WOMEN IN SPORT

VOLUME VIII OF THE ENCYCLOPAEDIA OF SPORTS MEDICINE

AN IOC MEDICAL COMMITTEE PUBLICATION

IN COLLABORATION WITH THE

INTERNATIONAL FEDERATION OF SPORTS MEDICINE

EDITED BY BARBARA L. DRINKWATER

WOMEN IN SPORT IOC MEDICAL COMMISSION

SUB-COMMISSION ON PUBLICATIONS

IN THE SPORT SCIENCES

Howard G. Knuttgen PhD (Co-ordinator) Boston, Massachusetts, USA Francesco Conconi MD Ferrara, Italy Harm Kuipers MD, PhD Maastricht, The Netherlands Per A.F.H. Renström MD, PhD Stockholm, Sweden Richard H. Strauss MD Los Angeles, California, USA WOMEN IN SPORT

VOLUME VIII OF THE ENCYCLOPAEDIA OF SPORTS MEDICINE

AN IOC MEDICAL COMMITTEE PUBLICATION

IN COLLABORATION WITH THE

INTERNATIONAL FEDERATION OF SPORTS MEDICINE

EDITED BY BARBARA L. DRINKWATER ©2000 by distributors Blackwell Science Ltd Marston Book Services Ltd Editorial Offices: PO Box 269 Osney Mead, Oxford OX2 0EL Abingdon, Oxon OX14 4YN 25 John Street, London WC1N 2BL (Orders: Tel: 01235 465500 23 Ainslie Place, Edinburgh EH3 6AJ Fax: 01235 465555) 350 Main Street, Malden MA 02148 5018, USA USA 54 University Street, Carlton Blackwell Science, Inc. Victoria 3053, Australia Commerce Place 10, rue Casimir Delavigne 350 Main Street 75006 Paris, France Malden, MA 02148 5018 (Orders: Tel: 800 759 6102 Other Editorial Offices: 781 388 8250 Blackwell Wissenschafts-Verlag GmbH Fax: 781 388 8255) Kurfürstendamm 57 Canada 10707 Berlin, Germany Login Brothers Book Company 324 Saulteaux Crescent Blackwell Science KK Winnipeg, Manitoba R3J 3T2 MG Kodenmacho Building (Orders: Tel: 204 837-2987) 7–10 Kodenmacho Nihombashi Chuo-ku, Tokyo 104, Japan Australia Blackwell Science Pty Ltd The right of the Authors to be 54 University Street identified as the Authors of this Work Carlton, Victoria 3053 has been asserted in accordance (Orders: Tel: 3 9347 0300 with the Copyright, Designs and Fax: 3 9347 5001) Patents Act 1988. A catalogue record for this title All rights reserved. No part of is available from the British Library this publication may be reproduced, stored in a retrieval system, or ISBN 0-632-05084-5 transmitted, in any form or by any means, electronic, mechanical, Library of Congress photocopying, recording or otherwise, Cataloging-in-publication Data except as permitted by the UK Copyright, Designs and Patents Act Women in sport / edited by Barbara L. Drinkwater; in collabo- 1988, without the prior permission ration with the International Federation of Sports Medicine. of the copyright owner. p. cm. — (The encyclopaedia of sports medicine; v. 8) Includes index. First published 2000 ISBN 0-632-05084-5 1. Woman athletes — Health and hygiene. I. Drink- Set by Excel Typesetters Co., Hong Kong water, Barbara L., 1926– II. International Federation of Printed and bound in Great Britain Sports Medicine. III. Series. by MPG Books Ltd, Bodmin, Cornwall RC1218. W65 W664 2000 617.1¢027¢082 — dc21 The Blackwell Science logo is a 99-057719 trade mark of Blackwell Science Ltd, registered at the United Kingdom For further information on Trade Marks Registry Blackwell Science, visit our website: www.blackwell-science.com Contents

List of Contributors, vii 7 Psychological Aspects of Training, 108 j.l. duda Forewords, x 8 Nutrition, 120 a.c. grandjean, j.s. ruud and Preface, xi k.j. reimers

Part 1: History Part 4: The Masters Athlete 1 Women and the Olympic Games, 3 g. pfister 9 Cardiorespiratory Function in Masters Athletes, 135 c.l. wells Part 2: Physiology of the Female Athlete 10 Muscle Function in Masters Athletes, 144 m.e. cress 2 Factors Influencing Endurance Performance, Strength, Flexibility and 11 Hormone Replacement Therapy, 158 Coordination, 23 w.m. e y k.d. mittleman and c.m. zacher

3 Effects of the Menstrual Cycle and Part 5: Medical Issues Oral Contraceptives on Sports 12 Preparticipation Examination, 169 Performance, 37 m.d. johnson c.m. lebrun

13 Gender Verification, 183 4 Environmental Challenges, 62 a. ljungqvist e.m. haymes 14 The Pregnant Athlete, 194 Part 3: Training the Female Athlete m.f. mottola and l.a. wolfe

5 Physiological Aspects of Training, 77 15 Musculoskeletal Injuries, 208 m.l. o’toole e. arendt and l. griffin

6 Biomechanics, 93 16 Cardiovascular Issues, 241 j.a. crussemeyer and j.s. dufek p. sangenis v vi contents

17 Physical Activity and Risk for Breast 30 Women’s Role in National and International Cancer, 250 Sports Governing Bodies, 441 p.s. freedson, c.e. matthews and k. fasting p.c. nasca Part 8: Sport-specific Injuries: 18 Diabetes and Sport, 265 b.n. campaigne Prevention and Treatment 31 Swimming, 453 19 Sport and Bone, 280 n. constantini and i. vuori and a. heinonen m. cale¢-benzoor

20 Women with Disabilities, 301 32 Track and Field, 470 k.p. depauw a. nattiv

21 Exercise-related Anaemia, 311 33 Rowing, 486 s.s. harris j.a. hannafin

22 Nutritional and Pharmacological 34 Gymnastics, 494 Ergogenic Aids, 321 a.d. smith p.m. clarkson and m.m. manore 35 Figure Skating, 510 23 Sexual Harassment and Abuse, 342 j.m. moran c. brackenridge 36 Cycling, 535 l. lamoreaux Part 6: The Female Athlete Triad 24 Body Composition, 353 37 Tennis, 550 w.m. kohrt c.l. otis

25 Eating Disorders, 364 38 Basketball, 564 j. sundgot-borgen s.w. ryan

26 Amenorrhoea, 377 39 Soccer, 575 l.a. marshall m. putukian

27 Osteoporosis, 391 40 Canoeing and Kayaking, 600 j. gibson k. kenal and p. trela

41 Alpine Skiing, 613 Part 7: Psychosocial Issues r. agostini 28 The Young Élite Athlete: the Good, the Bad and the Ugly, 409 42 Softball, 626 m.r. weiss, a.j. amorose and m.m. baker j.b. allen

Index, 647 29 Ethical Issues, 430 a. schneider List of Contributors

R. AGOSTINI MD, Virginia Mason Medical N. CONSTANTINIMD, Ribstein Center for Center, 904 7th Avenue, Seattle, Washington 98104, Sport Medicine Sciences and Research, Wingate USA Institute, Netanya 42902, Israel

J.B. ALLENMS, School of Physical Education, Sport M.E. CRESSPhD, Gerontology Center and and Leisure, De Montefort University, Bedford MK40 Department of Exercise Science, University of Georgia, 2BZ, UK Athens, Georgia 30602-6554, USA

A.J. AMOROSEPhD, Memorial Gym, Curry School J.A. CRUSSEMEYERPhD, Department of of Education, University of Virginia, Charlottesville, Kinesiology and Physical Education, California State Virginia 22903, USA University, 1250 Bellflower Boulevard, Long Beach, California 90840-4901, USA E. ARENDTMD, Department of Orthopaedic Surgery, 350 Variety Club Research Center, 401 East K.P. DePAUW PhD, Graduate School, Washington River Road, Minneapolis, Minnesota 55455, USA State University, Pullman, Washington 99164-1030, USA M.M. BAKERMD, Center for Bone and Joint Surgery, 832 Georgiana Street, Port Angeles, B.L. DRINKWATERPhD, Pacific Medical Center, Washington 98362, USA 1200 12th Avenue South, Seattle, Washington 98144, USA C. BRACKENRIDGEMA, Leisure and Sport Research Unit, Cheltenham and Gloucester College of J.L. DUDAPhD, School of Sport and Exercise Sciences, Higher Education, Swindon Road, Cheltenhan GL50 University of Birmingham, Edgbaston, Birmingham B15 4AZ, UK 2TT, UK

M. CALE¢-BENZOORPT MSc, Ribstein Center J.S. DUFEKPhD, Human Performance and Wellness for Sport Medicine Sciences and Research, Wingate Inc., 3265 Chambers Street, Eugene, Oregon 97405, USA Institute, Netanya 42902, Israel W.M. EY Med, Executive Director, Womensport West, B.N. CAMPAIGNEPhD, Eli Lilly and Co., Lilly Perth, Western Australia, Australia (Dr W.M. Ey Corporate Center, Drop Code 2044, Indianapolis, Indiana unfortunately passed away during publication of this 46285, USA volume)

P.M. CLARKSONPhD, Department of Exercise K. FASTINGPhD, Norwegian University of Sport Science, Totman Building, University of Massachusetts, and Physical Education, Sognsveien 220, PO Box 4014, Amherst, Massachusetts 01003, USA Kringsja N-0806, Oslo, Norway

vii viii list of contributors

P.S. FREEDSONPhD, Department of Exercise A. LJUNGQVISTMD, PhD, Swedish Sports Science, University of Massachusetts, 110 Totman Confederation RF, Idrottens Hus, S-12387 Farsta, Gymnasium, Box 37805, Amherst, Massachusetts Sweden 01003-7805, USA M.M. MANOREPhD, Department of Family J. GIBSONMD, Rheumatic Diseases Unit, Cameron Research and Human Development, Arizona State Hospital, Windygates, Fife KY8 5RR, UK University, Tempe, Arizona 85287, USA

A.C. GRANDJEANEdD, International Center for L.A. MARSHALLMD, Virginia Mason Clinic, Sports Nutrition, 502 South 44th Street, Room 3007, 1100 9th Avenue, Seattle, Washington 98111, USA Omaha, Nebraska 68105-1065, USA C.E. MATTHEWS PhD, Division of Preventive and L. GRIFFINMD, Suite 705, 2001 Peachtree Road NE, Behavioral Medicine, University of Massachusetts Atlanta, Georgia 30309, USA Medical Center, Worcester, Massachusetts 01655, USA

J.A. HANNAFINMD, PhD, Sports Medicine and K.D. MITTLEMANPhD, DesignWrite Inc., 189 Shoulder Service, Hospital for Special Surgery, 535 East Wall Street, Princeton, New Jersey 08540, USA 70th Street, New York, New York 10021, USA J.M. MORAN MD, Summit Injury Management S.S. HARRIS MD, MPH, Palo Alto Medical Clinic, Inc., 605 Discovery Street, Victoria, British Columbia Department of Sports Medicine, El Camino Real, Palo V8T 5G4, Canada Alto, California 94301, USA M.F. MOTTOLAPhD, Department of Anatomy and E.M. HAYMESPhD, Department of Nutrition, Food Cell Biology, School of Kinesiology, University of and Exercise Sciences, Florida State University, Western Ontario, Thames Hall, London, Ontario N6A Tallahassee, Florida 32306-1493, USA 3K7, Canada

A. HEINONENPhD, President Urho Kaleva P.C. NASCAPhD, Department of Biostatistics and Kekkonen, Institute for Health Promotion Research, PO Epidemiology, University of Massachusetts, 110 Totman Box 30, Fin-335000 Tampere, Finland Gymnasium, Box 37805, Amherst, Massachusetts 01003-7805, USA M.D. JOHNSONMD, Department of Pediatrics, University of Washington, Seattle, Washington 98195, A. NATTIV MD, UCLA Department of Family USA Medicine, Room 50-071, Center for the Health Sciences, 10833 Le Conte Avenue, Los Angeles, California 90095- K. KENALMD, University of Utah Health Network, 1683, USA Greenwood Medical Center, 7495 South State Street, Midvale, Utah 84047, USA C.L. OTIS MD, WTA Tour, 1247 Devon Avenue, Los Angeles, California 90024, USA W.M. KOHRTPhD, Department of Medicine, Division of Geriatrics, University of Colorado Health M.L. O’TOOLEPhD, Department of Obstetrics and Sciences Campus, 4200 East Ninth Avenue, Box B179, Gynecology, St Louis University, 1031 Bellevue Avenue, Denver, Colorado 80262, USA St Louis, Missouri 63117, USA

L. LAMOREAUXMD, 1990 Cook Road, Centralia, G. PFISTERPhD, Institut für Sportwissenschaft, Washington 98531, USA Freie Universität Berlin, Schwendener Strasse 8, D- 14195 Berlin, Germany C.M. LEBRUNMD, Fowler–Kennedy Sport Medicine Clinic, 3M Center, University of Western M. PUTUKIANMD, Center for Sports Medicine, Ontario, London, Ontario N6A 3K7, Canada Penn State University, 1850 East Park Avenue, Suite 112, University Park, Pennsylvania 16803, USA list of contributors ix

K.J. REIMERSMS RD, International Center for Physical Education, PO Box 40, Kringsja N-0807, Oslo, Sports Nutrition, 502 South 44th Street, Room 3007, Norway Omaha, Nebraska 68105-1065, USA P. TRELAPT, University of Utah Sports Medicine J.S. RUUDMS RD, International Center for Sports Center, Physical Therapy Clinic, 546 Chipeta, Suite Nutrition, 502 South 44th Street, Room 3007, Omaha, G-300, Salt Lake City, Utah 84108, USA Nebraska 68105-1065, USA I. VUORIMD, President Urho Kaleva Kekkonen S.W. RYAN MD, Denver Center for Sports and Family Institute for Health Promotion Research, PO Box 30, Fin- Medicine, Suite 210, 210 University Boulevard, Denver, 335000 Tampere, Finland Colorado 80206, USA M.R. WEISSPhD, Memorial Gym, Curry School of P. SANGENISMD, Institute for Sportsmedicine, Education, University of Virginia, Charlottesville, ‘Deporte y Salud’ Buenos Aires, Santa Fe 782, Acassuso Virginia 22903, USA 1640, Buenos Aires, Argentina C.L. WELLSPhD, President Emeritus of Exercise A. SCHNEIDERPhD, International Centre Science and Physical Education, Arizona State for Olympic Studies, Faculty of Health Sciences, University, Tempe, Arizona 85287-0404, USA(current University of Western Ontario, London, Ontario N6A address: PO Box 730, Arroyo Seco, New Mexico 87514, 5C1, Canada USA)

A.D. SMITHMD, Department of Orthopedics and L.A. WOLFEPhD, School of Physical Education and Pediatrics, Case Western Reserve University School of Health, Queen’s University, Kingston, Ontario K7L 3N6, Medicine, 11100 Euclid Avenue, Cleveland, Ohio 44106, Canada USA C.M. ZACHERBSc, Department of Exercise Science J. SUNDGOT-BORGENPhD, Department of and Sport Studies, Rutgers University, PO Box 270, New Sports Medicine, Norwegian University of Sport and Brunswick, New Jersey 08903, USA Forewords

