive measures. For in- stance, atherosclerotic plaques found in Electrocardiographic changes in trained women have similar compositions to those individuals include a variety of rhythm and of men,7 and daily aspirin use promotes pri- conduction disturbances, as well as depolar- mary prevention in women as well as in ization changes, that in other clinical set- men.8,9 Nevertheless, a gender bias in access tings would be characteristic of various to health care has been identified10,11 and diseases.6 The heart, as studied by echocar- might be called \"sex, lies, and balloon an- diography, shows changes in both chamber gioplasty.\" Attention to the need for size and myocardial mass, which vary with gender-neutral diagnosis and treatment is type of training. Endurance-trained athletes growing. tend to have dilated chambers with a minor degree of increase in left ventricular wall While the incidence of coronary heart dis- thickness, resembling the volume-overload ease is low in women, compared with men, pattern seen in valvular regurgitation. In diseases of the circulatory system account contrast, isometric or strength training in- for roughly two thirds of all deaths among duces a greater increase in wall thickness women in the United States. The incidence and total myocardial mass withoutchamber of mild myocardial infarction or death from dilatation, as is seen in valvular aortic ste- coronary heart disease in premenopausal nosis. Work hypertrophy, as documented by women is below 1 in 10,000per year. A large these studies, is associated with supernor- number of cardiovascular deaths occur in mal left ventricular performance duringex- women after age 75, but cardiovascular ercise, and, like the arrhythmias that may deaths also account for one third of all coexist, it is usually benign in nature. It is deaths from age 65 to 74. Death rates from generally felt that asymptomatic athletes cardiovascular disease in women are 40% with documented myocardial hypertrophy lower than in men for persons between 35 and abnormal electrocardiograms do not re- and 64 years of age, and the relative mortal- quire provocative or invasive cardiovascu- ity rate for women falls to 25%of male levels lar testing prior to training or competition. for ages 35 to 44.12Nevertheless, cardiovas- In the absence of chest pain or syncope, cular death rates may be increasing in bradyarrhythmias or even low grades of women, especially during the postmeno- heart block and ventricular irritabilityneed pausal period, perhaps related to increases not be pursued as they would in symptom- in the numbers of women who have smoked atic patients with suspected heart condi- cigarettes throughout their lives. Although tions. The sole caveat concerns the rare oc- smoking-adjusted rates for coronary heart currence of sudden cardiac death in young disease in women under 45years of age have athletes during sport, which is discussed in not increased in the United States, Framing- Chapter 16. ham data from other studies indicate an in- crease in coronary disease in postmeno- Primary and Secondary pausal women, with a risk profile similar to Prevention of Heart Disease that observed in men. Risk factors for coro- Through Exercise nary artery disease in women include the standard triad of hypertension, hypercho- According to the American Heart Associ- lesterolemia, and cigarette smoking. Regu- ation, nearly half of the 500,000 people who lar exercise produces a beneficial effect on die annually of heart attacks in the United such a risk profile, reducing resting blood States are women. Four recent studies of pressure, increasing the \"good\" or HDLcho- coronary artery disease in women point to lesterol, and creating a positive incentive to stopsmoking.

264 Special Issues and Concerns As has been shown for men, cardiac risk EXERCISE AND CANCER RISK reduction in women is closely tied to exer- cise. Diet programs for weight reduction A great volume of literature supports the should be augmented by exercise in order to beneficial effects of exercise in the primary increase HDLcholesterol levels.13 The im- and secondary prevention of coronary ar- portance of moderate exercise in a weight- tery disease, but few data exist on specific reduction program was demonstrated using relationships between exercise and cancer. brisk walking and light jogging designed to A recent study from the Journal of the Na- attain 60%to 80%of the maximal heart rate tional Cancer Institute reports a relationship for 25 minutes three times per week. Thus, between increased physical activity and de- the new guidelines endorsed by the Ameri- creased risk of colon cancer.25 Such a rela- can College of Sports Medicineindicate that tionship does not prove causality or a pro- an aerobic effect linked directly to an im- tective relationship, however. provement in cholesterol profiles may result from less intense exercise than had been ad- Low-dose postmenopausal estrogen re- vocated previously. The more conservative placement does not appear to increase the CDC recommendations are similar but do risk of breast cancer,26 and it does improve not specify intensity levels. the safety of exercise by preventing osteo- porosis and reducing coronary heart dis- The second risk factor for coronary artery ease. disease is hypertension, which also has been shown to improve with the additionof HAZARDS OF EXERCISE an exercise program.14 In addition, exercise has been found beneficial in patients with Heat Stress non-insulin-dependent diabetes mellitus, in Adaptation of the athlete to environmen- whom coronary artery disease is acceler- ated by approximately a decade.15 tal stresses such as heat, cold, or altitudede- pends on specific physiologic responses, Exercise trainingalso improves quit rates which may be different in