Need to know - sports medicine

16 Oct 07

1. Performance-enhancing dietary supplements and drugs are now widely used in many types of sport. What are the common side-effects that we should be aware of when treating a sportsman? Are there any prescribed drugs that might also cause issues we might not be aware of?

I would dispute the contention that performance-enhancing drugs are widely used in UK sport. Many serious athletes – both professional and recreational – use dietary supplements ranging from multivitamins to carbohydrate drinks during and after exercise. Although there is good evidence the latter works, there is very little evidence that vitamin and mineral supplements give added benefit for someone with a well balanced diet.

Anabolic steroids are probably the best--known drugs misused in sport. Side-effects include tendon rupture, male pattern baldness or hirsutism, testicular atrophy and gynaecomastia.

In athletes subject to UK Sport doping regulations, glucocorticosteroids, ß2-agonists and ß-blockers are probably the most common drugs a GP might prescribe requiring pre-authorisation. See the UK Sport website for guidance www.uksport.gov.uk or contact your local sports physician at the English Institute of Sport www.eis2win.co.uk.

2. What is meant by the term active rest?

Rehabilitation can almost always begin immediately after injury. Limbs and trunk soft tissue structures not affected by the initial injury can be prescribed physical therapies by a sports physiotherapist or conditioning coach which allow for maintenance of proprioception, muscle and tendon function and athlete wellbeing.

There is good evidence to suggest that even exercising the opposite leg to the injured one maintains muscle bulk better in the injured leg than not exercising at all. In this sense, the initial phase of rest after injury is often termed active. Maximising the speed of return to sport is the key preoccupation of most injured sportsmen and active rest seeks to maintain conditioning in non-injured parts while rehabilitation of the injury is undertaken.

3. What is the latest advice around warming–up and stretching, and is there any relation to injury prevention?

Warm-up often implies controlled movements of body parts as a rehearsal to the same or similar movements in sport. There is good evidence to suggest that warming up reduces the incidence of injury to muscle and tendon structures in the first phase of sporting participation.

Stretching is the voluntary elongation of muscle and tendon groups prior to exercise. Interestingly, data would suggest that those sportspeople that stretch regularly have the same injury profiles as those who don’t stretch at all. The cohort with the highest incidence of injury appears to be those who stretch infrequently. There are numerous stretching techniques, all with their advocates, but generally a good warm-up appears to be more effective at reducing the early incidence of injury in sport than stretching alone .

4. What does the term ‘shin splints‘ really mean and what is the best management?

Shin splints is a lay term for any running-related anterior shin pain. The most common two causes, which are usually bilateral, are medial tibial stress syndrome (MTSS) and an exercise induced compartment syndrome (EICS). There is some overlap between these two conditions.

MTSS is categorised by medial periosteal tibial pain and tenderness, often at the junction between the middle and lower third of the tibia, which persist after exercise. EICS usually presents with tense tender muscles, which settle, in the early phases, immediately after exercise. MTSS responds well to physio and podiatric input – the physio will often look to improving the core conditioning of the athlete and strength of the tibialis posterior muscles.

EICS is difficult to treat successfully without resorting to elective decompression surgery. Active rest and a very gradual incremental increase in running speed, assisted by treadmill prescription may be effective in sparing the surgeon’s knife.

Two other differential diagnoses should be considered in shin splints , both of which are often unilateral. A stress reaction or fracture of the tibia. X-rays may not be positive for six weeks after onset of symptoms; a bone isotope scan or MRI will make the diagnosis earlier.

Lastly, a muscle hernia – often of tibialis anterior – is a rare cause, the athlete giving a clear history of transient reproducible tender swelling on exercise. A stress fracture of the lower third of the tibia will often settle after six weeks’ rest from running, whereas proximal-third stress fractures are often complicated by delayed union and require referral.

5. We often see acute knee injuries and yet there is no where to refer acutely for assessment. What advice would you give for a typical football knee injury ? Who must be seen immediately?

Unfortunately there is no such thing as a ‘typical’ footballer’s knee injury. In my experience, the knee injury that should be seen as a priority is one that either:

• swells within one hour of injury or

• renders the player unable to bear weight the day after the injury or

• results in a locked knee.

In the first two scenarios, bone injury needs to be excluded and weight-bearing rehabilitation may need to be deferred if bone bruising or fracture is significant. A locked knee is at risk of further meniscal injury .

6. If individuals in our practice are skilled should they be giving LA/Kenalog injections? What caveats and indications would you advise – and how many times a year can a sportsperson have injected steroids?