On behalf of the International Olympic As opportunities for competitive participation Committee, I should like to welcome Volume and access to skilled coaching were presented, VIII of the Encyclopaedia of Sports Medicine girls and women came in increasing numbers to series. This new volume is devoted to women in experience sport competitions. Women clinicians sport. The advancements made in women’s and scientists identified special issues and needs sports during the last quarter century have been for these athletes and diligent researchers have astounding. The end result has been a consistent provided a strong foundation of science as increase in the quality of performance at all ages related to conditioning, nutrition, competitive and levels of competition and an improvement performance, injury prevention and treatment, in national, regional and Olympic records. This and general health issues. volume addresses both the basic science under- On behalf of the International Olympic lying the performance of the woman athlete and Committee and its Medical Commission I should the special issues involved in sports training and like to thank Professor Barbara Drinkwater and sports participation. over 50 internationally recognized sports medi- I should like to thank all those involved in the cine clinicians and sports science researchers preparation of this volume whose work is highly who cooperated to produce this important respected and appreciated by the whole Olympic volume. Women in Sport will stand as the single Family. best source of information on the topic for many Juan Antonio Samaranch years to come. Marqués de Samaranch Prince Alexandre de Merode Chairman, IOC Medical Commission

x Preface

The Sydney Olympics in the year 2000 will mark Now it will be up to each of these groups to the 100th anniversary of women’s participation implement these initial steps toward gender in the Olympic Games. Although the modern equity. Olympic Games actually began in 1896, women Along with the increase in the number of were not permitted to participate. If the father women athletes has come a parallel increase in of the modern Olympics, Baron Pierre de the number of women sports medicine physi- Coubertin, had prevailed the Olympics would cians and exercise physiologists. Many of these have remained the ‘. . . solemn and periodic women had their initial experience with sport as exaltation of male athleticism, with internation- athletes and later chose a career that combined a alism as a base, loyalty as a means, art for commitment to sport with their professional its setting and female applause as reward’. path. Twenty years ago it would have been diffi- Women’s lack of enthusiasm for their assigned cult to find women scientists and physicians to role led them to challenge the status quo and write chapters for this volume, Women in Sport. undertake the long and arduous task of achiev- For this publication it was a matter of selec- ing acceptance as athletes and equal participants ting a few women from among many equally in the Games. Year by year the number of events qualified to write about medical issues specific open to women and the number of female to women. athletes has increased. In the Atlanta Games, The volume is divided into eight sections. Part two-thirds of the competitors were women 1 surveys the history of women’s participation in competing in 58% of the events. Even better the Olympic Games. Today’s young athletes representation is expected in the Sydney 2000 would do well to read about how their opportu- Games. nities today came about through the efforts of Support for increasing women’s representa- strong and determined women long before they tion on IOC committees and other decision- were born. Part 2 examines the physiology of making positions has come from an unexpected female athletes. Are there gender differences in source. IOC President Samaranch initiated the qualities that mark the skilled athlete? How and led an effort to achieve gender equality in does she respond to environmental challenges these positions by establishing the goal of and how does the menstrual cycle affect her per- increasing women’s representation in leadership formance? In Part 3 the authors look at the basic roles within the IOC, National Olympic factors involved in training an athlete, whether Committees and International Federations to they differ between women and men, and if so 10% by the end of the year 2000 and to 20% by the how this affects training regimens. The growth of end of 2005. The recommendation was approved masters’ competition has extended the competi- by the General Session of the IOC in Atlanta. tive career of many women. Part 4 discusses how xi xii preface the physiological changes that occur with ageing women on sports governing bodies. Finally, in may affect a woman’s performance and how the Part 8, physicians apply their experience treating hormonal changes following menopause may women athletes in discussing injuries that are affect her success. There are a number of medical specific to or more common to women in 12 dif- issues that are specific to the female athlete as ferent sports. Although space limited the number well as areas of general concern which have of sports that could be included, an effort was unique factors relating to gender. These are made to select events from both team and indi- covered in Part 5. The potentially serious conse- vidual events representing the Summer and quences of a preventable problem, the female Winter Games. athlete triad, are covered in Part 6. In Part 7, three It has been a pleasure to work with so psychosocial areas are explored: the psychologi- many outstanding authors from around the cal effect of intense competition and parental world to add this volume, Women in Sport, to involvement on the child athlete; ethical issues the IOC series, The Encyclopaedia of Sports affecting women in sport and sports medicine; Medicine. and the increasing presence and influence of

Dedication Finally, I would like to dedicate this volume to very ill, Wendy travelled from Australia to the Wendy Ey (1938–1997), who exemplified the United States to speak at the 1996 Pre-Olympic passion and dedication of all the women who Congress in Dallas to dispute what she consid- have furthered the cause of women’s sport. ered an unfair application of the doping regula- Wendy was a Commonwealth Games silver tions to postmenopausal women on hormone medallist in 1958, a state sprint and hurdles therapy. Chapter 11, addressing that topic, was champion in Australia from 1954 to 1960, and a written during her final illness. Wendy was masters world champion. An author, administra- an outstanding athlete and an extraordinary tor and untiring advocate for women athletes of woman. In his eulogy to Wendy, Dr John Daly all ages, she was the first woman to manage included this appropriate quotation, ‘. . . don’t an Australian track and field team at the grieve at the loss of a friend, rejoice at having Commonwealth and Olympic Games. For her been privileged to have know them . . . learn services to sport, Wendy received an Award of something from their courage, their commit- Merit from the Confederation of Australian Sport ment, their life...’ . and the British Empire Medal in 1977. Although PART 1

HISTORY

Chapter 1

Women and the Olympic Games

GERTRUD PFISTER

Introduction Onlookers at the Olympic Games: 1900–12 For a long time women played no more than a marginal role in the Olympic movement. Even in In the 19th century, women, like the ovens they 1992 women represented less than 30% of the cooked on, belonged in the home and not on the competitors at the Summer Olympic Games. On sportsground. This was true of both Europe and their way to Olympia women were faced with a the USA. It lay ‘in the nature of things’ that girls great number of obstacles. The opposition which should be excluded from the first initiatives they met was directed at not only women’s par- and concepts of physical education which, like ticipation in sport but also the masculinization German Turnen or Swedish gymnastics, began that this was alleged to produce as well as the to appear in the early 19th century. Girls and ‘emancipation’ of women and the perceived women, for example, were not allowed on the threat of change in the gender order itself. In an first German Turnen grounds opened in 1811 in a age when the ideals, duties and roles of the two Berlin park known as Hasenheide; they could sexes in everyday life were being radically trans- only admire the feats of the Turner from the formed by processes of modernization, it was perimeter (Pfister, 1996a). Modern sport of hoped that sport and the Olympic Games might English origin was, in its early phase, also an contribute towards upholding the myth of the exclusively male domain. Although physical male as the ‘stronger sex’. exertion and competition were held to be con- The main parties in the controversy over the trary to a woman’s nature, by the end of the 19th participation of women in the Olympic Games century a few women did take part in bicycle were groups with divergent interests, such as the racing, swimming contests and even in parachut- International Olympic Committee (IOC), the ing or ski jumping, much to the horror of the international sports federations and the interna- public (Hargreaves, 1994; Hult, 1996; Pfister, tional women’s sport federation. The demands, 1996b). strategies and ideologies of these various groups It was no wonder then that the Olympic are examined in this chapter. In the reconstruc- Games were considered to be a male preserve as tion of the controversy it becomes apparent that, they had been in ancient Greece. Throughout his even among the women who took part in the life, de Coubertin, a typical man of his times, debate, the integration of women into the male- thought that women should not sully the Games dominated world of the Olympic Games did not with their sweat but should merely crown the go unquestioned. victors (Leigh, 1974; Simri, 1977; Boutilier & San Giovanni, 1991; Welch & Costa, 1994; Wilson, 1996). However, he only succeeded in excluding 3 4 history

women once, in 1896. The bold intention of a Greek woman to compete in the first Olympic marathon was firmly rejected. However, she was not to be deterred from carrying out her plan and ran the full distance of 42km 194m alone some days before the Games began. She completed the course in 4.5 hours. Another woman, a 35-year- old mother of seven children, was so excited about the victory of Spyros Louis that after the games she tried to emulate him. She, too, was able to run the full distance without any diffi- culty in 5.5 hours (Odenkirchen, 1996). Since the following Games in 1900 and 1904 were connected with World Fairs, the selection of events to be included in the Olympic programme was mainly in the hands of the Fairs’ organizing committees and thus to a large extent beyond the control of the IOC. Therefore, in many respects, a move was made away from the ‘Olympic spirit’. One of the developments that de Coubertin criti- cized as ‘incompatible with the Olympic idea’ was the participation of women in a festival Fig. 1.1 Charlotte Cooper (1870–1966), Great Britain, which he described as ‘l’exaltation solennelle et won a gold in tennis singles and a gold in tennis mixed périodique de l’athlétisme mâle’ (de Coubertin, doubles outdoors at the 1900 Olympic Games in Paris. 1912). As early as 1900, at the second Olympic Games in Paris, 12 women took part in the tennis and golf competitions, typical upper-class sports sport, that women’s sports achieved a modest (Fig. 1.1). Seven of them were Americans and all upswing, with women competing in four disci- seven came from rich families. They had all come plines – tennis, sailing, ice-skating and archery – to Europe more or less by chance and regarded all of them sports with high social prestige. The golf and tennis mainly as social events (Welch & battle for metres and seconds was first opened to Costa, 1994). In 1900 women were also allowed to women in 1912 when, according to the minutes take part in sailing, a so-called ‘mixed’ event, and of the IOC assembly in 1911, the ‘feminist’ it was here that a woman first won a gold medal Swedes allowed women to compete in swim- as a crew member of one of the winning yachts ming events (Mitchell, 1977). The inclusion of (Wilson, 1996). such a popular sport as swimming in the However, women participated in the Games women’s programme contributed considerably ‘without the official consent of or comment from to the participation of women athletes from the IOC’ (Mitchell, 1977; Simri, 1977). At the St many other countries, and 11 nations sent Louis Games in 1904 only eight American women athletes to Stockholm. As many as 55 women represented their country, this time in women, representing 2.2% of all competitors, archery, although IOC members, who were took part in these Olympic Games. Nevertheless, strong opponents of competitive sport for women’s sports remained a marginal phenome- women, declared the archery competition to be non and were still not officially recognized by the an exhibition only (Welch & Costa, 1994). It was IOC. Furthermore, women were not allowed to not until 1908, when the Olympic Games were compete in those sports that involved visible held in England, the birthplace of modern exertion, physical strength or bodily contact. The women and the olympic games 5

femininity of female athletes was to be safe- to compete; competition is alien to a woman’s guarded as far as possible (Spears, 1976; Pfister, nature. So let us do away with women’s athletics 1981; Simri, 1984). championships’ (Kühn, 1926). In spite of the The first women Olympic competitors came stereotypes of women taking part in track and predominantly from the countries hosting the field events, women started to enter sports sta- Games, but the only women athletes who took diums in a number of countries. In Germany, for part in the Olympic Games with any regularity instance, the Athletics Association, which had before the First World War were those from Great experienced a heavy loss of members during the Britain, the country with the longest sporting tra- First World War, encouraged sports clubs in 1920 dition. British women were absent only at the to create womens’ sections. In the same year 1904 Games in St Louis. the first women’s athletics championships were organized. Women’s Olympiads: the interwar years The International Women’s Sport Federation and the Women’s Olympic Games In the 1920s, women who had learned to take over men’s roles during the First World War There were two possibilities open to women who fought increasingly for their rights. In many wished to practise sport in general and competi- countries women acquired the right to vote in the tive sports in particular: they could either try to 1920s and were also given access to university integrate and become part of ‘men’s sports’ or study and the academic professions. The fashion they could establish their own associations and of short skirts and short hair freed women organize their own competition. Among the first from many restrictions and granted them new opportunities women had to take part in inter- freedom of movement. The fashionable ideal was national athletics contests, and especially in now the ‘new woman’ with a slim body, no hips ‘unfeminine’ track and field events, were the and long legs, gainfully employed and successful Women’s Olympiads that took place in 1921, in love as well as in sport. But this ideal, which 1922 and 1923 in Monte Carlo (Bernett, 1988; was transported via the mass media, especially Meyer, 1988). These first ‘Olympic Games for popular movies, did not influence the lives of the Women’ were organized by the International great majority of women, who had no money for Sporting Club of Monaco in Monte Carlo in order silk stockings or tennis club fees and had to work to attract and entertain wealthy sports enthusi- hard in order to maintain their families. Women asts on their visits to the Principality of Monaco remained disadvantaged in many areas of the (Meyer, 1988). labour market, discriminated against not only by Grounds below the casino normally used for law but also by social norms and values. Sport, clay-pigeon shooting served as a stadium. The especially competitive sport, was also a domain first Women’s Olympiad in 1921 lasted 5 days, in which women had to fight for their rights. with 300 sportswomen from France, England, The opposition towards the participation of the Switzerland and Italy competing against each ‘weaker sex’ in sporting competitions and in the other in track and field events (including those Olympic Games had not yet been overcome held to be male domains like shot-putting and (Hargreaves, 1994; Vertinski, 1994a,b). the 800m) as well as in basketball and pushball. Track and field events were particularly con- In addition, there were presentations of dancing troversial since they had been the classic domain that combined strong elements of gymnastics. It of male athletes from the very beginning. was this mixture of a sporting contest and artistic Karl Ritter von Halt, for example, a renowned performance that made this sports festival so German athlete and IOC member from 1929 to distinctive and contributed to the enthusiastic 1964, claimed in the 1920s that ‘Men were born reception it had among the public and press 6 history

alike. In 1922 the number of women who tra- 1992). In women’s sports clubs like Femina Sport velled to Monte Carlo to take part in either the or in the FSFSF it was usual for women to play sports contests or the gymnastic dance perfor- both ‘male’ and ‘female’ sports. At the ‘Fête du mances rose to as many as 700 from nine different Printemps’, for example, organized by the FSFSF countries. The third and last Women’s Olympiad and held in the Pershing Stadium in Paris, there in Monte Carlo, which took place the following were performances of formation gymnastics and year and opened with a 3-day gymnastics festi- ballet in addition to athletic contests and basket- val, ‘La fête fédérale de gymnastique’, was also ball matches. This combination of events as well an outstanding success. as the moderate objectives of the FSFI helped to The success of the first Women’s Olympiad take the wind out of the sails of all those opposed made it much easier to organize further to women’s sports. The aim of sport, Milliat international sports meetings for athletic events stressed, was to improve health and strength, and even for such ‘unfeminine’ competitions and to foster the ‘proper balance between the as soccer matches (Fischer, 1983; Pfister, 1999a). body and spirit’ in order for women to be able to These included, on 30 October 1921, a two-nation ‘found a healthy and robust family, help the championship contest between England and country in the fight against all social disease and France in athletics and soccer, initiated by the contribute to the preservation of world peace’ French Women’s Sport Federation (FSFSF). (Milliat, 1928). It can also be assumed that the The federation’s president, Alice Milliat, took rivalry between the various organizations advantage of this international event to invite involved in women’s sports, and thus also representatives of women’s sports from various between different definitions of femininity and countries, including England and the USA, to a different physical cultures in France, encouraged conference. The 12 delegates attending, among the striving for distinction and the international them two women, founded the Fédération commitment of the FSFSF and its president. Sportive Féminine Internationale and appointed The most important activities of the FSFI were Alice Milliat as its president (FSFI, 1928; Webster, the organization of the Olympic Women’s 1930; Pallett, 1955; Durry, 1992). The official Games, which took place in 1922 (Paris), in 1926 reason for founding FSFI was the refusal of (Gothenburg), in 1930 (Prague) and in 1934 the International Amateur Athletic Federation (London). Not only the name, which had later to (IAAF) to support and represent women’s athlet- be given up, but also the overall planning of the ics (FSFI, 1936). The main tasks of the new inter- women’s games, including individual elements national body were the drawing up of rules, the of staging like the entrance of the athletes with acknowledgement and supervision of records their national flags, were borrowed from the and, above all, the promotion of women’s sports men’s Olympic Games (Bergmann, 1925). The in general (FSFI, 1928). first Games were opened by Alice Milliat with This initiative to further women’s sports at an the words: ‘I declare the world’s first Olympic international level was helped by a favourable Games for Women open’ (Eyquem, 1944). constellation of circumstances then prevailing in As a whole, the Olympic Women’s Games French sports politics. For one thing, women’s documented the capacity for high performance sports organizations, several of which had been by female athletes and found a positive echo founded and sponsored by influential figures among the general public (Pfister, 1996b). They (including men), thrived at club and association also proved to be a trump card in the struggle for level. For another, a female sports culture had women’s Olympic sport. Not only did they developed in France that had no inhibitions provide women athletes with the chance of over- about practising types of sport which were con- coming the marginalization of women’s sports sidered to be ‘male’ sports like soccer or barette (a by competing in international contests, but they game similar to rugby) (Laget et al., 1982; Durry, also served the FSFI as a way of exerting pressure women and the olympic games 7