women. Aerobic in women participating in smoking cessa- exercise involves the generation of internal tion programs.16 The adverse effect of smok- heat through performance of muscular ing may be greater in women than in men.17 work. As the core temperature rises, an in- Young women now have high smoking rates, creased amount of cardiac output is deliv- and a combination of smoking cessation ered to the skin so that heat can be dissi- with exercise may be mutually reinforcing. pated in the form of sweating. Heat is lost Women who stop smoking may experience principally through evaporation of sweat minor weight gain, including increased from the body surface, which cools off the body fat, but lean body mass increases as a individual at the price of losing vital circu- benefit of exercise.18,19 In addition, the enjoy- lating fluids. Prolonged strenuous exercise ment of improved exercise performance is invariably leads to dehydration, which may an extra incentive to avoid smoking and to then lead to fatigue, confusion, lethargy, and pursue a prudent, low-fat diet. When persistent excessive body temperature. Ad- needed, transdermal nicotine may improve vanced states of heat exhaustion from exer- the effectiveness of smoking cessation pro- cise may lead to coma and even cardiac ar- grams.20,21 rhythmias and sudden death. These rare and extreme hazards can be avoided by ad- Finally, postmenopausal estrogens have equate knowledge of the steps that prevent been shown by careful studies to pro- dehydration and hyperthermia during ex- ong life and reduce coronary artery dis- ercise. ease mortality.22,23 On the other hand, anabolic steroids are atherogenic and hazardous.24

Medical Conditions Arising during Sports 265 The capacity to dissipate body heat gen- firm a resistance to heat-stress injury from erated duringprolonged strenuous exercise physical conditioning. Nevertheless, a high depends on both internal and environmen- level of physical fitness will not protect an tal factors. The capacity for heat acclimati- athlete from heat exhaustion or potentially zation depends on an increase in the rate of fatal heat stroke, which may accompany sweat generation for the level of exertion overexertion in a given level of training. and a lower sodium content. As judged by Considerations for women are almost iden- such changes, heat-acclimatized men and tical to those in men for heat-intolerance women show similar adaptive patterns. susceptibility. After acclimatization, women's heart rates and rectal temperatures in hot and humid The guidelines for prevention of heat in- conditions at rest and after activity are the jury as outlined by the American College of same of those of men.27 Lower sweat rates in Sports Medicine should be considered, women are required to maintaincomparable whether racingor out for a recreational jog.30 body temperatures, suggesting an improved The first tenet of prevention is adequate hy- efficiency in heat-release mechanisms. Ac- dration before exercise. This is best done by climatization to hot weather is facilitated by consuming 8 to 10 ounces of water 10 to 20 underlying fitness capacity, but still requires minutes before beginning a strenuous work- 7 to 10days for optimal adaptation. It should out. The warm-up phase of exercise allows be accomplished gradually, starting at 50% the muscles and tendons to adapt to the bio- maximum effort and increasing 5% to 10% mechanics of exercise while the blood flow daily. Competitiveathletes and recreational increases to exercising muscle. As body runners alike, men or women, must respect temperature rises, the sweating mechanism the limitations of internal (adaptive) and ex- kicks into place, with the perception of \"sec- ternal (climatic) stresses. ond wind.\" Prolonged exercise should in- An increased risk for heat exhaustion volve taking breaks to consume additional might be hypothesized in women during the water and, when appropriate, moistening second half of the menstrual cycle, from el- the body surface with sponging or spraying evations in basal body temperature owingto to assist in the cooling process. Such mea- progesterone effects. However, increased sures provide a form of \"external sweating,\" susceptibility to heat injury during the luteal which helps to dissipate heat through evap- phase has not been demonstrated in the sci- oYation without needing to use internal fluid entific literature.Wells28 studied the heat re- resources as the sole source of water for sponses of women at different stages in their evaporation. menstrual cycle in hot-dry and neutral en- vironments. Sweat rates and evaporative Sweating involves the loss of more water heat loss did not vary through the menstrual than sodium and chloride in comparison to cycle. their concentrations in blood. As a result, Drinkwater and colleagues29 studied heat serum levels of sodium rise continuously adaptation in female marathon runners and during exercise. For this reason, salt supple- showed a relationship between physical ments are undesirable prior to or during fitness as measured by Vo2max and resis- strenuous exercise, and in events lasting tance to heat injury. Female runners with less than 2 to 3 hours individuals should rely high gV–o1•2mmaixn (49 m L•kg–1•min–1 vs. 39 on the use of water alone as the optimal re- mL•k – 1) had lower heart rates, pletion fluid in the prevention of heat injury. Potassium supplements are likewise unnec- lower skin and rectal temperatures, and essary for participants in events lasting less quicker onset of sweating compared with than 3 hours. Exclusive and excessivewater less-conditioned individuals. These findings intake during prolonged events such as an are similarto patterns in men, and they con- ultramarathon, however, may lead to hypo- natremia or low sodium levels.