If a practitioner has the appropriate skills and training, local anaesthetic and steroid injections can certainly be done in an appropriate primary care setting.

Probably the most important questions to ask yourself before giving a cortisone injection are:

• Why you are giving it?

• Is local inflammation impeding rehabilitation?

• Do you know the anatomy of the area into which you are placing the needle?

If the answer to any of these questions is ‘no’, then don’t give the injection. Signs of local superficial or subcutaneous infection or tendon rupture are usually contraindications to injection with cortisone.

It is difficult to be definitive about frequency of injection. Obviously, cumulative dosage increases side-effects, particularly subcutaneous fat atrophy and possibly tendon thinning. As a rule I have never injected more than three times into one area in a year. To do further injections would imply I had not excluded all causative variables – such as correct rehabilitation, athlete compliance with advice – and that cortisone is the correct treatment for this pathology.

7. How can performance artists on low incomes, such as circus workers and dancers, get access to good sports medicine care?

Difficult. At the time of writing there are a few PCTs who employ sports and exercise medicine (SEM) doctors in outpatients. There is good evidence that they reduce waiting lists for orthopaedic outpatients and offer a more appropriate setting for soft tissue injury assessment. Petitioning your PCT for more musculoskeletal clinics would help, but the reality for the majority is that they pay for care in the private sector.

8. Which injuries, that a less experienced clinician might think non-urgent, need to be fast-tracked or red-flagged?

This is a question that’s impossible to answer adequately.

As a general rule, the clinician should have a high index of suspicion on all bone pain particularly night pain. Systemic symptoms of weight loss, pyrexias or fatigue in the presence of a swollen joint(s) could indicate joint infection or an inflammatory arthritis.

Groin pain, although non-urgent, can be very difficult to assess and manage successfully. Adolescent metaphyseal injuries need orthopaedic specialist management.

A history of injury following an episode of non-traumatic loss of consciousness usually needs a cardiological opinion in the first instance.

Pre-existing conditions such as diabetes and epilepsy make sportspeople more vulnerable under stressful environmental conditions, such as open water swimming. Counselling about exercise and specialist input is clearly important.

Finally, injury associated with the suspicion of abuse, which may be physical, sexual or abuse of neglect, needs a careful approach but almost always referral to social services or the police. In sport, unfortunately, there are plenty of opportunities for the abuse of trust between adults and children.

9. What is your approach to the anorexic – probably amenorrhoeic – female distance runner?

This consultation needs to be handled very delicately. I take the approach that I would like to work with her to maintain her career in running but that she is exposing herself to significant risks with anorexia and amenorrhoea. These risks include stress fractures, calorific depletion and underperformance.

I am always quick to include a sports dietician and psychologist and work with the coach and family, with the athlete’s consent.

Initially I will take a full sports and menstrual history including phases of time on the oral contraceptive pill – as this appears to be protective for bone mineral loss – and significant stressors in life. In anorexia athletica, often the reason for presentation is underperformance either through injury or psychological stress, rather than the symptom of amenorrhoea itself.

An FBC, iron studies, TFTs, prolactin and gynaecological serology are important as well as a bone mineral density assessment. Often the runner is not prepared to change behaviour and a slow increase in calorific intake negotiated between the dietician, psychologist and myself with the co-operation of the coach is the key to a degree of success.

Reversal of the whole eating disorder and menstrual disturbance is rare and success is usually measured by a resumption of intermittent periods, failure of progression of bone mineral loss and return to form. Sadly, such athletes, in the harsh world of performance-related funding, often drop out and remain medically problematic.

10. ONLINE ONLY What are the particular risks for young people taking up serious strenuous training before skeletal development has finished?

There are some significant differences in the structure of young growing bones compared with adults. Strenuous training usually implies either weight (resistance) training or endurance exercise.

The International Federation of Sports Medicine published a position statement on resistance training in young adults in 1998. Essentially this recommended all resistance training in children under 16 being supervised by a qualified strength and conditioning expert.

The potential risks include Scheuermann’s disease, spondylosis and other osteochondrosis like Perthes’ disease. Often the risks of resistance training are over-emphasised and are most likely in unsupervised weightlifting environments .

Overuse injuries are numerically more significant in young people. Many of the traction apophysitis cases like Sever’s and Osgood-Schlatter will settle with time and supervised titrated training. More serious problems occur in the wrist and feet with osteonecrosis of the lunate, navicular and metatarsal heads – clinicians need to have a high degree of suspicion in these areas.

Dr Rod Jaques is director of medical services at the English Institute of Sport at the University of Bath

Competing interests None declared