on the IOC as well as influencing the develop- ment of resistance had developed in the 1920s ment of women’s sports as a whole (Leigh & that rejected competitive sports for women Bonin, 1977). (Hult, 1989) and which was strongly supported by physical training teachers at colleges and uni- versities. Their goal was the spread of sports for Struggles and conflicts all, their motto being: ‘A sport for every girl and The growing significance of women’s sports and every girl in a sport’ (Guttmann, 1991). the increasing activities of the FSFI forced the In the committees of the IOC and the IAAF IOC at regular intervals to turn its attention to various strategies were developed. At first there the role of women in the ‘Olympic family’. At the was a general consensus that women should be IOC assembly in 1920, for example, de Coubertin prevented from competing in Olympic track and announced that women should be excluded from field disciplines, but later the men were forced to the Games. In 1923 there was renewed debate in concede a minimum degree of integration in the IOC about the ‘abus et excès’ of this new order not to lose their influence on women’s women’s sports movement and it was recom- sport completely. The main strategy used was mended that women’s sport should be placed that of limiting women’s participation to only a under the supervision of the international sports small number of disciplines. However, the federations. From then on the ‘women’s issue’ attitudes of IOC and IAAF members to the was on the agenda of almost all IOC meetings, ‘women’s issue’ varied, not least because they and the international federations started to play also followed the interests and directives of a major role in the debate on ‘Olympic Women’ national sports federations. One result of this is (Pfister, 1999a). It was above all the intrusion of to be seen in the run-up to the 1932 Olympics in women into the very heart of the Olympic Move- Los Angeles, where the American members of ment, the stadium, that gave rise to the vigorous, the IOC supported the participation of women in obstinate, but ultimately fruitless opposition of track and field events since they were aware that de Coubertin and many IOC members. The there were good chances of their female athletes dispute between the FSFI and its president, Alice winning medals in these disciplines (Müller, Milliat, on the one side and the IOC and the IAAF 1983). on the other did not end until 1936 when the FSFI gradually lost power and was more or less forced The Olympic woman: developments in the to disband (Pfister, 1999a). interwar years The 15-year history of the FSFI is marked by the shifting focus of its objectives. At first the After the First World War the women’s Olympic FSFI fought for the right of women to compete in programme was extended slightly. In 1924 track and field, then for the expansion of the ath- women were allowed to compete in foil fencing letic programme at the Olympic Games, and later and in 1928 they also took part in the team con- for the establishment of separate Olympic Games tests in gymnastics. However, the demands of for women in a wide variety of disciplines. The the FSFI that women should be provided with an separatist cause was especially taken up by the extensive track and field programme including FSFI delegates from Great Britain, who argued at least 10 disciplines at the 1928 Olympics were that the integration of women into ‘men’s sport’ only partly fulfilled, although it must be added would have to be paid for by giving up much of that for the first time women were allowed to their power and influence. Although the dele- compete in an Olympic stadium. Of the disci- gates from the USA backed Alice Milliat and her plines included in the programme (high jump, efforts to be admitted into the ‘men’s Olympic discus, 100m, 4¥100m relay and 800m) it was club’, they knew that they would meet with great the 800m that caused by far the most contro- opposition at home. In the USA a broad move- versy. That several of the women dropped to the 8 history

ground exhausted at the end of the race seemed gramme as well as the numbers of women com- to confirm the worst fears of all those opposed peting: 11.5% of the events were contested by to women’s sports. Although the athletes female athletes and 9.6% of all competitors were quickly recovered and put their exhaustion women, a ratio not attained again until 1952. down to insufficient training, their behaviour German Olympic teams included a relatively was deemed both scandalous and unaesthetic large proportion of women. A large number of and generally regarded as proof that women German women athletes were also selected for were not made for sports which required track and field events even though these were stamina. The 800m race provided the IOC with considered ‘unfeminine’ in Germany too. These an opportunity to reconsider the question of athletes were successful in both the 1928 and women’s track and field events. Although the 1936 Olympics. In 1928 Lina Radke-Batschauer resolution put forward in 1930 by IOC President won the first gold medal for Germany in a track Baillet-Latour to abolish all women’s track and and field event when she came first in the 800m field events was not carried by the majority of (Pfister & von der Lippe, 1994) (Fig. 1.2). By con- members, the 800m was excluded from the trast, some other European countries, Norway Olympic programme of the 1932 Games (Har- for example, sent only a few women to the greaves, 1994; Welch & Costa, 1994; Pfister, Olympic Games. Even in the years 1912 and 1999a). It is interesting to note that it was not only men who were against the participation of women at the Olympic Games. In the 1920s wide-ranging opposition to women’s competi- tive sports had formed, especially in the USA (Hult, 1989). A major role in this opposition was played by the Committee on Women’s Athletics of the American Physical Education Association and by the women’s division of the National Amateur Athletic Federation (NAAF) (Gerber et al., 1974; Lucas & Smith, 1982; Guttmann, 1991). These groups were of the opinion that female physical education and training had to take into account the purported natural physical and psy- chological differences between the sexes and had to prepare girls for their future roles as mothers and ‘worthy citizens’. Enjoyment of sport and team spirit were considered more important than individual performance and achievement. Com- petitions ought to be kept to a minimum, if not entirely abolished. As an alternative some col- leges began to organize ‘play days’ where fun and recreation, cooperation, and playing together were intended to take the place of con- tests and competing for first place (Guttmann, 1991). In spite of the opposition described above, women’s sport enjoyed further success at the Fig. 1.2 Karoline Radke (1903–83), Germany, won a 1928 Games in Amsterdam with regard to both gold in the 800 m in the 1928 Olympics; Kinue Hitomi the number of disciplines included in the pro- of Japan took the silver. women and the olympic games 9

1920, when the Games took place virtually was also faced with conflicting ideals of feminin- around the corner in Stockholm and Antwerp, ity (Borish, 1996). thus theoretically allowing Norway to send large teams, the percentages of Norwegian women A short interlude: the Workers’ Olympiads competitors were a mere 0.5% and 1% respec- tively. In 1928 and 1932 not a single Norwegian Besides the Women’s Olympiads and the ‘offi- woman took part in the Games. Not one of the cial’ Olympic Games there were also workers’ seven women who represented Norway at the sports Olympiads, which took place in Frankfurt Summer Games before the Second World War in 1925, Vienna in 1931 and Antwerp in 1937 took part in events held to be ‘unfeminine’, such (Krüger & Riordan, 1996). In Germany in 1893 as track and field or fencing; four competed in a national federation of gymnasts had been swimming events, one in figure skating and two founded with socialist objectives and, in the in tennis (Pfister & von der Lippe, 1994). Because period that followed, it grew into the largest and of the opposition to women’s athletics in the most influential workers’ sports organization USA, American women also only played a minor in Europe. Workers’ sports federations were role at the Olympic Games. However, at the 1932 formed in other European countries as well, and Games in Los Angeles, women’s sports in the these amalgamated into the Socialist Workers’ USA received a new and positive impetus. The Sport International and the Red Sport Interna- American athlete, Mildred ‘Babe’ Didrikson, tional, both founded in 1921. In the 1920s roughly became the first female idol of the sporting 15% of the members of the German Workers’ public (Fig. 1.3). An all-round athlete and winner Gymnastics and Sports Federation were women of three medals, she seemed to personify (Pfister, 1994). Female athletes of the workers’ America’s capabilities. However, apart from the sports movement were able to compete in track great controversy about her amateur status, she and field events as early as 1925 at the games in Frankfurt, where the German women’s team even set a world record in the 4¥100m relay. In Germany, the workers’ sports movement was abolished by the National Socialist regime in 1933. In protest against, and in opposition to, the Olympic Games to be held in National Socialist Germany, the International Socialist Workers’ Sports Movement organized alterna- tive Olympic Games in Antwerp in 1937. The poster announcing the Workers’ Olympiad in Antwerp depicted a muscular woman athlete throwing the discus, showing that women in the workers’ sports movement were faced with less opposition than their fellow athletes in bourgeois sports clubs (Guttmann, 1991).

The Olympic Games in National Socialist Germany

At the 1936 Games in Berlin, organized and Fig. 1.3 Mildred ‘Babe’ Didrikson (1911–56) won a gold in both the javelin and the 80 m hurdles and a exploited for propaganda purposes by the silver in the high jump at the 1932 Los Angeles Olympic National Socialists, Germany put together the Games. strongest women’s team, not only in track and 10 history

field but also in the overall reckoning, winning 13 of the National Socialists towards women’s of the 45 medals. Although women’s competitive bodies and women’s athletics. sports ran counter to the principles of ‘racial hygiene’ and national socialist ideals of femi- Digression: women’s sport as reflected in the ninity, top women athletes like Christl Cranz medical discourse and Gisela Mauermayer were given intensive backing since they were supposed to demon- The great controversy about allowing women to strate the superiority of the Nazi system. On compete in sports events is closely connected the other hand, there was no increase in the with the stereotype views on the nature of proportion of women competitors in 1936, women and the myth of the ‘weaker sex’. In the neither was the programme of women’s events 1920s the arguments put forward in this debate extended. were wholly supported, like all the popular theo- The female image at the 1936 Olympics was ries on the abilities and roles of the sexes both in not only shaped by female athletes. In the deco- sport and elsewhere, by mainstream medicine. rative sculptures adorning the Olympic stadium, The central issues of the medical discourse in the mass outdoor exercises of Berlin school- focused on the forms of physical activities suit- children and, particularly, in the festival per- able for women as well as the participation of formance created by Carl Diem, the prevailing female athletes in competitive sports. In the view gender hierarchy was ‘staged’ (Alkemeyer, of the medical profession, forms of women’s 1994). The huge, solid, rigidly erect male statues physical culture were determined by their obliga- in and around the stadium ‘embodied’ ideals of tion to bear children. Women seemed to be both masculinity; they signalled firmness, strength the products and the captives of the reproductive and a combative spirit. The mass performance system. For most doctors, therefore, the only ‘Olympic Youth’ glorified the ‘Combat of Youths’ question raised by women’s participation in that ended with their ‘sacred, sacrificial death’ sports was that of its possible effects on child- (Alkemeyer, 1994). The bodies of girls and birth. It was the general belief that ‘all sporting women were used as decorative ornaments and activities undertaken by adult women have to be as framework and backdrop to an event on judged from the point of view of reproduction’ which they had no influence. (Küstner, 1931). Although there was little knowl- In Leni Riefenstahl’s film of the 1936 Games, edge about the effects of physical exertion and especially in the sequence introducing the ‘festi- athletic activity on the number of children a val of nations’, nude men with oiled, muscular woman might have or on the course of childbirth, bodies and powerful movements are glorified as most doctors discouraged women from partici- ancient as well as contemporary heroes. Women, pating in competitive and strenuous sports. With on the other hand, are presented in the first the authority of medical science they constructed frames of the film as creatures of nature, their a variety of theories on the negative effects of movements representing billowing grain and sports on the female body (Pfister, 1990; Vertin- the opening of blossoms, their bodies girlish, sky, 1990; Park 1991, 1994). The ‘vitalistic’ theory, graceful and flower-like. In his analysis of popular in the 19th century, contended that the the ‘Olympic film’ Müller (1993) comments: human body contained only a limited, unrenew- ‘Mysterious familiarity seems to envelop the able amount of energy. Applied to women’s women, who do not have the straightforward sports, this meant that women had to conserve muscular character of men. Nor are muscular their energy for their essential purpose in life, i.e. women considered desirable. . . . Thus, it is not for bearing and looking after children: ‘Its prema- surprising that the athletic victories of women ture exhaustion [by sporting activities] violates are not emphasised as much as those of men’. It the nature of girls and women’ (Müller, 1927). In was a film that expressed the ambivalent attitude the 19th century it was a widespread belief that women and the olympic games 11

the uterus was the most vulnerable and fragile strength, daring and endurance, or other traits part of the female body. Even in the 1920s gynae- men considered ‘unfeminine’, were especially cologists were still of the opinion that the uterus discouraged by the medical profession and ‘pulls at its sinews with every vigorous jump a branded as potentially dangerous. woman makes, and may even tilt backwards’ Scarcely any male doctors and only a handful (Sellheim, 1931). In addition, excessive physical of female doctors were convinced that women by exercise was said to hinder the development of nature were not as weak and needful of care and the pelvis and, as a result, cause difficulty during rest as was claimed in the medical textbooks. childbirth. A further, very influential theory put Many of the first doctors (in Germany, at least) forward by a well-known gynaecologist claimed to begin systematic research into the effects of that women should have slack muscles capable of physical activities on the female body were expansion: ‘Each attempt to train the muscles of women. Female doctors, for example, inter- the female abdomen and pelvis leads to a taut- viewed and examined more than 1500 partici- ening of the muscle fibres so that childbirth pants at a sports festival in 1928. They were, like becomes much more difficult, if not impossible’ many of their colleagues, unable to discover any (Sellheim, 1931). negative effects of sporting activities on the The notion that women might lose their ability women they examined (Pfister, 1990). The results to bear children was closely linked with the fear of investigations into women’s sports were sum- that they could become physically and psychi- marized at an international congress of women cally more masculine and, as a result, turn away doctors in 1934. By that year 120 scientific publi- from heterosexuality. According to Sellheim cations on women’s sports had already appeared (1931), ‘femininity and masculine build are con- in Germany, and some 10000 girls and women tradictions...Too frequent exercise, as practised who practised sport had been examined. There by males, will lead to masculinisation. ...The were no results presented from any of the female abdominal organs wither and the artifi- studies, carried out according to scientific stan- cially created virago is complete’. Furthermore, dards, that might have justified the reservations the perceived ‘masculinization’ of women repre- about women’s competitive sports. However, it sented a threat to the division of labour between must be taken into consideration that standards men and women and hence to the structure of of performance and the corresponding training society as a whole. The polarity of the sexes, not differed fundamentally from the world records their assimilation, was believed to guarantee the and training practices of today. progress of civilization. Major importance was The findings of scientific research into the therefore attached to the physical differences effects of physical activity on the female body between the sexes. In many standard works on were scarcely acknowledged by the mainstream medicine, anatomical and physiological differ- of medicine and failed to convince the opponents ences between the sexes were generalized and of women’s sports, who continued to believe in often exaggerated. In medical literature man was the myth of the weaker sex. On the whole, the the norm; women, accordingly, were described medical discourse, with its warnings and pre- as deviant and deficient. For example, Sellheim scriptions, contributed quite considerably to the (1931) characterized the female organs as ‘incom- marginalization of women in competitive sport plete’, while Müller (1927) held women to be (Pfister, 1990). physically ‘underprivileged’. Although most doctors were against competi- Women athletes in the limelight tive sports for women, their recommendations were quite contradictory, rhythmical gymnastics The debate on the participation of women in the being the only form of physical exercise that was Olympic Games went on after the Second World universally accepted. Exercises that required War. In 1952 it was IOC President Avery 12 history

Brundage who advocated the removal of teams of sportswomen from the Soviet Union women’s contests from the Olympic programme from 1952 onwards that led to rapid integration (Mayer, 1960); as late as 1966 the IOC was still of women in the Olympic movement. And it was discussing whether or not to exclude the shot- above all the Soviet IOC members who, in order put and discus from the women’s Olympic pro- to increase their chances of winning more gramme (Hargreaves, 1994). This would further medals, demanded a wider Olympic programme the IOC’s objectives in two ways: for one thing, it for women. Even though the IOC rejected Con- was thought increasingly necessary to reduce the stantin Andrianov’s proposal, put forward in number of Olympic events; for another, IOC 1957, that all women’s events should be included members still wished to prevent women from in which officially recognized world champi- taking part in all too ‘unfeminine’ sporting onships were held, new disciplines were succes- activities. This time, the IOC’s wishes were not sively added to the women’s programme fulfilled; on the contrary, there was a continual (Wilson, 1996). increase in the number of competitions open to It must be added, however, that the medical women in the Olympic Games. reservations about women taking part in com- Important milestones in the history of petitive sports as well as in numerous other types women’s Olympic sports have been the partici- of sport had by no means been given up. Espe- pation of strong teams of female athletes from the cially difficult to shake off was the idea that pro- Soviet Union since 1952. In the wake of political longed exertion might be harmful to the health of and economic consolidation in Europe in the girls and women. Physical contests and aggres- postwar period, sport began to flourish again in sive body contact were also claimed to have the 1950s. In the following decades it became also negative effects on the female body, with doctors an increasingly important factor in the conflict continuing to provide arguments for excluding between East and West; sport became a weapon women from long-distance running and team in the cold war. The result was the same intense sports; among the latter, soccer especially was competition in the stadium as in the arms race, considered too rough for women. The first team marked by a sharp rise in the performance and sport in which women were allowed to take part achievements of athletes from the socialist in the Olympic Games was volleyball in 1964. countries especially. A great deal was invested by This was followed by basketball and handball in these countries in the success of their athletes 1976 and hockey in 1980. Soccer, long considered (partly at the expense of providing sports for all) a typical male preserve, was not open to women in order to ‘demonstrate’ the superiority of their as an Olympic discipline until 1996. political and economic system. On the Olympic How suitable endurance sports were for the stage, upon which it was possible to achieve not purportedly weaker sex was a subject which only international recognition but also political proved particularly controversial. Women, it success, the gender of medal-winners was of no was said, should be spared from strenuous great importance. Since women played only a long-distance racing, especially such inhuman minor role in sport in many western countries, tortures as the marathon (Pfister, 1999b). Fur- investing in women’s sport was especially worth thermore, the legendary Boston Marathon was while. Consequently, in the German Democratic not to be debased by the participation of the Republic (GDR) and other countries of eastern ‘weaker sex’; thus, in 1966, Roberta Gibb had to Europe competitive sports for girls and women run this traditional race without a start number. were given particularly intensive support. As a In 1967, giving her name simply as K.V. Switzer, result, women became an increasingly important Kathrine Switzer also tried to take part in the factor in sport, and the Western countries were Boston Marathon. In the very first miles she forced to make a greater effort in the field of was discovered and attacked by an official, women’s competitive sports. who attempted to pull her out of the race by It was above all the participation of strong force. However, her coach and her boy friend women and the olympic games 13

came to her aid and she was able to continue and ously male domains, such as judo (1992) and complete the marathon. It was not until 1972 that soccer (1996). In 1980 only about 25% of the women were officially allowed to take part in this events were exclusively women’s events, race without having to disguise themselves whereas in 1996 this figure increased to 36% in (Blue, 1988). Nevertheless, women marathon the Games in Atlanta. In addition to these, there runners still had to wait more than 10 years were also 11 events open to both men and before they were able to run in their event in the women, so that women were able to compete in Olympic Games. 40% of the disciplines (Théberge, 1991; Wilson, In the 1980s a break was made with persistent 1996). Women continue to be excluded from conventions and traditions when women three types of sport, boxing, wrestling and were finally allowed to take part in the Olympic weight-lifting, although the International Games in both endurance sports and team sports Weight-lifting Federation is currently trying to with body contact (Pfister, 1981; Simri, 1984). In have the latter included in the women’s Olympic 1984, not only cycling and the marathon were programme. made women’s Olympic disciplines but also As the number of women’s Olympic disci- rhythmical gymnastics and synchronized swim- plines has progressively risen, so too has the ming, events in which only women compete. It number of women competitors. In 1980, the was not until 1988, however, that women were percentage of women athletes competing in the allowed to compete in the Olympic 10000m. Games amounted to just under 22%; by 1996 this Since then the women’s programme has steadily figure had risen to 34.3% (Table 1.1). The gradual been extended to include sports that were previ- increase in the number of women competitors