266 Special Issues and Concerns Appropriate dress during exercise is an- cising, and saunas and hot tubs can cause other important component to the preven- considerable additional fluid loss, even in tion of heat stress. This involves dressing in the absence of visible sweating. light and loose-fitting clothing during hot- weather exercise, especially on humid days Educating runners about heat acclimati- when the sweating mechanism is less effi- zation, prehydration, and control of exer- cient. In addition, exercising in full sunlight cise intensity during training and racing increases the risk, but usinga hat for protec- should result in less frequent heat injury. tion from radiant energy in sunlight will help Emergency care when such complications to protect the athlete from dehydration. do arise should prevent the fatalities that still occur from the medicalconsequences of Finally, individuals should use extreme severe exertional heat stroke. Physicians caution when they sit in saunas or hot tubs should encourage heat-injury precautions, after exercising. They should immediately encouraging races to be run at cooler times leave if they feel the least bit dizzy, weak, or of the day and canceled when wet-bulb tem- faint. All people are dehydrated after exer- peratures exceed 28.0°C. Drinking 10 to 12 Table 15-1. MEDICAL ADVICE TORUNNERS Training If possible, try to acclimatize yourself to heat if the race if is to be run in hot weather. Try to run at least 36 to 50 miles a week in training runs and take occasional longer runs. If you cannot comfortably run 15 miles 1 month before the marathon, you may have trouble running the race safely. Cut back mileage several days before the race to avoid exhaustion on race day. Diet Eat what you feel comfortable with. Extreme changes, such as carbohydrate loading, may affect you adversely. A slight increase in vitamin C and salt intake may be beneficial, especially in hot-weather races. Decreasing protein intake and substituting carbohydrates several days before the race may increase your stores of muscle glycogen. Clothing Wear light-colored clothing to protect against heat and, if possible, wear mesh clothing on a hot day. Natural fibers such as cotton will chafe less than synthetics. On a warm day, if you are comfortably warm at the starting line, you are probably overdressed. Fluids Drink early and often. Try to drink 1 pint of water 10 minutes before you run and at least half a cup of water every 15 minutes thereafter. Wetting the skin with hose sprays or sponges can bring temporary comfort but is no substitute for drinking.You are adequately hydrated before a race if your urine is a pale straw color. Since dehydration can actually blunt your thirst mechanism, don't let thirst be your guide for drinking.If you are not used to electrolyte-glucose drinks, you may want to avoid them during the race. Running the Race Begin slowly. On humid days, when the temperature is 75°F or greater, slow your pace by 45 to 60 s/mile. If you experience persistent localized pain, seek medical help. The signs of heat exhaustion are headache, tingling or pins and needles in the arms, back, and extremities, fatigue, a weak pulse, cool, moist skin, profuse sweating, and cold chills. The signs of heatstroke are headache, convulsions, altered behavior or mental state, red-hot skin, and absence of sweating. If you feel any of those symptoms, seek medical help or at least slow down or walk. Race officials will be instructed to remove you from the course if you appear to be at risk of injuring yourself. If you have a pre-existing injury or medical condition that could endanger your health, do not run. Finish Line Get out of the sun. Drink fluids. If you don't feel well or feel faint, seek medical help. Get into dry clothes as quickly as possible. Source: From Editorial Staff: Marathon medicine. Emerg Med 17(16):89,1985, with permission.

Medical Conditions Arising during Sports 267 ounces of cold fluids, either diluted com- durance training, which is discussed in mercial drinks or fruit juice diluted with 2 to greater detail later in the chapter. A differ- 3 parts cold water, is recommended to re- entiation of true anemia (an absolute de- plenish fluid and potassium losses (see crease in red cell mass) from pseudoanemia Chapter 6). Athletes should not wait to be- (a relative or dilutional decrease in hemo- come thirsty, since 2 to 4 Ib of fluid loss may globin value) cannot be made from mea- occur before thirst becomes intense. Warm surement of the hemoglobin and hematocrit fluids should not be consumed, as they are determinations alone. The clarification of absorbed more slowly than cold fluids. Com- true iron-deficiency anemia versus \"pseu- mercial drinks are high in sugar and may doanemia\" in female athletes requires the cause abdominal cramps if not diluted.Cot- direct measurement of body iron stores. ton socks to absorb sweat, and white or This can be done by measurement of serum light-colored clothing to reflect the sun's iron and iron-binding capacity or serum fer- rays are also recommended. These preven- ritin levels, which are normal in the case of tive strategies are summarized in Table 15- the \"pseudoanemia\" but low in the case of 1. The best prevention, though, is an in- true iron deficiency.5 This differential is formed runner who knows her limits. shown in Table 15-3. The best treatment of heat injury is im- In addition to menstrual losses, women mediate rapid cooling performed on-site face the additional possibility of ongoing and without delay. In an Australian study,31 iron loss during endurance training through the mean time it took to cool patients who additional body fluids such as sweat, urine, had rectal temperatures 41.5°C was 37 and feces. A significant loss of stores may minutes. No runners experienced the severe occur over time if not accompanied by a bal- sequelae of heat stroke with this rapid-cool- anced intake of iron in the diet. Recent stud- ing approach. If treatment is delayed, major ies have shown that some long-distance run- medical complications including fulminant ners develop guaiac-positive stools during rhabdomyolysis, acute renal failure requir- long-distance training and competition, ing dialysis, hepatic necrosis, and dissemi- which revert to normal within 72 hours.36 nated intravascular coagulation can occur, Runners with anemia and guaiac-positive although infrequently.32,33 Common heat in- stools deserve a systematic medical inves- juries and their treatment are seen in Table tigation to rule out an intrinsic bowel prob- 15-2. lem unrelated to the exercise training. Hematologic