Table 1.1 Women’s participation in the Olympic Games

No. of national Nations Events with Olympic with female No. of No. of female No. of Female Year committees athletes (%) sports events athletes (%) participants athletes (%)

1896 14 – 9 43 – 245 – 1900 19 26.3 17 86 3.5 1078 1.1 1904 13 7.7 14 89 2.2 687 0.9 1908 22 18.2 20 107 2.8 2035 1.8 1912 28 39.3 13 102 5.9 2437 2.3 1920 29 44.8 19 152 3.9 2607 2.5 1924 44 45.5 17 126 8.7 3072 4.3 1928 46 54.3 14 109 12.8 2884 9.5 1932 37 48.6 14 117 12.0 1333 9.3 1936 49 53.1 19 129 11.6 3936 8.4 1948 59 55.9 17 136 14.0 4092 9.5 1952 69 59.4 17 149 16.8 5429 9.3 1956 67 58.2 17 151 17.2 3337 11.2 1960 83 54.2 17 150 19.3 5313 11.2 1964 93 57.0 19 163 20.2 5133 13.3 1968 112 48.2 18 172 22.7 5498 14.1 1972 121 53.7 21 195 22.1 7121 14.9 1976 92 71.7 21 198 24.7 6043 20.8 1980 80 67.5 21 203 24.6 5283 21.5 1984 140 67.1 21 221 28.1 6802 23.1 1988 159 73.6 23 237 36.3 8473 26.1 1992 169 80.5 25 257 38.1 9368 28.9 1996 197 85.8 26 271 39.9 10744 34.3 14 history

obscures the fact that a woman’s chance of com- Although women were represented on 160 peting at the Olympic Games depends to a large teams in 1988, only 28 countries (18%) won any extent on her nationality. Even among European women’s medals (Boutilier & San Giovanni, nations there are considerable differences. At the 1991); 79% of these medals were won by seven Seoul Olympics, for example, the proportion of countries (five eastern bloc countries, the USA women in the Great Britain team was 35%, while and West Germany), 23% being won by women that of the Spanish delegation was only 18%. In of the GDR. The efficient system of selecting the 1972 Games at Munich only 12% of all talent, the excellent training conditions and the women competitors came from Africa, Latin concentration of sport sciences on high-level America and Asia; in Barcelona these women sports, in fact the whole material and human accounted for 34% of the total women athletes resources that the eastern countries and (Wilson, 1996). Since the Tokyo Olympics in 1964 especially the GDR invested in women’s sports, the number of female athletes from Asian coun- yielded an excellent return. It must be added, tries has increased especially (Welch & Costa, however, that the price for this sporting success 1994). Furthermore, in 1996, approximately 86% was high, both from a socioeconomic and from of the participating countries sent a women’s an individual point of view. The funds chanelled team to the Games. into sport were taken from areas in which they It is still generally true that the greater a were urgently needed, and the women athletes country’s economic resources, the greater the not infrequently put their health at risk for the proportion of women athletes in the country’s sake of success in sport. Olympic team. However, this rule does not hold Also conspicuous in recent decades has been true for Cuba and China. As soon as China reap- the great increase in, as well as success of, black peared on the Olympic stage in 1984, it presented women athletes at the Olympics. In 1932 and a remarkably strong women’s delegation and in 1936, on the orders of the trainers, these women 1988 the proportion of women in the Chinese were not allowed to compete even in events in team (46%) was higher than that of any other which they had qualified. It was not until 1948 country competing in the Games. In comparison, that black women, all of them students at black the proportion of women athletes in the US team colleges, took part in Olympic competitions was 37%; the overall proportion was only 26% (Welch & Costa, 1994). In 1952, Alice Coachman when all countries are taken into account. The was the first black female to win a gold medal, success of the Chinese women was not only in taking first place in the high jump. At the 1960 numbers and percentages but also in perfor- Olympics, Wilma Rudolph was made a star after mance and achievement. Within a few years they winning three gold medals and thus became the had shaken off their image as ‘nobodies’ to most successful woman athlete of the Games. In become world champions and gold-medal the 1970s and 1980s, black athletes like Valerie winners. Contributing to this success, besides the Briskoe-Hooks, Evelyn Ashford, Florence Grif- favourable conditions prevailing in China for fith-Joyner and Jackie Joyner-Kersee were out- high-level sports and the intensive support given standing Olympic champions. ‘Black women to women’s sports, was an image of sport that have led the way for America’s pursuit of was not traditionally associated with masculin- Olympic gold medals in track and field’ (Davis, ity. On the other hand, Chinese sporting success 1992). is also attributable to stringent training methods During the 1990s, women’s sport has increas- and the use of pharmaceuticals (Riordan & ingly found its way into the limelight. In the Jinxia, 1996). The example of Chinese women 1930s and 1940s, athletes like Babe Didrikson, athletes illustrates the two sides of the Olympic Sonja Henie and Fanny Blankers-Koen, ‘the medal: the opportunities sport can open up and flying Dutch housewife’ and mother of two chil- the price that must often be paid. dren who won four gold medals in 1948, became women and the olympic games 15

this process gender images and stereotypes are seized upon by the advertising industry, which exploits the athletes’ sporting achievements and successes, thus creating roots for new meanings and cultural indicators of femininity and mas- culinity in the material world.

Equal opportunities for women and then what?

The development of women’s participation at the Olympic Games reflects both the increasing integration of women in sport and the continu- ing male dominance of sport. Even today approximately 65% of all Olympic athletes are men. Of the 160 countries that took part in the Seoul Olympics, 42 (including 21 Islamic coun- tries) sent only male athletes (Hargreaves, 1994); in Barcelona 33 countries and in Atlanta 28 countries did not include women on their teams. In many developing nations, and above all in Islamic countries, women’s sport is confronted with numerous difficulties, ranging from the lack of physical education for girls at school and the limited opportunities women have of practising Fig. 1.4 Olga Korbut (born 1955), the Soviet Union, sports to the prohibition of joint training sessions won three golds in the 1972 games in Munich: the for men and women. Religious precepts in par- balance beam, floor exercises and all-round team. ticular (having to cover the body in public, not She also won a silver in the uneven parallel bars. being able to take part in sporting activities with men) are barriers that prevent or at least hinder the spread of sporting practices that are custom- celebrities. In the television age and the age of the ary in Western countries. Furthermore, in many media, Wilma Rudolph and Olga Korbut and countries, sport is incompatible with the prevail- later Nadia Comaneci and Katharina Witt have ing somatic culture of girls and women and/or been turned into idols representing contempo- cannot be integrated into the context of their lives rary ideals of the female, slim, graceful, not too (Hargreaves, 1994). Current debate on these muscular and, above all, ‘feminine’ (Fig. 1.4). The issues centres on two antithetical strategies and star of the Seoul Games, Florence Griffith-Joyner, perspectives. On one side, the initiative Atlanta+, made up for her androgynous figure by wearing founded by French women politicians and today extremely feminine clothes. Highly marketable a worldwide organization, has formulated the in recent years have been young-looking women demand that nations which do not send women (‘women in girls’ bodies’), who combine excel- to the Games should be excluded from member- lent athletic performance with the looks of a ship of the Olympic family. On the other side, model and signal female eroticism in the way Islamic Women’s World Games have taken place they move and dress. Today, representations of (Teheran in 1993) from which men are barred, female Olympic athletes play a decisive role in even as spectators. The IOC has rejected the popular culture and, with their help, fashion, demands of Atlanta+, calling them ‘anti-Islamic’ beauty and other products can be marketed. In and referring to them as interfering in the inter- 16 history

nal affairs of sovereign countries. However, this sexes. As Borish (1996) has noted: ‘In fact, gender does not solve the problems raised by Atlanta+. lines remained in force, and the status quo held As Wilson (1996) has pointed out, ‘Nevertheless, sway in the history of the modern Olympic the issue raised by Atlanta+ is a legitimate one Games, delineating the control of women’s par- that will not go away’. ticipation. The female body existed [and still According to Hargreaves, a further problem exists] as a zone of conflict in the social dis- plaguing the international sports movement is course’. It must also be pointed out that in the that of the distribution of resources. In many typically feminine disciplines like rhythmic countries poverty is linked with gender, women gymnastics and gymnastics on apparatus girls being affected by it to a much greater extent than are most successful when their bodies are not men. Moreover, the opportunities available to ‘feminine’. This means that girl gymnasts must women for taking part in any kind of sporting start training at an ever earlier age and that they activity are extremely limited. Hargreaves there- must be extremely careful to keep their weight fore asks, in view of the daily struggle for sur- low and thus expose themselves to the risk of vival of many women in the world, whether it is anorexia. The growing problems linked with right to spend resources on high-level sport, gymnastics on apparatus have prompted Blue from which men chiefly benefit. (1988) to speak of ‘killer gymnastics’. In recent years women have been admitted to a Responsibility for the Olympic programme wider range of Olympic contests, including dis- lies with international sports federations and the ciplines that require endurance and which were IOC. However, the decision-makers in the IOC, long considered harmful to women’s health. In the national Olympic committees and the inter- the 1996 Games in Atlanta, women’s teams com- national sports federations have almost always peted for medals in soccer for the first time, and been exclusively male; in 1995 only five of the 196 thus a sport that until recently was regarded as a national Olympic committees were chaired by a male preserve has now become a women’s woman. A survey carried out by the Amateur Olympic discipline. Nevertheless, women con- Athletic Foundation in Los Angeles revealed that tinue to be barred from a great number of dis- only 5% of the approximately 13000 positions in ciplines, including boxing and wrestling (i.e. executive bodies of sport around the world are especially combative sports and those involving occupied by women (DeFrantz, 1991). Today, the body contact), which are also considered to have issue of power and responsibility can no longer an adverse effect on women’s health. Hargreaves be swept aside. As noted above in the dispute disputes the reasons given for excluding these between the IOC and the FSFI, the role of women sports from the women’s Olympic programme, in the Olympic family was a result of a struggle pointing out that the medical arguments only for power and influence. It was not until 1981 serve to legitimize and preserve the differences that the first two women (Pirjo Haggmann from between the sexes: ‘The ethics of arguments to Finland and Flor Isava-Fonseca from Venezuela) ban dangerous sports such as boxing are as were appointed members of the IOC; by 1995 appropriate to men as they are to women; the only seven of the 107 members were female, reason they are applied only to women is women thus making up a tiny minority (Daven- cultural, not biological’ (Hargreaves, 1994). Not port, 1996; Wilson, 1996). Although medical only the exclusion of women from certain types questions have always played a key role in the of sport but also the inclusion of disciplines various discussions of women and sport, the open to women alone (synchronized swimming Medical Commission of the IOC includes and rhythmical gymnastics since 1984) help to not a single woman. Without any influence in strengthen the view that men and women are decision-making bodies and without any say in born with different attributes, women, for the destiny of the Olympic movement, women example, being the more graceful of the two will remain outsiders, dependent upon the atti- women and the olympic games 17

tudes and interests of male functionaries. It athletes are considerably younger than their must be recognized that in the practice of sport, male counterparts. women have different needs and pursue differ- Observable progress has been made in the ent objectives. struggle for equal opportunities among men and In recent years there has been a growing women in the Olympic movement, but is this awareness of the problems that women face in enough? When women have achieved integra- the Olympic movement. One result of this was tion and are thus potentially able to exert influ- the addition in 1991 of a clause to the Olympic ence, are they not called upon at the same time to Charter ruling out sexual discrimination. In 1995, play a more active role than they have done up to at the Centennial Olympic Congress, the small the present in seeking solutions for the problems number of women in leading positions was connected with high-level sports? Furthermore, discussed and recommendations made. In addi- in many countries women have scarcely any tion, a working group was set up ‘to advise opportunity of taking up a sport in their leisure the IOC Executive Board and its President on time. In a time of economic austerity and limited the measures which should be taken to resources, the question here is how and where enhance women’s participation in sport and priorities are to be set. Whatever conclusions are in its administrative structures’ (International reached, it must always be borne in mind that Olympic Committee, 1996). Four concrete pro- women’s Olympic successes are good publicity posals, addressed to each and every organization for women’s sport in general and that this pub- of the Olympic movement, were drafted and licity must at the same time be used to help dis- later adopted at the 105th IOC Session in Atlanta. mantle the barriers which prevent or hinder the In 1996 a World Conference on Women and Sport active participation of women in sport. was held in Lausanne, Switzerland, at which the participants could exchange views and draw up References perspectives for the future. Equality in the Olympic movement: what Alkemeyer, T. (1994) Vom Wettstreit der Nationen zum might this signify? Interpreting equal participa- Kampf der Völker. Aneignung und Umdeutung der tion with equality is problematical, not least ‘Olympischen Idee’ in deutschen Faschismus. Unpub- lished PhD thesis, Berlin. because the sporting activities, performance and Bergmann, W. (1925) Die Frau und der Sport. Stalling, achievements of men and women have different Oldenburg. meanings and can convey different messages. Bernett, H. (1988) Die ersten ‘olympischen’ Wettbe- Sport, with its seemingly impartial hierarchy of werbe im internationalen Frauensport. Sozial und achievement, contributes in no small way to the Zeitgeschichte des Sports 2, 66–87. Blue, A. (1988) Faster, Higher, Further. Women’s Triumphs construction of the gender order, and above all to and Disasters at the Olympics. Virago Press, London. the naturalization of gender and gender differ- Borish, L.J. (1996) Women at the modern Olympic ences (Théberge, 1991). Games: an interdisciplinary look at American Today, the Olympic movement, like competi- culture. Quest 48, 43–56. tive sports generally, is subject to all kinds of Boutilier, M.A. & San Giovanni, L.F. (1991) Ideology, public policy and female Olympic achievement: a influence and developments, many of which lie cross-national analysis of the Seoul Olympic Games. beyond the control of the IOC and the sports In F. Landry, M. Landry & M. Yerlès (eds) Sport: federations. These include factors such as com- The Third Millennium, pp. 397–409. Les Presses de mercialization, the drastic increase in hours and l’Université Laval, Sainte-Foy. resources spent on training, and the constant Davenport, J. (1996) Breaking into the rings: women on the IOC. Journal of Physical Education, Recreation, and raising of standards and performance. Many Dance 67, 26–30. of the problems arising from these factors Davis, M. (1992) Black American Women in Olympic affect women and men differently, if only Track and Field. McFarland & Company, Jefferson/ because in a great number of sports women London. 18 history

De Coubertin, P. (1912) Les femmes aux Jeux Meyer, H.P. (1988) Die ersten ‘Olympischen Spiele’ der Olympique. Revue Olympique July, 109–110. Frauen 1921 in Monte Carlo. Unpublished Master DeFrantz, A.L. (1991) Progress made, pitfalls and con- thesis, Köln. ditions for further advancement of women in the Milliat, A. (1928) FSFI. Der Leichtathlet 5, 19. Olympic movement. In F. Landry, M. Landry & M. Mitchell, S. (1977) Women’s participation in the Yerlès (eds) Sport: The Third Millenium, pp. 413–417. Olympic Games 1926. Journal of Sport History 4, Les Presses de l’Université Laval, Sainte-Foy. 208–228. Durry, J. (1992) Le combat des femmes et l’évolution Müller, J. (1927) Eignung der Frauen und Mädchen für des structures. In R. Hubscher (ed.) L’Histoire en Leibesübungen. Naumann, Leipzig. Mouvements, pp. 287–313. Arman Colin, Paris. Müller, N. (1983) Von Paris bis Baden-Baden. Die Olymp- Eyquem, M.-T. (1944) La Femme et le Sport. J. Susse, ischen Kongresse 1894–1981. Schors, Niedernhausen. Paris. Müller, U. (1993) Ausgrenzende Vor-Bilder. In Sport- Fédération Sportive Feminine Internationale (1928) museum Berlin (ed.) Sportstadt Berlin in Geschichte Fédération Sportive Feminine Internationale. FSFI, Paris. und Gegenwart, pp. 199–207. Sportmuseum Berlin, Fédération Sportive Feminine Internationale (1936) Berlin. Fédération Sportive Feminine Internationale. FSFI, Paris. Odenkirchen, E. (1996) Auch Frauen beteiligt. In Fischer, H. (1983) Der Weltverband für Frauensport und K. Lennartz (ed.) Die Olympischen Spiele 1896 in seine besonderen Aufgaben. Unpublished Master Athen. Erläuterungen zum Neudruck des Offiziellen thesis, Köln. Berichts, pp. 133–135. Agon, Kassel. Gerber, E.R., Felshin, J., Berlin, P. & Wyrick, W. (1974) Pallet, G. (1955) Women’s Athletics. Normal Press, The American Woman in Sport. Addison Wesley, New Dulwich. York. Park, R. (1991) Physiology and anatomy are destiny!? Guttmann, A. (1991) Women’s Sports: A History. Brains, bodies and exercise in nineteenth century Columbia University Press, New York. American thought. Journal of Sport History 18, 31–64. Hargreaves, J. (1994) Sporting Females. Routledge, Park, R. (1994) A decade of the body: researching and London. writing about health, fitness, exercise and sport, Hult, J. (1989) Women’s struggles for governance in 1983–1993. Journal of Sport History 21, 59–82. U.S. amateur athletics. International Review for the Pfister, G. (1981) Les femmes et les Jeux Olympiques. Sociology of Sport 24, 249–261. In B. Errais (ed.) La Femme d’Aujourd’hui et le Sport, Hult, J. (1996) Women’s sports, North America. In D. pp. 39–51. Amphora, Paris. Levinson & K. Christensen (eds) Encyclopedia of Pfister, G. (1990) The medical discourse on female World Sport: From Ancient Times to the Present, Vol. III, physical culture in Germany in the 19th and early pp. 1170–1182. ABC-CLIO, Santa Barbara. 20th centuries. Journal of Sport History 17, 183–199. International Olympic Committee (1996) Women in the Pfister, G. (1994) Demands, realities and ambivalences: Olympic Movement. IOC, Lausanne. women in the proletarian sports movement in Krüger, A. & Riordan, J. (eds) (1996) The Story of the Germany (1893–1933). Women in Sport and Physical Worker Sport. Human Kinetics Publishers, Cham- Activity Journal 3, 39–69. paign, Illinois. Pfister, G. (1996a) Physical activity in the name of the Kühn, W. (1926) Wohin führt der Weg? Eine kritische fatherland: Turnen and the National Movement Betrachtung zur Frauensportbewegung. Leibesübun- (1810–1820). Sporting Heritage 1, 14–36. gen 8, 193–196. Pfister, G. (1996b) Women’s Sports, Europe. In D. Küstner, H. (1931) Frau und sport. Medizinische Welt, Levinson & K. Christensen (eds) Encyclopedia of 757–758; 791–793. World Sport: From Ancient Times to the Present, Vol. III, Laget, F., Laget, S. & Mazot, J.-P. (1982) Le Grand Livre du pp. 1159–1169. ABC-CLIO, Santa Barbara. Sport Féminin. SIGEFA, Belle Ville. Pfister, G. (1999a) Die Frauenweltspiele. In Sport- Leigh, M. (1974) Pierre de Coubertin: a man of his time. museum Berlin (ed.) Jahrbuch 1999. Sportmuseum Quest 22, 19–24. Berlin, Berlin. Leigh, M. & Bonin, T. (1977) The pioneering role of Pfister, G. (1999b) Vom schwachen zum starken Madame Allice Milliat and the FSFI in establishing Geschlecht? Frauensport im medizinischen Diskurs international track and field competition for women. in denersten 30 Jahren der Bundesrepublik Deutsch- Journal of Sport History 4, 72–83. land. In T. Terret (ed.) Sport and Health in History. Lucas, J. & Smith, R. (1982) Women’s sport: a trial Proceedings of the 4th ISHPES Congress, Lyon, 1997, of equality. In R. Howell (ed.) Her Story in Sport, pp. 202–214. Academia, St Augustin. pp. 239–265. Leisure Press, Westpoint. Pfister, G. & Reese, D. (1995) Gender, body culture, and Mayer, O. (1960) A Travers les Anneaux Olympiques. body politics in National Socialism. Sport Science Cailler, Genf. Review 4, 91–122. women and the olympic games 19

Pfister, G. & von der Lippe, G. (1994) Women’s The Third Millennium, pp. 385–395. Les Presses de participation in sports and the Olympic Games in l’Université Laval, Sainte-Foy. Germany and Norway: a sociohistorical analysis. Vertinsky, P. (1990) The Eternally Wounded Woman. Journal of Comparative Physical Education and Sport 16, Woman, Exercise and Doctors in the Late Nineteenth 30–41. Century. Manchester University Press, Manchester. Riordan, J. & Jinxia, D. (1996) Chinese women and Vertinsky, P. (1994a) Gender relations, women’s history sport: success, sexuality and suspicion. China Quar- and sport history: a decade of changing enquiry, terly 145, 130–152. 1983–1993. Journal of Sport History 21, 1–24. Sellheim, H. (1931) Auswertung der Gymnastik der Vertinsky, P. (1994b) Sport history and gender relations. Frau für die ärztliche Praxis. Medizinische Klinik 27, Journal of Sport History 21, 25–58. 1439–1442. Webster, S.A.M. (1930) Athletics of To-Day for Women. Simri, U. (1977) Women at the Olympic Games. Wingate Frederick Waren, London/New York. Institute, Natanya, Israel. Welch, P. & Costa, D.M. (1994) A century of Olympic Simri, U. (1984) Frauen und Olympia: Sport und competition. In D.M. Costa & S.R. Guthrie (eds) Emanzipation. In M. Blödorn (ed.) Sport und Women and Sport: Interdisciplinary Perspectives, pp. Olympische Spiele, pp. 89–104. Rororo, Reinbek bei 123–138. Human Kinetics Publishers, Champaign, Hamburg. Illinois. Théberge, N. (1991) Women and the Olympic Games: Wilson, W. (1996) The IOC and the status of women a consideration of gender, sport and social change. in the Olympic Movement: 1972–1996. Research In F. Landry, M. Landry & M. Yerlès (eds) Sport: Quarterly for Exercise and Sport 67, 183–192.

PART 2

PHYSIOLOGY OF THE FEMALE ATHLETE

Chapter 2

Factors Influencing Endurance Performance, Strength, Flexibility and Coordination

KAREN D. MITTLEMAN AND CRISTINE M. ZACHER

Introduction had better performances at 90km (Speechly et al., 1996). However, certain biological differences When Joan Benoit Samuelson crossed the finish discussed below will probably preclude élite line of the inaugural women’s Olympic mara- women athletes from surpassing their male thon in the 1984 Los Angeles Games the long- counterparts, especially in events in which standing myth perpetuated in the 1920s that strength and power predominate. ‘women were considered to be physiologically The gains in performance that women athletes incapable of prolonged physical activity’ (Lucas have achieved over the last 20 years are not & Smith, 1982) was officially laid to rest. limited to endurance events. This chapter sum- However, for most individuals involved in marizes the research literature since 1985 and sport, the notion of the ‘weaker sex’ had previ- investigates the factors that may influence end- ously been demystified in scientific reviews urance performance, strength, flexibility and (Drinkwater, B.L., 1973; Drinkwater, B.A., 1984) coordination in women athletes. and textbooks (Wells, 1991) devoted to the physiological aspects of sport and exercise in Endurance performance women. In the years since women have competed in Endurance performance is determined by the officially sanctioned endurance events, the dra- complex integration of a number of physiologi- matic improvements in their performance times, cal indices, including maximal oxygen uptake · especially in running events, led to the specula- (VO2max), economy of movement and lactate tion that in the near future women’s and men’s threshold (see Joyner, 1993 and Coyle, 1995 for running times would coincide (Whipp & Ward, detailed discussion). These major components 1992). Although this speculation has been ques- are influenced by morphological and functional tioned (Joyner, 1993; Sparling et al., 1993), recent characteristics (e.g. stroke volume, muscle fibre studies in ultra-endurance athletes have con- type, aerobic enzyme activity, haemoglobin con- firmed this hypothesis. As shown in Fig. 2.1, Bam centration, muscle capillaries) that are, to some and colleagues (1997) studied equally trained extent, genetically determined (Bouchard et al., men and women and reported that at distances 1992). In addition, the ability to sustain relatively · greater than 42.2km sex differences in running high exercise intensities (65–75% VO2max) over speeds are negligible, with women potentially long periods is also dependent on the utilization outperforming men at distances greater than and availability of energy substrates (Gollnick, 70km. Research in male and female ultra- 1988). Although there are few investigations of endurance athletes matched for marathon (42.2 the interaction of these factors in determining km) performances has indicated that women endurance performance in women, Joyner (1993) 23 24 physiology of the female athlete

·

) Y = –0.006 (X–66) VO2max, corrected for lean body mass, does not –1 s . 0.4 r = –0.98 always negate these differences. Additional P < 0.001 factors related to oxygen delivery may also play 0.2 a role: the importance of alterations in haemoglo- bin concentration and blood volume, both of which are lower in women, in determining 0.0 · VO2max have been demonstrated (Warren & Cureton, 1989). –0.2 Telford and Cunningham (1991) investigated Male running speeds minus female running speeds (m haematological variables in nationally ranked 0 20 40 60 80 100 Race distance (km) male and female athletes from a variety of sports and reported haemogloblin values for women Fig. 2.1 Differences in running speeds of matched men (144g·l–1, average for eight sports, 190 athletes) and women racing at increasing distances. Results are that were 10% lower than men (159g·l–1, average means ± SEM. The 95% confidence intervals of the dif- for eight sports, 249 athletes) who were matched ferences between the men’s and women’s running speeds were significantly greater than zero over dis- by sport. Durstine et al. (1987) noted similar dif- tances of 5–42.2 km. (From Bam et al., 1997 with permis- ferences in haemoglobin values between male sion of Williams & Wilkins.) and female distance runners, while others have reported sex differences that range from 2.5 to 15% in runners and cross-country skiers (Berglund et al., 1988; Weight et al., 1992). suggests that they are probably similar in men Whether the linear relationship between haemo- and women. globin concentration and body size (body mass index) observed by Telford and · Cunningham (1991) may account, in part, for the Determinants of VO 2max variability in sex differences between studies is In a previous review of the literature on women not known. in sport, Drinkwater (1984) reported average However, the influence of lower haemoglobin · values for aerobic power around 55ml· values on VO2max and ultimately endurance per- kg–1·min–1 for women distance runners. Since formance in women athletes may not be as · –1 –1 that time VO2max values of 67–68ml·kg ·min important as previously proposed (Joyner, 1993). have been measured in élite women distance In a study of 34 male and 16 female distance runners (Pate et al., 1987; Daniels & Daniels, 1992; runners, Weight and colleagues (1992) found Bunc & Heller, 1993). This dramatic improve- higher concentrations of 2,3-diphosphoglycerate ment probably reflects improvements in training (a phosphate compound that enhances release of · methodology. Despite these gains, the VO2max oxygen to the tissues) in the women, which values of women athletes are typically reported the authors suggest compensates for the lower to be 10–15% lower than comparably trained haemoglobin values. Similar findings were men (Joyner, 1993). Exceptions to these gender reported by Pate et al. (1985) in their study of differences have been noted in studies with com- male and female distance runners, matched for · petitive triathletes, where running VO2max values, performance time over 24.2km. Sex differences ranging from 58 to 68ml·kg–1·min–1, were similar have not been found in serum erythropoietin, a in men and women (O’Toole et al., 1987; Kohrt et regulatory hormone for red blood cell formation al., 1989). Although a higher body fat has often (Berglund et al., 1988; Weight et al., 1992), or in been implicated in the lower aerobic power mea- the rightward shift of the oxygen dissociation sured in endurance-trained women (Drinkwater, curve following exercise (Weight et al. 1992) in 1984; Pate et al., 1987; Ogawa et al., 1992), relative endurance athletes. factors influencing performance 25

Total blood volumes are approximately 30% letes. In a study of similarly trained male and lower in women than men (see Sanborn & female endurance athletes, Hutchinson et al. Jankowski, 1994 for review). However, when (1991) determined that the reduced left ventricu- expressed relative to body weight, Weight and lar mass of the women accounted for 68% of · colleagues (1991) reported similar blood and the difference in VO2max. This effect of cardiac plasma volumes in female (blood volume 78± size, in combination with the higher fat mass in 8ml·kg–1, plasma volume 52±6ml·kg–1) and the women athletes, accounted for almost 99% of –1 · male (blood volume 86±10ml·kg , plasma the VO2max differential they observed. volume 53±8ml·kg–1) endurance-trained ath- The proposal by Dempsey (1985) that the pul- · letes. This expansion in blood volume with monary system may limit VO2max in highly endurance training, measured using radiola- trained athletes has led to the speculation that belling techniques, resulted in values that were this may influence female athletes to a greater 36% and 16% higher than those in non-exercising extent due to their smaller pulmonary capillary men and women respectively. This training- volumes (Mitchell et al., 1992). To date, this induced increase in blood volume has been hypothesis has not been addressed. linked to the lower haemoglobin values (i.e. dilu- tional effect) observed in endurance athletes of Lactate threshold both sexes (Weight et al., 1991; Eichner, 1992), · · although its role in enhancing VO2max is question- Although VO2max is an important determinant of able (Rowell, 1993). endurance performance, Coyle and colleagues As reviewed by Saltin and Strange (1992) the (1988) demonstrated, in trained male cyclists · importance of the pumping capacity of the heart with similarly high VO values, a strong rela- · 2max on VO has been studied for over 100 years. tionship between the lactate threshold (defined 2max · The smaller heart volume in women results in as the percentage VO2max corresponding to an lower maximal values for both cardiac output increase in blood lactate of 1mmol·l–1) and and stroke volume compared with men (see endurance performance. Lactate threshold Wells, 1991 for review). Meanwhile, exercise values are reported to be similar in male and training results in an increased maximal cardiac female endurance athletes (Iwaoka et al., 1988; output that can be explained to a large extent by Kohrt et al., 1989; Weyand et al., 1994). Because the increase in stroke volume (Saltin & Strange, the lactate threshold has been closely linked to 1992). Although it is generally accepted that aerobic enzyme activity (see Coyle, 1995 for dis- cardiovascular adaptations to exercise training cussion), the findings of similar enzyme adapta- (i.e. increased stroke volume) are similar in men tions in women matched to men trained for the and women (Drinkwater, 1984; Mitchell et al., same distances (Costill et al., 1987) further sup- 1992), Ogawa and colleagues (1992) noted subtle ports this concept. sex differences in the contribution of the cardio- The trainability of the lactate threshold in · vascular alterations to VO2max. These authors women athletes is evident from a unique study of reported that training had a larger effect on an élite marathon runner whose exercise train- maximal cardiac output and stroke volume but a ing was studied for 16 weeks following child- smaller effect on maximal arteriovenous oxygen birth (Potteiger et al., 1993). Although minimal · difference in men compared with women. These changes were observed in VO , her postpar- 2max · sex differences were more prevalent in older than tum lactate threshold increased from 68% VO · 2max younger individuals, leading to the speculation at 4 weeks to 82% VO2max at 8 weeks and that sex hormones may modulate the cardio- remained stable for the duration of training. vascular adaptations with exercise training. This final value is similar to that reported in However, it should be noted that the subjects female collegiate distance runners (Weyand et al., in the previous study were not competitive ath- 1994). 26 physiology of the female athlete