Effects: Iron Status The possible causes of blood loss include and Anemia intestinal ischemia, stress gastritis, drug-in- duced lesions, and loss of blood from pre- Obligatory iron loss through menstrua- existing lesions. Another possible cause of tion creates a potential risk for iron deple- iron loss is hematuria, as discussed in a later tion and, if mild or subclinical, secondary section. All these disorders may add to the anemia. Studies in apparently normal, burden of iron depletion in the athlete and healthy college-age women document the create a true iron-deficient state. depletion of total body iron stores (by ex- amination of stained bone marrow aspi- The diagnosis of iron-deficiencyanemia rates) in up to 25%of subjects.34 Rates of iron in women or men requires specific measure- deficiency among apparently healthy col- ment of the serum iron parameters as noted lege athletes may be somewhat higher, as previously. Low values for serum iron with a reported in one blood study.35 reciprocally increased serum iron binding capacity or a low serum ferritin level, or Confusion is likely to arise between true both, indicate the depletion of total body iron-deficiency anemia and the so-called iron stores and the need for specific supple- pseudoanemia, or \"runner's anemia,\" of en- mentation. Treatment should consist of 300 mg of ferrous sulfate given once or twice

268 Special Issues and Concerns Table 15-2. COMMON RACE INJURIES AND THEIR TREATMENT Heat Cramps A mild response to heat stress. Treatment If unaccompanied by serious complications, treat with rest, oral fluids, cooling down, stretching, ice and massage, and muscle massage. Heat Exhaustion A serious situation in which hypovolemia develops as a result of excessive fluid loss. The rectal temperature may range between 100and 105°F or higher. The runner experiences lassitude or dizziness, nausea, headache, and muscle weakness. Althoughthe runner is probably volume-depleted, sweating should be evident. Treatment For mild cases, treat the same as for heat cramps. For serious cases, including those with hypotension, persistent headache and vomiting, or altered mental states, initiate IVfluid resuscitation, cool vigorously (with an ice- water bath, for example), and consider transport to an emergency facility. Heatstroke Often characterized by motor disturbances, such as ataxia, and severe nervous system disturbances, such as confusion, delirium, or coma. Circulatory collapse and hypotension are possible. Rectal temperatureusually exceeds 105°F but may be lower after a period of collapse and cooling. The skin is usually warm but the victim may not sweat, although sweating usually occurs in the initial stages. Treatment Cool the runner immediatelywith hosing or fanning and ice applied to major arteries such as the carotid, axillary, femoral, and popliteal. If rectal temperature monitoringis possible, place the patient in an ice-water bath. Massage her extremities, raise her legs, place her in the shade, and begin volume replacement with 1 to 2 liters of half-normal saline, although more may be required. Transport immediately to a medical facility. Hypothermia, Exposure Rare and most likely to occur in underdressed runners during cold-weather runs who either don't run fast enough to generate adequate heat or exhaust themselves early. Treatment Runners with a rectal temperature of 96.8°F or lower should be stripped of wet clothing, given warm clothing, and wrapped in blankets. If the runner is not shivering, she may be hypoglycemic.Give slightly sweet drinks. Monitor rectal temperature in those whose temperature is 91.2°F or lower. Hypoglycemia May present as sweating, tremor, mental confusion, and combativeness. Treatment Rest and sugar or electrolyte glucose drinks. Hypovolemic Collapse Seen most often in hot-weather races at the finish line, especially in runners who drink little or no liquid during the race. Hypotension, caused by diminishedvasoconstriction, can lead to syncope. Runner's pulse will be weak and runner may be faint, cyanosed, or vomiting. It can occur as late as half an hour after the runner finishes the race if fluid intake is insufficient and will be worse if she's vomitingor has diarrhea. Treatment Take rectal temperature; have patient rest with legs raised; hydrate intravenously initially, then orally. Hypovolemia is usually self-limiting. Source: Modified from Editorial Staff: Marathon medicine. Emerg Med 17(16):82, 1985, with permission. daily for at least a year. Patients should be serve further clinical investigation for rechecked after that time to establish the re- sources of iron loss (menses, renal losses, turn of serum iron stores to the normal gastrointestinal losses) if compliance with range. Persistent abnormalities may de- the treatment has been established.

Medical Conditions Arising during Sports 269 Table 15-3. LABORATORY \"Runner's Diarrhea\" DIFFERENTIATION OF TRUE ANEMIA More common than gastrointestinal VERSUS PSEUDOANEMIA bleeding is the rather frequent occurrence True of runner's diarrhea, which is an expression Pseudoanemia Anemia of increased bowel motility akin to the irri- table bowel syndrome seen with emotional Hemoglobin/ Decreased Decreased stress in a large number of individuals. Man- hematocrit Normal Decreased ifestations range from minor abdominal Increased Normal cramping to severe, watery diarrhea during Red cell mass Increased Normal prolonged strenuous exercise, which can in- Plasma volume Normal Decreased terfere with performance and is intensified Total blood volume Normal Decreased by the stress of competition. This condition, Iron/iron-binding sometimes termed \"runner's trots,\" is often successfully treated with precompetition capacity (IBC) doses of antispasmodic agents.38 Ferritin Effects on the Urinary Tract Source: From Siegel AJ,5 with permission. As discussed in the subsequent section on It is reasonable to suggest routine iron \"athletic pseudonephritis,\" many apparent supplementation for female athletes under- urinary abnormalities in athletes are tran- going intense training, just as is recom- sient, benign conditions, although more se- mended for pregnant women, because both rious complications can sometimes arise. A conditions increase iron requirements. Rou- positive Hemastix reaction without detect- tine iron supplementation, however, does able blood on microscopic analysis of urine not yield demonstrable benefits for the ath- is suggestive of myoglobinuria. This reac- lete with adequate iron stores. tion may be quite common, if not universal, in marathon runners after peak efforts, re- Even in the