majority of work on cycling efficiency has been Economy/efficiency of movement performed in male cyclists, Berry et al. (1993) Economy of movement, generally defined as the reported that cycling efficiency in women was · oxygen uptake (VO ) needed to maintain a given related to body mass, work rate and pedal fre- 2 · velocity of movement, interacts with VO2max and quency, correlates previously demonstrated in lactate threshold to affect endurance perfor- men. Also, since the percentage of type I muscle mance ( Joyner, 1993; Coyle, 1995). In an earlier fibres has been linked to cycling efficiency (Coyle review, Wells (1991) reported equivocal results et al., 1992), similarities in mechanical efficiency from previous studies citing sex differences in between trained men and women are not sur- running economy, although the studies in highly prising as muscle fibre type distribution is also trained men and women indicated that running similar in sport-matched élite male and female economies were similar. Data from more recent athletes (see review by Drinkwater, 1984). studies continue to provide inconsistent results. A number of studies in equally trained men Substrate utilization and women have shown no sex differences in running economy (Pate et al., 1985, 1987; Billat The importance of the availability of muscle et al., 1996; Speechly et al., 1996), while others glycogen and blood glucose on endurance per- have reported advantages for men (Helgerud et formance is well established and has been previ- al., 1990; Daniels & Daniels, 1992) or women ously reviewed (Gollnick, 1988). Because of the (Helgerud, 1994; Weyand et al., 1994). Although potential lipolytic action of female sex hormones it has been postulated that gender effects on the (Bunt, 1990), a number of studies have focused biomechanics of running (e.g. stride length, on the effect of menstrual cycle phase on sub- vertical displacement, pelvic width) may affect strate utilization during endurance exercise; running economy (Wells, 1991), Williams and these are discussed in Chapter 3. colleagues (1987) reported minimal correlations Whether sex differences in substrate utiliza- between running economy and biomechanical tion contribute to differences in endurance per- variables in élite female distance runners. formance is also of interest. Based on the data Studies addressing the importance of the con- shown in Fig. 2.1, Bam et al. (1997) suggest that tribution of running economy to endurance their findings of better performances in women performance in women have also produced running distances greater than 42.2km may be equivocal results. Evans et al. (1995) investigated partially explained by greater glycogen sparing 10-km performance correlates in endurance- due to increased fat oxidation. Since 1985, several · trained women. Lactate threshold and VO2max, studies in comparably trained men and women but not running economy, were significantly (Tarnopolsky et al., 1990, 1995) support this related to performance. Helgerud and colleagues conclusion, although others do not (Friedmann (1990) studied sex differences in performance- & Kindermann, 1989). During prolonged (90– · · matched marathon runners. While VO2max was 100min) treadmill exercise at 65% VO2max, similar between the groups, running economy Tarnopolsky and colleagues (1990) observed was poorer in the women. In contrast, others greater lipid utilization (calculated from non- have reported a high correlation between protein respiratory exchange ratio) in the female running economy and endurance performance runners, which the authors suggest accounted in trained women (Pate et al., 1987; Daniels & for the smaller reduction in muscle glycogen Daniels, 1992). compared with the male runners. In a follow-up Coyle (1995) has suggested that during study, Tarnopolsky et al. (1995) confirmed their endurance cycling mechanical efficiency, defined previous findings of greater lipid utilization in as the ratio of work performed to energy women compared with men during prolonged · expended, may influence economy. Although the exercise at 75% VO2max. In contrast, Friedmann factors influencing performance 27

and Kindermann (1989) found no gender differ- CHO diet. Of interest is that performance times ences in lipid metabolism or in the regulatory were similar between men and women when hormones (e.g. growth hormone, insulin, adren- 55–60% CHO was consumed. Since the rela- aline, noradrenaline, cortisol) in endurance- tive intensities sustained by endurance-trained · trained women and men who ran at 80% VO women during long-term exercise (i.e. distances 2max · for 14 and 17km respectively. Although >21km) are reported to be below 80% VO2max Tarnopolsky et al. (1990) observed sex differences (Speechly et al., 1996), the relevance of these find- in growth hormone, insulin and adrenaline ings to endurance performance is questionable. responses during prolonged exercise, these alter- In a study recently completed in our laboratory ations could not account for the observed differ- (Fig. 2.2; S.P. Bailey et al., unpublished data), sup- ences in substrate metabolism. These equivocal plementation with a 6% CHO drink every 30 min findings for the influence of gender on lipid prolonged exercise time to fatigue by 14% in · metabolism during endurance exercise may be trained women (VO ~50ml·kg–1·min–1) who · 2max related to the different exercise intensities and cycled at 70% VO2max (Fig. 2.3). durations among the protocols. In addition to the potential gender effects on The potential impact of gender differences lipid and carbohydrate utilization during pro- in glycogen sparing on substrate metabolism longed exercise, data from Tarnopolsky et al. during endurance exercise, with and without (1990, 1995) and Phillips et al. (1993) indicate that carbohydrate (CHO) loading, was investi- endurance-trained women oxidize less protein gated by Tarnopolsky and colleagues (1995). than similarly trained men. Although the contri- Somewhat surprisingly, the women athletes bution of protein to energy metabolism during failed to respond to a 75% CHO diet with prolonged exercise is relatively small (Gollnick, increased muscle glycogen, although muscle 1988), the relationship between protein, fat and glycogen increased by 41% in similarly trained carbohydrate availability has been proposed men. The authors speculated that potential dif- to influence fatigue during prolonged exercise ferences in glucose transporters may be re- via the central nervous system (see Davis & sponsible for the gender differences; however, this hypothesis has not been investigated in endurance-trained men and women. Gulve and 200 Spira (1995) reported that short-term endurance training (7–10 days) increased the glucose trans- port protein, GLUT-4, in muscle of previously 175 untrained men and women; no sex differences were reported by these authors. In contrast to their previous study 150 (Tarnopolsky et al., 1990) demonstrating glycogen sparing in endurance-trained women · Exercise time (min) 125 following 1.5hours of exercise at 65% VO2max, Tarnopolsky et al. (1995) failed to find gender dif- ferences in muscle glycogen use during exercise · 100 at 75% VO2max for 1hour on a 55–60% CHO diet. Placebo CHO When a high CHO diet (75% over 4 days) was consumed, glycogen use was greater in the men. Fig. 2.2 Exercise time to exhaustion (mean· ± SEM) for In terms of performance, the women’s time to nine subjects who cycled at 70% VO2max. Subjects · ingested a drink containing flavoured water (placebo) fatigue at 85% VO2max was similar for both or a 6% carbohydrate solution (CHO) every 30 min. dietary regimens, while the men improved their Exercise time was significantly greater (P < 0.05) during performance by approximately 6% on the 75% the CHO trial. 28 physiology of the female athlete

Fig. 2.3 Subject and researcher during blood sampling.

1.75

1.50 ) 1

– Fig. 2.4 Relationship between l

. 1.25 plasma free tryptophan (f-TRP) and plasma free fatty acids (FFA) 1.00 · during cycling at 70% VO2max to exhaustion. Subjects either FFA (mmol 0.75 ingested a placebo drink () or a 6% carbohydrate drink () every 0.50 30 min. Blood samples were taken at the end of each hour and at 0.25 fatigue. Each symbol represents 468 10 12 the means ± SEM for eight . –1 f-TRP (µmol l ) subjects.

Bailey, 1997 for review). These authors discuss CHO supplementation in trained women, the mechanisms by which the ratio of free- f-TRP:BCAA was not reduced during the CHO tryptophan (f-TRP) to branched chain amino acid trial even with a greater exercise time to fatigue. (BCAA) concentrations may influence central Whether these disparate results are due to nervous system fatigue by modulating the gender differences in protein catabolism during production of serotonin. In trained male cyclists, exercise requires further study. dietary supplementation with a CHO drink (6% or 12% CHO) suppressed mobilization of plasma Summary and future directions free fatty acids (FFA), resulting in a reduction in f-TRP:BCAA and prolonged exercise time to The complex integration of physiological factors exhaustion (Davis et al., 1992). Although we that influence endurance performance presents similarly observed a linear relationship between a challenge to our understanding of the women FFA and f-TRP (Fig. 2.4; S.P. Bailey et al., unpub- athletes who compete in these events. Although lished data) as well as a reduction in FFA with the last 25 years have resulted in an exponential factors influencing performance 29

increase in studies of endurance-trained women, studies that have investigated training influences a great deal of our knowledge of endurance on muscular strength have focused on men, performance and its correlates are based on research on women has dramatically increased research primarily performed on male athletes. over the last two decades. The impact of cardiac size on the delivery of oxygen is a factor that will probably preclude Neural adaptation most élite women from achieving the same · VO2max values as sport-matched élite men. It is well accepted that the gains in muscular However, the evidence that ultra-endurance strength observed in the initial phases (2–8 events favour women’s performances over simi- weeks) of a resistance training programme are a larly trained men reveals physiological advan- result of neural alterations with little change in tages for female athletes that override the muscle cross-sectional area (CSA) (see Sale, 1988 · importance of VO2max in endurance performance. and Kraemer et al., 1996 for reviews). Moritani Although lactate threshold and economy of and deVries (1979) investigated the role of neural movement have been shown to interact with factors and hypertrophy in the time course of · VO2max in determining endurance performance in gains in muscle strength in seven men and eight men, it is not clear how these factors are inte- women who performed progressive resistance grated to affect women’s performances. Further exercise training for 8 weeks. These authors studies of the regulatory enzymes and hormones reported identical time-course responses for that control energy metabolism in women ath- strength gains between the men and women, letes during prolonged endurance events are also noting that neural factors were predominant in necessary. It is important that future studies in the initial (<4 weeks) gains in strength. Staron this area take into consideration factors that may and colleagues (1994) confirmed the influence influence exercise responses. These include, but of neural factors in maximal dynamic strength are not limited to, sex hormones, training status gains in both men and women following an 8- and history, dietary status, circadian effects, week heavy resistance training programme. body size and composition, and intensity and Although muscle fibre size was not increased duration of the exercise stimulus. The smaller in this short-term training programme, these differential in performance times between men authors noted alterations in muscle fibre type and women over the last 20 years indicates that composition and phenotypic expression of con- the adaptability of the human body to exercise tractile proteins (myosin heavy chain content) training is not as sexually dimorphic as previ- concomitant with the early strength gains in both ously proposed by those who opposed women’s sexes. participation in endurance events. Whole muscle hypertrophy Strength Prior to the 1980s, strength gains following resis- Muscular strength, defined as the maximum tance training in women were reported to be force or tension generated by a muscle, is a re- accompanied by minimal muscle hypertrophy quirement for all athletic events. Physiological (Brown & Wilmore, 1974; Wilmore, 1974) or factors that contribute to the development of hypertrophy that was approximately 50% of that muscular strength include neurological adapta- observed in men (Moritani & deVries, 1979). tions (e.g. recruitment of motor units, disinhibi- However, more recent studies using computer- tion), muscle hypertrophy, alterations in muscle ized tomography or muscle biopsies for mea- fibre composition, and hormonal responses. surement of muscle CSA and muscle fibre area These have been recently reviewed by Kraemer have demonstrated that women respond with et al. (1996). Although the majority of human similar hypertrophic adaptations as those seen 30 physiology of the female athlete

in men following heavy resistance training As part of a follow-up study, Staron et al. (1991) (Cureton et al., 1988; Hickson et al., 1994; Staron investigated the effects of detraining and retrain- et al., 1994). Cureton et al. (1988) reported signifi- ing on muscle strength, hypertrophy and fibre cant increases in strength in both men and type conversions. Of the women that partici- women following a 16-week progressive resis- pated in the heavy resistance training pro- tance training protocol. Although the men exhib- gramme in the previous study (Staron et al., 1990) ited a greater absolute change in arm strength, six underwent long-term (30–32 weeks) detrain- the relative change in arm strength did not differ ing. During this time the women were not between men and women. Absolute increases in involved in any type of endurance or resistance muscle CSA of the upper arm were the same training. Following detraining the subjects were for women and men. Cureton et al. attributed retested and resumed the training protocol for 6 the greater gains in absolute arm strength to the weeks (neural adaptation phase) followed by an larger pretraining muscle fibre size and number additional 7 weeks of training (muscle hyper- in men compared with women that had previ- trophy phase, n = 4). Detraining resulted in a ously been reported by Sale et al. (1987). decrease in strength, although values remained greater than those measured prior to the initial training protocol. Similar changes were noted Muscle fibre type and cross-sectional area in the CSA of type IIAB + IIB fibres and, to a Although previous research elucidated the lesser extent, of type IIA and type I muscle fibres. importance of muscle fibre type on sport per- In contrast, the detraining period resulted in a formance in women athletes (Drinkwater, 1984), return of the composition of type II fibres to pre- few of these studies investigated the influence of training levels (i.e. increase in percentage of resistance training on alterations in muscle fibre type IIB and decrease in percentage of type IIA). types in women. Staron et al. (1990) studied 24 Following the 6-week retraining period, 1-RM women who participated in a heavy resistance values were comparable to those obtained at training programme (6–8 repetition maximum the conclusion of the initial 20-week training pro- (RM), three sets) designed to elicit an increase in gramme and the percentage of type IIB fibres thigh muscle strength. In addition to significant significantly decreased. Muscle fibre CSA in- improvements in maximal dynamic strength (1 creased in type IIA and type IIAB + IIB fibres RM), histochemical and photomontage analyses from their detrained values. The additional of muscle biopsies of the vastus lateralis before hypertrophic training period resulted in signifi- and after training showed significant increases in cant increases in percentage of type IIA fibres, CSA of type I (slow-twitch), type IIA (fast-twitch with no further alterations in the CSA of any oxidative–glycolytic) and type IIAB + IIB [combi- muscle fibre type. These data suggest that in nation of fast-twitch glycolytic (IIB) and interme- women maximal dynamic strength and muscle diate between types IIA and IIB], with the fibre CSA may be retained over long periods of greatest gains observed in the fast-twitch fibres. detraining and that a rapid return to the trained The distribution of fibre types was also altered state is possible with short-term (6 weeks) heavy following the training programme: the percent- resistance training. age of type IIB fibres decreased with a reciprocal More recently, Staron and colleagues (1994) increase in percentage of type IIA fibres, suggest- investigated the time course of alterations in ing conversion of type IIB to IIA. The muscle muscle strength and morphology in women hypertrophy detected by histochemical tech- and men who performed an 8-week progressive niques was not confirmed by anthropometric resistance training protocol. Both men and measurement of thigh girth, which the authors women exhibited similar increases in absolute attributed to a decrease in thigh subcutaneous and relative dynamic strength of the lower skinfold thickness. extremity as well as decreases in the percentage factors influencing performance 31

of type IIB fibres. However, the hormonal mecha- during running events greater than 42.2km is nisms for these alterations were gender specific. a fatigue resistance of their musculature (Bam et al., 1997). Two studies using physically active men and women provide evidence to support Hormonal factors this suggestion. Clarke (1986) measured a hand- The hypertrophy that accompanies heavy resis- gripping exercise and reported a slower fatigue tance training is modulated by endocrine rate in the women compared with the men. responses, which are both gender and protocol Misner and colleagues (1990) observed similar specific (Kraemer et al., 1996). In men this results for both finger-flexion and leg-extension response to training is believed to be mediated exercises. Although mechanisms for these differ- by an increase in several anabolic hormones, ences have not been elucidated, Coetzer et al. including testosterone and growth hormone (1993) have reported an inverse relationship (GH) (Kraemer et al., 1990). Recently Staron et al. between peak isometric torque and time to (1994) observed a correlation between the early fatigue in élite black male distance runners. changes in muscle fibre types with heavy resis- Whether the lower absolute strength reported tance training and increased testosterone and in women compared with men (Heyward et al., decreased cortisol levels in men. However, these 1986; Sale et al., 1987; Cureton et al., 1988; Misner endocrine responses were not evident in the et al., 1990) contributes to this fatigue resistance women who demonstrated similar muscular is unknown. adaptations. Previous studies investigating the hormonal Summary and future directions factors that modify muscular strength and hypertrophy in women have produced equivo- Since 1985 a large body of research has estab- cal results. While Cumming et al. (1987) found lished that women respond to resistance training a significant increase in serum testosterone and with similar hypertrophic adaptations as previ- cortisol values in women who performed resis- ously observed in men, although hormonal tance exercise, other researchers have found no mechanisms responsible for these changes are increase in serum testosterone in women during sex specific. The smaller fibre CSA and total resistance training (Krahenbuhl et al., 1978; muscle CSA of women result in a sport-specific Westerlind et al., 1987; Kraemer et al., 1991, 1993, gender difference in absolute strength, although 1995). Heavy resistance exercise did result in relative strength (per body mass or lean body significant increases in GH in women (Kraemer mass) may be similar. It is interesting to note et al., 1991, 1993); however, this was only that the studies detailed above have not included observed if the exercise protocol was designed to women athletes in sports that depend on induce hypertrophy rather than strength (i.e. absolute strength for success (e.g. athletic field lower resistance, more repetitions, shorter rest events). Further studies of the interrelationship period). This protocol resulted in a greater eleva- between fatigue resistance, muscular strength tion in lactic acid, which the authors suggest may and endurance performance are also warranted. have stimulated the release of GH. Cumming et al. (1987) also suggested that lactic acid concen- Flexibility trations were related to the hormonal responses to resistance training in the women they studied. Flexibility, which may be defined as the athlete’s ability to move a joint through a normal range of motion without undue musculotendinous Muscle endurance stress (Chandler et al., 1990), has been advocated One of the potential reasons noted for the for enhanced performance as well as reduced enhanced performance of women over men injury rates (Smith, 1994; Plowman & Smith, 32 physiology of the female athlete

1997), although conclusive evidence is lacking left knee flexor >15% at 180°·s–1) and flexibility (Plowman, 1992; Plowman & Smith, 1997). The (right hip vs. left hip >15%) were associated with commonly stated assumption that women have the first incidence of lower extremity injury in greater flexibility than men has also been chal- these athletes. Over the course of the 3-year lenged by Plowman and Smith (1997), who study, 40% of the women suffered one or more suggest that evidence is based on tests of hip injuries. flexion, which has been shown to be greater Although laxity of joints is considered a in women than men (Shephard et al., 1990; primary factor in risk of injury in a number of McHugh et al., 1992) and does not necessarily sports in which women participate (Agostini, reflect general flexibility. However, Kibler and 1994), this is more likely a sport-specific rather colleagues (1989) studied total-body flexibility than sex-specific issue. (11 measurements) in 629 female and 1478 male athletes participating in a variety of sports and Coordination found that the women were more flexible than the men on all measurements. In addition, these In their review of neurophysiology of motor authors noted that lower-body female athletes skills in sport, Henatsch and Langer (1985) had reduced flexibility compared with upper- suggest that the development of precision in body female athletes; this finding was not appar- sport is the culmination of the motor learning ent in the male athletes. It was suggested that process, which involves hierarchical levels of the discrepancy between the sexes was due to the coordination (i.e. crude < fine < super-fine). initially reduced flexibility of the male athlete It has been postulated that the greater inci- (i.e. less to lose). Caution is advised in interpret- dence of injury in female athletes compared with ing these data as the athletes were recruited male athletes in the same sport may be due to from junior high school through collegiate pro- inadequate skill development, which Beck and grammes but age was not factored into the Wildermuth (1985) suggest is a result of poor analyses. training experience in the developmental years. McHugh et al. (1992) compared the mechanical In other words, the discrepancy in skill develop- component of flexibility, assessed by viscoelastic ment is due to sociological rather than biological stress relaxation, in men and women. Although factors. Whether women athletes who have par- the women had greater hip flexibility, the stretch- ticipated in organized youth sport programmes induced electromyographic response and vis- since their formative years are less prone to coelastic stress relaxation were similar between injury has not been studied, although more the sexes. Differences in muscle mass, joint current information on athletes indicates that geometry or sex-specific collagenous muscle injury rates are more sport specific than sex structure were suggested as factors potentiating specific, with minor exceptions (e.g. anterior the greater muscle extensibility in the women; cruciate ligament) (Arendt, 1994). however, these were not evaluated. In contrast to this sociological argument, Support for the importance of flexibility and research studies have demonstrated sex differ- muscular strength in determining injury rates ences in performance on motor tasks (Watson & in women athletes is provided by the study of Kimura, 1989; Hall & Kimura, 1995; Nicholson & Knapik and colleagues (1991). These authors Kimura, 1996), which Kimura (1992) attributes to evaluated lower-body isokinetic knee torque and the effect of sex hormones on brain organization flexibility in 138 female collegiate athletes par- during development. In general, women have ticipating in eight weight-bearing varsity sports. been shown to be superior to men on tasks Tests were conducted during the preseason and involving fine motor coordination (Kimura, were related to occurrences of lower extremity 1992; Hall & Kimura, 1995) and speed of motor injuries. Results indicated that imbalances in programming (Nicholson & Kimura, 1996), strength (flexion/extension ratio <0.75; right vs. whereas men outperform women on target- factors influencing performance 33

directed motor skills (Watson & Kimura, 1989; Bam, J., Noakes, T.D., Juritz, J. & Dennis, S.C. (1997) Kimura, 1992). Watson and Kimura (1989) Could women outrun men in ultramarathon races? Medicine and Science in Sports and Exercise 29, 244–247. reported that the differential patterns of motor Beck, J.L. & Wildermuth, B.P. (1985) The female programming they observed in men and women athlete’s knee. Clinics in Sports Medicine 4, 345–366. performing target-throwing and interception Berglund, B., Birgegård, G. & Hemmingsson, P. tasks were not related to differences in physique (1988) Serum erythropoietin in cross-country skiers. or athleticism. However, the ‘athleticism’ of their Medicine and Science in Sports and Exercise 20, 208–209. Berry, M.J., Storsteen, J.A. & Woodard, C.M. (1993) subjects was determined by a self-rated ques- Effects of body mass on exercise efficiency and VO2 tionnaire of experience in athletics and organized during steady-state cycling. Medicine and Science in baseball. Whether similar results would be found Sports and Exercise 25, 1031–1037. in equally trained male and female athletes Billat, V., Beillot, J., Jan, J., Rochcongar, P. & Carre, F. whose sport-specific training matched the (1996) Gender effect on the relationship of time limit at 100% VO with other bioenergetic characteris- motor skills evaluated is yet to be determined. 2max tics. Medicine and Science in Sports and Exercise 28, The finding of improved manual coordination in 1049–1055. women during the luteal phase of their men- Bouchard, C., Dionne, F.T., Simoneau, J.-A. & Boulay, strual cycle (Hampson & Kimura, 1988) further M.R. (1992) Genetics of aerobic and anaerobic perfor- supports the hypothesis that sex hormones may mances. Exercise and Sport Sciences Reviews 20, 27–58. Brown, C.H. & Wilmore, J.H. (1974) The effects of influence motor skills. maximal resistance training on the strength and Although the research on sex differences in body composition of women athletes. Medicine and motor learning is intriguing, there is no evidence Science in Sports and Exercise 6, 174–177. to suggest that the final outcome of sport pre- Bunc, V. & Heller, J. (1993) Ventilatory threshold in cision is different in men and women. Whether young and adult female athletes. Journal of Sports Medicine and Physical Fitness 33, 233–238. female athletes utilize a different motor pro- Bunt, J.C. (1990) Metabolic actions of estradiol: signifi- gramme strategy to achieve these skills may have cance for acute and chronic exercise responses. implications for coaching practices. In addition, Medicine and Science in Sports and Exercise 22, 286–290. studies on coordination in women athletes and Chandler, T.J., Kibler, W.B., Uhl, T.L., Wooten, B., Kiser, its potential role on injury rates and performance A. & Stone, E. (1990) Flexibility comparisons of are warranted. junior elite tennis players to other athletes. American Journal of Sports Medicine 18, 134–136. Clarke, D.H. (1986) Sex differences in strength and Conclusion fatigability. Research Quarterly for Exercise and Sport 57, 144–149. Over the last 25 years research has shown that the Coetzer, P., Noakes, T.D., Sanders, B. et al. (1993) Superior fatigue resistance of elite black South training response of the female athlete is similar African distance runners. Journal of Applied to the male athlete, with minor exceptions. As Physiology 75, 1822–1827. young girls participate in sports from their Costill, D.L., Fink, W.J., Flynn, M. & Kirwin, J. (1987) formative years, many of the sex differences Muscle fibre composition and enzyme activities in observed in the past will be reduced to the basic elite female distance runners. International Journal of Sports Medicine 8 (Suppl.), 103–106. biological differences (e.g. cardiac size, muscle Coyle, E.F. (1995) Integration of the physiological CSA) and women will achieve their true factors determining endurance performance ability. potential. Exercise and Sport Sciences Reviews 23, 25–63. Coyle, E.F., Coggan, A.R., Hopper, M.K. & Walters, T.J. (1988) Determinants of endurance in well trained References cyclists. Journal of Applied Physiology 64, 2622–2630. Coyle, E.F., Sidossis, L.S., Horowitz, J.F. & Beltz, J.D. Agostini, R. (ed.) (1994) Medical and Orthopedic Issues (1992) Cycling efficiency is related to the percentage of Active and Athletic Women. Hanley and Belfus, of type I muscle fibres. Medicine and Science in Sports Philadelphia. and Exercise 24, 782–788. Arendt, E.A. (1994) Orthopaedic issues for active Cumming, D.C., Wall, S.R., Galbraith, M.A. & and athletic women. Clinics in Sports Medicine 13, Belcastro, A.N. (1987) Reproductive hormone 483–503. 34 physiology of the female athlete

responses to resistance exercise. Medicine and Science Helgerud, J. (1994) Maximal oxygen uptake, anaerobic in Sports and Exercise 19, 234–238. threshold and running economy in women and Cureton, K.J., Collins, M.A., Hill, D.W. & McElhannon men with similar performance level in marathons. Jr, F.M. (1988) Muscle hypertrophy in men and European Journal of Applied Physiology 68, 155–161. women. Medicine and Science in Sports and Exercise Helgerud, J., Ingjer, F. & Stromme, S.B. (1990) Sex differ- 20, 338–344. ences in performance-matched marathon runners. Daniels, J. & Daniels, N. (1992) Running economy of European Journal of Applied Physiology 61, 433–439. elite male and elite female runners. Medicine and Henatsch, H.-D. & Langer, H.H. (1985) Basic neuro- Science in Sports and Exercise 24, 483–489. physiology of motor skills in sport: a review. Davis, J.M. & Bailey, S.P. (1997) Possible mechanisms International Journal of Sports Medicine 6, 2–14. of central nervous system fatigue during exercise. Heyward, V.H., Johannes-Ellis, S.M. & Romer, J.F. Medicine and Science in Sports and Exercise 29, 45–57. (1986) Gender difference in strength. Research Davis, J.M., Bailey, S.P., Woods, J.A., Galiano, F.J., Quarterly for Exercise and Sport 57, 154–159. Hamilton, M.T. & Bartoli, W.P. (1992) Effects of carbo- Hickson, R.C., Hidaka, K. & Foster, C. (1994) Skeletal hydrate feedings on plasma free tryptophan and muscle fibre type, resistance training, and strength- branched-chain amino acids during prolonged related performance. Medicine and Science in Sports cycling. European Journal of Applied Physiology 65, and Exercise 26, 593–598. 513–519. Hutchinson, P.L., Cureton, K.J., Outz, H. & Wilson, G. Dempsey, J.A. (1985) Is the lung built for exercise? (1991) Relationship of cardiac size to maximal Medicine and Science in Sports and Exercise 18, 143–155. oxygen uptake and body size in men and women. Drinkwater, B.A. (1984) Women and exercise: physio- International Journal of Sports Medicine 12, 369–373. logical aspects. Exercise and Sport Sciences Reviews 12, Iwaoka, K., Hatta, H., Atomi, Y. & Miyashita, M. (1988) 339–372. Lactate, respiratory compensation thresholds, and Drinkwater, B.L. (1973) Physiological responses of distance running performance in runners of both women to exercise. Exercise and Sport Sciences Reviews sexes. International Journal of Sports Medicine 9, 1, 125–153. 306–309. Durstine, J.L., Pate, R.R., Sparling, P.B., Wilson, G.E., Joyner, M.J. (1993) Physiological limiting factors and Senn, M.D. & Bartoli, W.P. (1987) Lipid, lipoprotein, distance running: influence of gender and age on and iron status of elite women distance runners. record performances. Exercise and Sport Sciences International Journal of Sports Medicine 8, 119–123. Reviews 21, 103–133. Eichner, E.R. (1992) Sports anemia, iron supplements, Kibler, W.B., Chandler, T.J., Uhl, T. & Maddus, R.E. and blood doping. Medicine and Science in Sports and (1989) A musculoskeletal approach to the prepartici- Exercise 24 (Suppl.), S315–S318. pation physical examination. American Journal of Evans, S.L., Davy, K.P., Stevenson, E.T. & Seals, D.R. Sports Medicine 17, 525–531. (1995) Physiological determinants of 10-km perfor- Kimura, D. (1992) Sex differences in the brain. Scientific mance in highly trained female runners of different American 267, 118–125. ages. Journal of Applied Physiology 78, 1931–1941. Knapik, J.J., Bauman, C.L., Jones, B.H., Harris, J.M. & Friedmann, B. & Kindermann, W. (1989) Energy meta- Vaughan, L. (1991) Preseason strength and flexibility bolism and regulatory hormones in women and imbalances associated with athletic injuries in female men during endurance exercise. European Journal of collegiate athletes. American Journal of Sports Medicine Applied Physiology 59, 1–9. 19, 76–81. Gollnick, P.D. (1988) Energy metabolism and pro- Kohrt, W.M., O’Connor, J.S. & Skinner, J.S. (1989) longed exercise. In D.R. Lamb and R. Murray (eds) Longitudinal assessment of responses by triathletes Perspectives in Exercise Science and Sports Medicine, pp. to swimming, cycling, and running. Medicine and 1–42. Benchmark Press, Indianapolis. Science in Sports and Exercise 21, 569–575. Gulve, E.A. & Spina, R.J. (1995) Effect of 7–10 days of Kraemer, R.R., Heleniak, R.J., Tryniecki, J.L., Kraemer, cycle ergometer exercise on skeletal muscle Glut-4 G.R., Okazaki, N.J. & Castracane, V.D. (1995) protein content. Journal of Applied Physiology 79, Follicular and luteal phase hormonal responses to 1562–1566. low-volume resistive exercise. Medicine and Science in Hall, J.A. & Kimura, D. (1995) Sexual orientation and Sports and Exercise 27, 809–817. performance on sexually dimorphic motor tasks. Kraemer, W.J., Marchitelli, L., Gordon, S.E. et al. (1990) Archives of Sexual Behavior 24, 395–407. Hormonal and growth factor responses to heavy Hampson, E. & Kimura, D. (1988) Reciprocal effects resistance exercise protocols. Journal of Applied of hormonal fluctuations on human motor and per- Physiology 69, 1442–1450. ceptual–spatial skills. Behavioral Neuroscience 102, Kraemer, W.J., Gordon, S.E., Fleck, S.J. et al. (1991) 456–459. Endogenous anabolic hormonal and growth factor factors influencing performance 35