absence of anemia, a decrease sulting from transient rhabdomyolysis dur- in body iron stores may cause a diminished ing extended physical exertion.39 Elevations exercise performance or capacity, related to of serum creatine kinase up to 30 times nor- the role of iron in the tissue cytochrome and mal have been noted in marathon runners myoglobin systems. Recent reports have without perceived urinary symptoms or ev- highlighted the importance of identifying idence of injury. Other studies have shown borderline iron-deficiency states in athletes, transitory decrements in creatinine clear- even in the absence of anemia, through mea- ance following marathon competition, surement of serum ferritin levels. Low which may be prerenal or related to volume serum ferritin levels indicate a need for depletion rather than due to tubular injury.40 treatment, even in the presence of normal serum iron levels. However, normal ferritin Whereas exertional rhabdomyolysis is levels may not always exclude iron defi- common, acute renal failure is extremely ciency. Acute inflammation, such as can be rare.33 It has been reported in patients with caused by infection or injury from heavy sickle cell trait, who are at increased riskof training, can transiently raise serum ferritin renal tubular necrosis following rhabdomy- levels to normal range. Therefore,when iron olysis, which may then proceed to other deficiency is strongly suspected, ferritin lev- complications such as disseminated intra- els should be assessed after the athlete has vascular clotting. recovered from any febrile illness or stopped training for 2 or 3 days. Symptoms Heat stress, prolonged strenuous exer- of fatigue and decliningperformance may be cise, muscle injury, and urinary abnormali- identical in \"overtraining\" and in marginal ties are interrelated. It is crucial for physi- iron-deficiency states. Clinical observations suggest that repletion of diminished iron stores may reverse these symptoms and im- prove exercise performance.37

270 Special Issues and Concerns Table 15-4. DIFFERENTIAL DIAGNOSIS FOR ABNORMAL TEST RESULTS Laboratory Findings Clinical Condition Exercise-Induced Findings Low hemoglobin, low hematocrit Anemia (true iron deficiency) Pseudoanemia (see Table 15-3) Abnormal urinalysis (hematuria, Renal disease Transient changes Intrinsic gastrointestinal Transient finding due to maximal proteinuria) Positive test for GI bleeding pathology exercise Abnormal liver enzymes: lactic Hepatic inflammation (true Transient muscle injury accompanied acid dehydrogenase (LDH), hepatitis) by release of enzymes from serum glutamic oxaloacetic skeletal muscle that are also transaminase (SGOT) Myocardial disease present in liver tissue Elevation of total creatine kinase (pseudohepatitis) and the MBisoenzyme Chronic skeletal muscle injury or exercise-induced rhabdomyolysis Note: The pseudosyndromes listed above (last column) are more common in rigorously trainingendurance athletes than in beginners. Source: From Siegel AJ,5with permission. cians to identify runners with acute dividuals with an allergic or asthmatic back- hypovolemia occurring in heat-stress injury ground, in whom exercise provokes or so that they can institute the rapid rehydra- increases symptoms. Bronchospasm also tion that will prevent attendant renal injury. occurs in subjects who do not have aclinical Cases of acute renal failure following severe history of overt asthma, in whom symptoms dehydration in marathon runners have been may be unappreciated or subclinical until reported, although such injury is clinically the additional work of breathing during ex- preventable.33 There is no evidence that per- ercise is imposed. The frequency with which manent or progressive renal injury results such reactions are detected depends upon from prolonged strenuous training,as done the sensitivity of measurements used, as by long-distance runners. Reported acute well as on the type of exercise. increases in serum creatinine levels are readily reversible with rest and rehydration. The typical course of symptoms is a slow Progressive renal damage from recurrent onset of bronchospasm as one starts exer- low-grade rhabdomyolysis and myoglobin- cising, reaching a peak in 6 to 8 minutes. uria is a theoretical possibility but has not Symptoms often stabilize or subside if exer- been demonstrated to date. Again, preven- cise is continued,and some of these individ- tion is the best treatment, and runners uals can exercise through their attacks after should be encouraged to take fluids liberally some initial difficulty. The postexercise re- during and immediately after strenuous bound is well described, as difficulty may re- physical effort. The differential diagnostic turn or intensify after cessation of activity. features of urinary sediment changes and Figure 15-1 shows the typical pattern of ob- other diagnostic tests are shown in Table served pulmonaryfunction parameters with 15-4. Prevention and treatment are summa- the relationship to time in healthy subjects rized in Tables 15-1 and 15-2. and in those with EIA. The four parameters of lung function shown reflect the impair- Exercise-Induced Asthma ment during and after exertion. Simple spi- rometry with a measure of the timed or 1- Exercise-induced asthma (EIA) is a rela- second vital capacity is adequate to confirm tively common, readily diagnosable and suspected clinical cases in most instances. treatable form of reversible broncho- spasm.41 It occurs with high frequency in in- Exercise-induced asthma causes the same bronchial smooth-muscle contraction that results from allergen-triggered asthmatic

Medical Conditions Arising during Sports 271 Figure 15-1. Comparison of spirometric measurements following exercise in healthy subjects and in patients with exercise-induced asthma. (Adapted from Gerhard H, and Schachter FN: Exercise-in- duced asthma. Postgrad Med 67(3):93, 1980, with permission.) response. Recent investigations, however, fully saturated with water at body tempera- reveal that EIAis not triggered by an allergic ture. Airway cooling from heat loss during response, but rather by reactions of large high ventilatory work is the specific precip- and small airways to changes in humidity itant. These findings explain why corticoste- during cold-air breathing. McFadden and roids are ineffective in treating exercise-in- Ingram41 have shown that the magnitude of duced asthma, whereas warmingof inspired the bronchoconstrictive response to a fixed air through a face mask can be effective. exercise task or to a fixed level ofventilation depends on the temperature and/or water A wide range of treatments is available for content of the inspired air. Lower air tem- patients with EIA,including warming of in- peratures and lower humidity favor the ob- spired air in cold weather as a preventive structive response, which does not occur in measure, and use of specific pharmacologic susceptible subjects when inspired air is agents employed in the treatment of tradi- tional asthma. Those treatments approved

272 Special Issues and Concerns Table 15-5. ANTIASTHMATIC eralized hives or urticaria. Such symptoms MEDICATIONS APPROVED BY THE may occur after years or decades of beingal- INTERNATIONAL OLYMPICCOMMITTEE lergy-free and may be limited to minor dis- FOR THE OLYMPICGAMES* comfort. The reaction can, however, pro- gress to generalized angioedema, including Medication Aerosol Oral facial swelling and laryngeal spasm, with compromise of the upper airways. This re- Theophylline NA Yes action was reported in a group of youngath- Cromolyn sodium Yes NA letes after a variety of sports and may be un- Albuterol Yes Yes predictable in occurrence and severity for Terbutaline sulfate Yes Yes any individual.42 Some authors have sug- Corticosteroid Yes Yes gested that exposure to a specific allergen such as shellfish, to which the individualis *Drug Commission of IOC requires name of athlete, subclinically sensitized, may then combine country, drug, and dosage. with exercise to trigger the allergic re- sponse. Exercise causes mast cells to re- Source: From Eisenstadt WS, Nicholas SS, Velick G, et lease vasoactive mediators similar to those al: The Physician and Sportsmedicine 12(12):100, in cold-induced urticaria, in which hista- 1984, with permission. mine is released in the skin after cold expo- sure. Susceptibility is not related totraining by the International Olympic Committee for or expertise, and exercise-induced anaphy- the OlympicGames are listed in Table 15-5. laxis has been reported in national champi- These agents can be taken as pre-exercise ons and in world record holders.43 Manage- doses to block the onset of or to minimize ment can entail preventive measures such bronchoconstriction. A warm-up period is as the administration of mildantihistamines often useful in reducing EIA, but inhalation or perhaps cromolyn sodium prior to exer- of a bronchodilator just prior to peak exer- cise. However, these treatments are only cise is highly beneficial. Sympathomimetics partially effective at best and do notcom- are disallowed in some competitive situa- pletely prevent the reaction. Such pretreat- tions, so that alternatives such as cromolyn ment may be necessary for individuals only sodium must be used. Cromolyn is not a at times of peak risk, since the urticarial re- bronchodilator and is most effective when sponse may occur only seasonally, when al- administered 30 minutes prior to peak ef- lergic predisposition is heightened. Just as a fort. Physicians must be aware of these spe- shellfish-allergic patient avoids eatingshell- cial circumstances as well as of the rangeof fish,avoiding specific foods prior to exercise treatments available to the recreationalath- may control or eliminate the allergic re- lete. sponse in theseindividuals. Persons susceptible to exercise-induced The pathogenesis of exercise-induced asthma should be encouraged to participate anaphylaxis is identicalto immunologic-me- in sports and exercise, which may have a diated anaphylaxis,even though the trigger beneficial effect on general physical condi- is physical rather than allergic.42 Effector tioning and preservation of lung function. mast cells fire to release histamine, the The adequately informed primary care phy- slow-reacting substance of anaphylaxis, bra- sician can enhance the capability of patients dykinins, and other mediators, which then to lead full and active lives despite the need cause the angioedema. Facial swelling is an for specific treatment. indication for specific emergency measures, such as the intramuscular administration Exercise-Induced Anaphylaxis of 8 mg of dexamethasone or the subcutane- Individuals with a history of allergic re- ous administration of aqueous epinephrine 1:1000, 0.1 to 0.3 mL, along with the inser- actions such as childhood eczema, seasonal tion of an IV tube for fluid administration. rhinitis, or even asthma are prone to a sec- ond exercise-related reaction that begins with diffuse itching and may result ingen-

Medical Conditions Arising during Sports 273 Hypotension may develop from generalized, stores. Systematic observations have docu- increased vascular permeability, which may mented a drop in hemoglobin, hematocrit, require stabilization with fluids and vaso- and red blood cell count at the end of a 9- pressive drugs. Dopamine (400 mg) and week trainingprogram in previously seden- D5W (500 mL), given intravenously at an ap- tary college women.37 Values may fall to low- propriate rate, may sustain blood pressure normal or within abnormal ranges during in the face of circulatory collapse. While po- progressive training, with a return to base- tentially life-threatening, exercise-induced line upon resumption of sedentary status. anaphylaxis has not yet resulted in a re- \"Pseudoanemia\" also occurs in male ath- ported fatality. Patients who have had this letes, owing to hemodilution from an in- reaction, as well as individuals with known crease in plasma volume. Studies of red cell bee-sting sensitivity (hymenoptera), should mass in athletic pseudoanemia show normal have epinephrine available for administra- or high values, with low hemoglobinparam- tion if severe allergic manifestations de- eters resulting from an expanded plasma velop. volume. The specific measurement of body iron stores, or its reflection in normal values Exercise-Induced Urticaria for serum iron and iron-binding capacity or In the spectrum of allergic reactions to ex- ferritin levels, establishes this dilutional cause of a low hemoglobin concentration. ercise, some individuals may develop blotchy red rashes, sometimes with itching, \"Athletic Pseudonephritis\" during a workout. This is called exercise-in- The occurrence of exercise-related uri- duced hives or urticaria, and it results from histamine release in the skin owing to rapid nary abnormalities has been extensively superficial temperature changes. Like exer- reviewed in the literature and in medical- cise-induced asthma, exercise-induced ur- specialty books, with the term \"athletic ticaria may occur more readily with temper- pseudonephritis\" applied to conditions as- ature provocation, either cold or warm. sociated with abnormal urinary sedi- Local symptoms of cold urticaria are red- ments.40,44 Severe volume depletion and de- ness, itching, wheals, or edema in the skin, hydration can,indeed, lead to proteinuria not the subcutaneous swelling seen in ana- and hematuria with the presence of formed phylaxis, as described previously. Systemic elements such as proteinaceous casts. A symptoms and circulatory collapse do not prospective study of 50 male physician mar- occur. athon runners showed that microscopic he- maturia occurred in 18% in initial postrace This condition is benign and can be han- urinalyses, but cleared within 24 to 48 dled with reassurance to the athlete. Low hours.45 doses of antihistamines may diminish symptoms and may be prescribed if the side Exercise-related hematuria appears to be effect of drowsiness is not more bothersome a frequent and self-limited benigncondition than the itching. that does not warrant extensive invasive work-up. Gross hematuria occurred in only PSEUDOSYNDROMES IN 1 out of 50 subjects and must be considered ATHLETES a complication of nontraumatic sports such as running. A work-up of a series of patients Pseudoanemia (\"Runner's with so-called 10,000-meter hematuriaiden- Anemia\"] tified bladder trauma as the cause of this he- maturia.46 Other studies suggest that the As previously mentioned, athletes may bleeding may come from the kidneys.Con- show a low hemoglobin concentration with- comitant bladder or renal pathology cannot out actually suffering from depleted iron be summarily excluded after gross hematu- ria related to exercise; therefore, it is rea-

274 Special Issues and Concerns sonable to suggest intravenous pyelography clude chronic hepatitis, but need not lead to and cystoscopy to exclude specific causes. invasive testing such as a liver biopsy. Many runners have been referred to specialists for Serum Enzyme Abnormalities: consideration of this procedure on the basis Muscle Injury and of the muscle injury parameters, as de- Pseudohepatltis scribed earlier. Such invasive testing is usu- ally unnecessary and should be avoided. Prolonged strenuous exercise may be as- sociated with transient elevations of skeletal With reference to the biliary tract, it muscle enzymes, which are also present in should be noted that some individuals have hepatocytes or liver cells. Serum levels of a genetic condition (Gilbert's disease) in glutamic-oxalo-acetic transaminase and lac- which bilirubin conjugation may be im- tic dehydrogenase are routinely used as paired under physiologic stress such as screening tests for hepatic dysfunction, and strenuous exercise, infections, or prolonged elevated levels of these enzymes may fre- fasting. Such individualsmay develop an in- quently be assumed to represent hepatitis in crease primarily in unconjugated serum bil- runners. Measurement of specific serum en- irubin and may appear mildly jaundiced. zymes such as creatine kinase can resolve This condition is benign and asymptomatic, this dilemma, so that elevations of creatine and can be detected by somewhat elevated kinase and these other enzymes indicate levels of unconjugated bilirubin in the face transient muscle injury rather than liver dis- of otherwise normal liver enzymes. This el- ease in the endurance-trained athlete. Sev- evation of unconjugated bilirubin is usually eral recent studies indicate that athletes transient, whereas liver disease usually may have enzyme elevations two to three leads to persistent elevations of unconju- times the upper limits of normal compared gated bilirubin in the face of elevated liver with age-matched and sex-matched seden- enzymes. These findings are in contrast to tary individuals (seeTable 15-4). These val- those in patients with chronic hemolytic ues may increase tenfold after racing, anemias, in whom pigment gallstones may because of transient exertional rhabdomy- be formed because of an increased biliary olysis.39 These findings are often accompa- excretion of breakdown products of hemol- nied by muscle soreness in the athlete and ysis, leading to significant elevations of di- indicate the need for rest and maintenance rect bilirubin. Pigmentgallstones have been of hydration. Specific clinical symptoms reported in long-distance runners and at- such as persistent headache, nausea, vom- tributed to runner's hemolysis, although iting, or flank pain should lead to the inves- this must be a very rare and unusual occur- tigation of impaired renal function or other rence.48 complications, as noted in the prior sec- tions. Pseudomyocarditis In addition to the abnormalities in total One avenue for excluding liver disease in a runnerwith abnormal enzyme profiles is to creatine kinase that indicate transient mus- measure liver-specific \"enzymes\" such as cle injury, as noted earlier, chronic endur- alanine aminotransferase and y-glutamyl ance sports participation may lead to tran- transpeptidase. Some transient increases in sient elevations of the MB isoenzyme or these liver-specific proteins have beendoc- heart-specific fraction of creatine kinase in umented in marathon runners after racing, serum.49 Such elevations may at times be indicating possible release from hepato- quantitatively similar to findings in patients cytes due to indirect trauma or decreased with a variety of heart diseases such as car- hepatic blood flow.47 Persistence of abnor- diomyopathy, myocarditis, or injury sec- mal liver function tests might warrant mea- ondary to ischemic heart disease. surement of serum hepatitis markers to ex- Large increases in the serum total cre-

Medical Conditions Arising during Sports 275 atine kinase and CK-MB activities may be Appendix 15-3. This focuses on acute con- found in both men and women after compe- ditions that should be evaluated prior to tition. Cardiac isoenzymes are present in competitive sports participation. These trained skeletal muscle, perhaps on the sample materials are useful for identifying basis of chronic muscle fiber injury and re- pre-existing medical conditions that may in- pair.50 Studies using heart scan techniques fluence or affect sports participation, and fail to reveal any underlying heart injury in they help prepare the athlete for safer train- these individuals. Abnormal elevations of ing and participation. serum CK-MB in an otherwise asymptomatic female athlete without cardiorespiratory CAUTION: WHEN NOT TO symptoms can be reasonably attributed to EXERCISE an exercise-induced injury to skeletal mus- cle and not to a myocardial source (see While the preceding sections emphasize Table 15-4). the health benefits of exercise, the question remains of how much and how soon. Chest SCREENING THE ATHLETE FOR pain, dyspnea, or syncopal episodes should MEDICAL CLEARANCE be contraindications to exercise until the causes are established and relieved, and se- With an estimated 25 to 50 million young rious medical conditions are excluded. Ill- women engaging in sports activity, some nesses such as diabetes, ischemic heart dis- basic concepts of medical clearance prior to ease, and arthritis may in fact be sports participation justifiably arise. A ameliorated by appropriate low levels of ex- sports-related questionnaire for athletes ercise. Safe limits can be established provides an opportunity for health screen- through cardiovascular assessment, includ- ing with the purpose of identifying predis- ing exercise testing in such cases. Cardiac, posing medical conditions that might lead to pulmonary, and musculoskeletal diseases complications duringsports participation. A may make exercise difficult, but patients re- sample questionnaire is included in Appen- spond positively to exercise training, with dix 15-1, which addresses the major factors improved levels of function. Old age itself is of sports injury as complications for young not a contraindication to regular exercise, athletes and also screens for pre-existing which in fact facilitates balanced nutrition medical conditions, medication allergies, and cardiovascular health.51 In addition, and other possible complications. Such a physical activity correlates with a reduced medical checklist is useful in preventing risk of depression in healthy adults of all problems during training and competition, ages.52 such as exercise-induced asthma, anaphy- laxis, and other conditions discussed in this After musculoskeletal injury, orthopedic chapter. This gives the physician an oppor- surgery, and even general surgery, a gradu- tunity to screen for areas of major concern ated return to exercise and training is nec- such as possible familial heart disease, and essary. The intensity and duration of work- also to practice prevention with regard to outs should be decreased to start, with conditions such as sports-related anemia training progressively increased at incre- and oligomenorrhea, which commonly ments of no more than 10% per week. A grad- arise. A sample physical examination form ual return to exercise intensity promotes for recording findings is given in Appendix smooth recovery and reduces risk of rein- 15-2, and a list of medical conditionsdis- jury or clinical setback. qualifying an individual for sports partici- pation as provided through guidelinesof the Similarly, athletes must adjust to the re- American Medical Association is found in alities of medical illness, including the im- pact on exercise capacity of minor illnesses such as viral syndromes, flulike illnesses,

276 Special Issues and Concerns and especially respiratory infections. Ath- coach, who must counsel sound principles letes must take time off from training during of moderation and consistency over time. In febrile illness, as acute illness places stress this fashion, the physician can promote on all organ system reserves and exercise health-enhancing levels of exercise for in- would pose the danger of prolonging the ill- active patients, and facilitate long-range ness and incurring additional injury. Many planning for athletes who are likely to ex- viral illnesses are systemic; that is, all organ perience overuse injury through an imbal- systems are subject to transient viral expo- ance of stress over rest and recovery. sure. Exercise at such times can be hazard- Whether the goal is an improvement in car- ous and even lead to arrhythmias and col- diorespiratory fitness from recreational ex- lapse during workouts or competition. As a ercise or competition from structured working guideline, 1 emphasize to athletes sports participation, moderation remains an the importance of rest as well as stress in important preventive and rehabilitative pre- training, and point out the necessity of al- scription. lowing the body to recover from intercur- rent illness in order to make future training REFERENCES safe and productive. 1. Councilon Ethical and JudicialAffairs, Amer- Appendix A gives greater detail on exer- ican Medical Association: Gender disparities cise following an infection. in clinical decision making. JAMA 226:559, 1991. SUMMARY 2. Healy B: Women's health, public welfare. JAMA 226:566,1991. This chapter has addressed various med- 3. Harris SS, Caspersen CJ, DeFriese GH, et al: ical conditions that may arise in sports-ac- Physical activity counseling for healthy tive women and that present clinical dilem- adults as a primary preventive intervention mas to the office practitioner. On the one in the clinical setting: Report for the US Pre- hand, athletes may develop abnormal clini- ventive Services Task Force. JAMA 261:3588, cal or laboratory findings that represent 1989. physiologic adjustments to training and are 4. Bunch TW: Blood test abnormalities in run- not indications of underlying illness. On the ners. Mayo Clin Proc 55:113,1980. other hand, athletes do place themselves at 5. Siegel AJ: Understanding abnormal lab val- risk for developing problems such as tran- ues in the female athlete. Contemp Obstet Gy- sient hematuria, gastrointestinal bleeding, necol 25:73, 1985. anemia, and heat injury, which require spe- 6. Huston TP, Puffer JC, and Rodney WM: The cific monitoringto rule out non-exercise-re- athletic heart syndrome. N Engl J Med lated conditions. 313:24, 1985. 7. Dollar AL, Kragel AH, Fernicola DJ, et al: Careful assessment of the individual ath- Composition of atherosclerotic plaques in lete, together with a background fund of coronary arteries in women <40 years of age information, will enable the practicing phy- with fatal coronary artery disease and impli- sician to provide reassurance when appro- cations for plaque reversibility. Am J Cardiol priate and to respond to underlying clinical 67:1223, 1991. problems as they may arise. 8. Manson JE, Stampfer MJ, Colditz GA, et al: A prospective study of aspirin use and primary The knowledgeable physician can assist prevention of cardiovascular disease in the sports-active patient in enhancing her women. JAMA 266:521, 1991. athletic goals while reducing concern over 9. Appel LJ, and Bush T: Preventing heart dis- sports-related symptoms or conditions. ease in women: Another role for aspirin? (Ed- When dealing with athletes, the physician itorial). JAMA 266:565, 1991. should monitor and prescribe exercise as a 10. Steingart RM, Packer M, Hamm P, et al: Sex differences in the management of coronary artery disease. N Engl J Med 325:226, 1991. 11. Ayanian JZ, and Epstein AM: Differences in