responses to heavy resistance exercise in males and leucine kinetics and nitrogen balance in endurance females. International Journal of Sports Medicine 12, athletes. Journal of Applied Physiology 75, 2134–2141. 228–235. Plowman, S.A. (1992) Physical activity, physical fitness, Kraemer, W.J., Fleck, S.J., Dziados, J.E. et al. (1993) and low back pain. Exercise and Sport Sciences Reviews Changes in hormonal concentrations after different 20, 221–242. heavy-resistance exercise protocols in women. Plowman, S.A. & Smith, D.L. (1997) Exercise Physiology Journal of Applied Physiology 75, 594–604. for Health, Fitness, and Performance. Allyn and Bacon, Kraemer, W.J., Fleck, S.J. & Evans, W.J. (1996) Strength Boston. and power training: physiological mechanisms of Potteiger, J.A., Welch, J.C. & Byrne, J.C. (1993) From adaptation. Exercise and Sport Sciences Reviews 24, parturition to marathon: a 16-weeks study of an elite 363–397. runner. Medicine and Science in Sports and Exercise 25, Krahenbuhl, G.S., Archer, P.A. & Pettit, L.L. (1978) 673–677. Serum testosterone and female trainability. Ergo- Rowell, L.B. (1993) Human Cardiovascular Control. nomics 18, 359–364. Oxford University Press, New York. Lucas, J.A. & Smith, R.A. (1982) Women’s sport: a trial Sale, D.G. (1988) Neural adaptation to resistance of equality. In R. Howell (ed.) Her Story in Sport: A training. Medicine and Science in Sports and Exercise Historical Anthology of Women in Sports, pp. 239–265. 20 (Suppl.), S135–S145. Leisure Press, West Point, New York. Sale, D.G., MacDougall, J.D., Alway, S.E. & Sutton, J.R. McHugh, M.P., Magnusson, S.P., Gleim, G.W. & (1987) Voluntary strength and muscle characteristics Nicholas, J.A. (1992) Viscoelastic stress relaxation in in untrained men and women and male body- human skeletal muscle. Medicine and Science in Sports builders. Journal of Applied Physiology 62, 1786–1793. and Exercise 24, 1375–1382. Saltin, B. & Strange, S. (1992) Maximal oxygen uptake: Misner, J.E., Massey, B.H., Going, S.B., Bemben, M.G. & ‘old’ and ‘new’ arguments for a cardiovascular limi- Ball, T.E. (1990) Sex differences in static strength and tation. Medicine and Science in Sports and Exercise 24, fatigability in three different muscle groups. Research 30–37. Quarterly for Exercise and Sport 61, 238–242. Sanborn, C.F. & Jankowski, C.M. (1994) Physiologic Mitchell, J.H., Tate, C., Raven, P. et al. (1992) Acute considerations for women in sport. Clinics in Sports responses and chronic adaptation to exercise in Medicine 13, 315–327. women. Medicine and Science in Sports and Exercise 24 Shephard, R.J., Berridge, M. & Montelpare, W. (1990) (Suppl.), 258–265. On the generality of the ‘sit and reach’ test: an analy- Moritani, T. & deVries, H.A. (1979) Neural factors vs. sis of flexibility data for an aging population. hypertrophy in the time course of muscle strength Research Quarterly for Exercise and Sport 61, 326–330. gain. American Journal of Physical Medicine 58, Smith, C.A. (1994) The warm-up procedure: to stretch 115–130. or not to stretch. A brief review. Journal of Ortho- Nicholson, K.G. & Kimura, D. (1996) Sex differences in paedics and Sports Physical Therapy 19, 12–17. speech and manual skill. Perceptual and Motor Skills Sparling, P.B., Nieman, D.C. & O’Connor, P.J. (1993) 82, 3–13. Selected scientific aspects of marathon racing. An Ogawa, T., Spina, R.J., Martin III, W.H. et al. (1992) update on fluid replacement, immune function, psy- Effects of aging, sex, and physical training on car- chological factors and the gender difference. Sports diovascular responses to exercise. Circulation 86, Medicine 15, 116–132. 494–503. Speechly, D.P., Taylor, S.R. & Rogers, G.G. (1996) O’Toole, M.L., Hiller, W.D.B., Crosby, L.O. & Douglas, Differences in ultra-endurance exercise in perfor- P.S. (1987) The ultraendurance triathlete: a physio- mance-matched male and female runners. Medicine logical profile. Medicine and Science in Sports and and Science in Sports and Exercise 28, 359–365. Exercise 19, 45–50. Staron, R.S., Malicky, E.S., Leonardi, M.J., Falkel, J.E., Pate, R.R., Barnes, C. & Miller, W. (1985) A physiologi- Hagerman, F.C. & Dudley, G.A. (1990) Muscle hyper- cal comparison of performance-matched female and trophy and fast fibre type conversions in heavy resis- male distance runners. Research Quarterly for Exercise tance-trained women. European Journal of Applied and Sport 56, 245–250. Physiology 60, 71–79. Pate, R.R., Sparling, P.B., Wilson, G.E., Cureton, K.J. & Staron, R.S., Leonardi, M.J., Karapondo, D.L. et al. Miller, B.J. (1987) Cardiorespiratory and metabolic (1991) Strength and skeletal muscle adaptations responses to submaximal and maximal exercise in in heavy-resistance-trained women after detraining elite women distance runners. International Journal of and retraining. Journal of Applied Physiology 70, Sports Medicine 8, 91–95. 631–640. Phillips, S.M., Atkinson, S.A., Tarnopolsky, M.A. & Staron, R.S., Karapondo, D.L., Kraemer, W.J. et al. (1994) MacDougall, J.D. (1993) Gender differences in Skeletal muscle adaptations during early phase of 36 physiology of the female athlete

heavy-resistance training in men and women. Journal Weight, L.M., Alexander, D., Elliot, T. & Jacobs, P. of Applied Physiology 76, 1247–1255. (1992) Erythropoietic adaptations to endurance Tarnopolsky, L.J., MacDougall, J.D., Atkinson, S.A., training. European Journal of Applied Physiology 64, Tarnopolsky, M.A. & Sutton, J.R. (1990) Gender dif- 444–448. ferences in substrate for endurance exercise. Journal Wells, C.L. (1991) Women, Sport and Performance. of Applied Physiology 68, 302–308. Human Kinetics Publishers, Champaign, Illinois. Tarnopolsky, M.A., Atkinson, S.A., Phillips, S.M. & Westerlind, K.C., Byrnes, W.C., Freedson, P.S. & Katch, MacDougall, J.D. (1995) Carbohydrate loading and F.I. (1987) Exercise and serum androgens in women. metabolism during exercise in men and women. Physician and Sportsmedicine 15, 87–94. Journal of Applied Physiology 78, 1360–1368. Weyand, P.G., Cureton, K.J., Conley, D.S., Sloniger, Telford, R.D. & Cunningham, R.B. (1991) Sex, sport, M.A. & Liu, Y.L. (1994) Peak oxygen deficit predicts and body-size dependency of hematology of trained sprint and middle-distance track performance. athletes. Medicine and Science in Sports and Exercise Medicine and Science in Sports and Exercise 26, 23, 788–794. 1174–1180. Warren, G.L. & Cureton, K.J. (1989) Modeling the Whipp, B.J. & Ward, S.A. (1992) Will women soon effect of alterations in hemoglobin concentration on outrun men? Nature 355, 25. VO2max. Medicine and Science in Sports and Exercise 21, Williams, K.R., Cavanagh, P.R. & Ziff, J.L. (1987) 526–531. Biomechanical studies of elite female distance Watson, N.V. & Kimura, D. (1989) Right-hand superior- runners. International Journal of Sports Medicine 8 ity for throwing but not for intercepting. Neuro- (Suppl.), 107–118. psychologia 27, 1399–1414. Wilmore, J.H. (1974) Alterations in strength, body com- Weight, L.M., Darge, B.L. & Jacobs, P. (1991) Athletes’ position and anthropometric measurements conse- pseudoanaemia. European Journal of Applied Physi- quent to 10-week weight training program. Medicine ology 62, 358–362. and Science in Sports and Exercise 6, 133–138. Chapter 3

Effects of the Menstrual Cycle and Oral Contraceptives on Sports Performance

CONSTANCE M. LEBRUN

Introduction monal replacement therapy in postmenopausal women. There has been much debate about the Sports performance is a multifaceted entity, effect of these variations on sports performance determined by a multitude of diverse cardio- but relatively few valid scientific studies. pulmonary, musculoskeletal, biomechanical, For the practitioner caring for the female cellular and enzymatic adaptations. In addition, athlete, it is important to have an understanding there is intraindividual variability in body tem- of the rhythmic alterations in female sex steroids perature, heart rate, ventilation and ventila- that occur during the biological life cycle and tory responses, as well as in muscle fibre type. their physiological implications. Knowledge in Psychological state (affect, perception, cognition) this area has advanced somewhat over the past can also affect performance dramatically. Despite few decades because of the substantial increase the typical selection bias of many investigations in women who are physically active and the towards male subjects, it is currently accepted larger population of well-trained female athletes that women respond to physical training as do for researchers to study. There are still many men, with decreased blood pressure and heart unanswered questions. This chapter reviews rate, reduced percentage body fat and increased what is currently known about the impact of maximal aerobic capacity. puberty, phases of the menstrual cycle and OCs Although aerobic capacity is the ‘gold stan- on sports performance. Weaknesses of the evi- dard’ by which fitness is evaluated, other para- dence in the literature to date as well as areas for meters such as running economy and mechanical future research are also addressed. efficiency are equally important. Many of the measurable physiological differences between Performance parameters male and female athletes can be minimized if cor- rected for percentage lean body mass, as dis- There are many components of sports perfor- cussed in Chapter 2. Nevertheless there remain mance (Table 3.1). Physical fitness is frequently significant gender differences that are largely defined by five physiological measures: aerobic attributable to the influence of the male and fitness, local muscle endurance (anaerobic female sex steroids, particularly after puberty. fitness), muscle strength and power, flexibility Women must also deal with fluctuating levels and body fat percentage. The relative importance of endogenous hormones in the course of an of each depends upon the nature of the given ovulatory menstrual cycle, as well as during sport. For example, success in long-distance pregnancy, parturition and menopause. Com- endurance events is determined by a high- binations of exogenous hormones are frequently performance velocity maintained for a given used in oral contraceptives (OCs) and for hor- distance. Other sports rely upon performance 37 38 physiology of the female athlete

Table 3.1 Components of sports performance. (From Winget et al., 1985) Puberty and sports performance Prior to puberty there is little difference between Sensory–motor: simple reaction time Psychomotor: hand–eye coordination male and female athletes in terms of aerobic Sensory perceptual: pain threshold capacity (Turley & Wilmore, 1997), anaerobic Cognitive: information processing capacity or muscle strength. In young females, Neuromuscular: strength menarche signals the monthly variation of the Psychological female sex steroids, oestrogen and progesterone. Affective: mood Psychophysiological: arousal Oestrogen is either directly secreted from the Cardiovascular ovary or formed from aromatization of testos- Heart rate terone in peripheral adipose tissues. Oestrogen is Stroke volume responsible for the development of primary and Metabolic secondary sex characteristics but also plays an Core body temperature important role in fat accumulation and protein Resting oxygen consumption. o Aerobic capacity: V 2max anabolism. There is extensive debate regarding the poten- tial delay in sexual development in female ath- letes who have been involved in very physical sports from an early age. It has previously been power or power output maintained for a given postulated that each year of hard training before time. Still others require coordination and a puberty delays menarche by 5 months. More steady hand and/or eye for athletic success. recently, these interpretations of the demo- Functionally, the onset of fatigue is linked to graphic data have been questioned. Stager et al. lactate concentration. Lactate concentration rep- (1990) suggested that it would be more appropri- resents the balance between lactate production ate to state that age of menarche is ‘later’ rather by muscle, diffusion into blood and its removal. than ‘delayed’. This issue remains controversial, The degree of muscle and blood lactate accu- in part due to differences in research design. For mulation during exercise is also influenced by example, Plowman et al. (1991) examined a cross- the amount of muscle mass sharing in the dis- sectional group of 73 premenarcheal athletes and tribution of power output. Energy consumption 53 non-athletes. Despite a lower percentage body depends upon oxygen consumption by the fat in the athletes, the authors concluded that working muscles. Morphological components sexual maturation of the athletes was not essential to oxygen delivery include heart rate, impaired. In contrast, a recent prospective study stroke volume, haemoglobin concentration, from Sweden followed 22 female gymnasts and muscle capillary density and aerobic enzyme 22 inactive girls for 5 years, and demonstrated a activity. delay in menarche and a reduction in peak height Power and strength, and aerobic and anaero- in the gymnasts (Lindholm et al., 1994). bic capacity can all be documented quantita- tively, but psychological conditions such as Menstrual phases mood state, arousal level, etc. are not as easy to measure. Some factors are modifiable through Review of normal menstrual physiology and sport-specific training or improvements in changes with training equipment. However, there are still a significant number of relevant physiological processes that During the course of a normal ovulatory men- can be altered by changes in the hormonal strual cycle, many hormonal changes occur in a milieu, with subsequent implications for female well-defined predictable pattern. Gonadotro- sports performance. phin-releasing hormone (GnRH) from the menstrual cycle and oral contraceptives 39

hypothalamus initiate secretion of luteinizing upon the relative proportion of each hormone, hormone (LH) and follicle-stimulating hormone there can be alterations in blood pressure and (FSH) at the pituitary level. Subsequent changes blood volume, heart rate and vascular tone. Body in the female sex steroids throughout the men- temperature, electrolyte and water exchange, strual cycle modulate the endocrine events, respiration/ventilation and energy metabolism leading to ovulation and preparation of the may also be affected to varying degrees. uterine endometrium for implantation of a fertil- ized ovum. During the follicular phase, levels of actions of oestrogen both oestrogen and progesterone are low. Imme- diately preceding ovulation, there is a peak in The physiological actions of oestrogens in the oestrogen levels and a change in the negative body extend well beyond those related to devel- feedback to the hypothalamus. During the luteal opment of secondary sexual characteristics phase of the cycle, secretion from the corpus (Bunt, 1990). Oestrogens promote deposition of luteum results in high concentrations of both fat in the typical female areas of the breasts, but- hormones. If conception and implantation do not tocks and thighs; more importantly, they have a occur, falling levels of hormones cause the lining number of significant actions on the cardio- of the uterus to be shed as menstrual blood flow vascular system. The decrease in total and low- and the entire process begins anew (Fig. 3.1). density lipoprotein cholesterol levels and It is well accepted that strenuous physical increase in high-density lipoproteins confer pro- training in conjunction with other factors such as tection against atherosclerosis, while alterations an inadequate diet can lead to menstrual dys- in plasma fibrinolytic activity and platelet aggre- function, including short luteal phase, anovula- gation can lead to a detrimental increase in tory cycles and amenorrhoea. It is less well thrombosis. Sodium and chloride retention can understood whether the endogenous variations cause oedema, weight gain and increase in blood in female hormones during an ovulatory men- pressure. The latter actions are of particular strual cycle or the administration of exogenous concern when oestrogens are used in OCs. female hormones, such as in OCs or hormonal replacement therapy, have any impact on sports Metabolic effects performance. In general, vigorous regular exer- cise is thought to decrease the physical perturba- Metabolic actions of oestrogen include facilita- tions related to phases of the menstrual cycle, tion of glycogen storage and uptake in both liver such as pelvic and low back pain, headache, and muscle. This has been demonstrated in anxiety, depression and fatigue, and decrease the animals and humans. There is also a glycogen- use of analgesics (Prior et al., 1987). However, sparing effect at rest and during exercise, with there are myriad and complex physiological fluc- increased lipid synthesis, enhanced lipolysis in tuations throughout an ovulatory menstrual muscle and a shift in metabolism towards more cycle with potential to alter performance, partic- utilization of free fatty acids (FFA) for fuel (Bunt, ularly at the élite level. 1990). Compared with their male counterparts, female athletes have been shown to have a greater reliance on fat stores for energy at a spe- Physiological effects of the female cific exercise intensity, as reflected by lower sex steroids blood lactate and respiratory exchange ratio The interrelationship of the various sex steroids (RER) values (Tarnolpolsky et al., 1990). Elevated is detailed in Fig. 3.2. Changing patterns of either levels of oestrogen promote lipolytic activity. endogenous or exogenous hormones may have This has been postulated to be due to an alter- multiple consequences for the cardiovascular, ation of the sensitivity to lipoprotein lipase and respiratory and metabolic systems. Depending by an increase in the levels of human growth 40 physiology of the female athlete

70 LH )

–1 60 ml . 50 40 30 20

FSH and LH (mIU 10 FSH

0 246810 12 14 16 18 20 22 24 26 28 (a) Day of menstrual cycle

400 20 Progesterone ) ) Oestradiol –1

–1 300 15 ml . ml .

200 10

100 5 Oestradiol (pg Progesterone (ng

0 0 2 4 6810 12 14 16 18 20 22 24 26 28 (b) Day of menstrual cycle Developing follicle Day 1 Discharge of ovum Ovarian Follicular Luteal phases Day 15 Corpus luteum Day 30 Day 1 Endometrial Proliferative Secretory Uterus phases (c) Day 15

Day 30

4 2 (mm) thickness Endometrial 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 Ovulation (d) Menses Menses

Fig. 3.1 Hormonal events of the menstrual cycle: (a) follicle-stimulating hormone (FSH) and luteinizing hormone (LH), (b) oestradiol and progesterone. (c) Phases of the ovarian and endometrial cycles. (d) Endometrial thickness throughout the menstrual cycle. (Adapted from Shangold & Mirkin, 1994.) menstrual cycle and oral contraceptives 41

O

OH O O C C4H9

HO HO HO Oestradiol 17-β Oestrone Testosterone

CH3 CH3 OH C O C O

C CH O C CH3 O

HO O O Ethinyloestradiol Progesterone Medroxyprogesterone acetate

(a)

21 CH3 CH3 20C O OH OH CH CH 18 3 C CH 2 C CH 12 17 11 13 16 19 14 15 1 9 2 10 8 3 7 4 6 O 5 O O Progesterone Norethindrone Levonorgestrel (norethisterone) O

O C CH3 OH OH CH CH CH CH CH CH 3 2 C CH 3 2 CCH 3 2 CCH H2C

HON O Norgestimate Desogestrel Gestodene

(b)

Fig. 3.2 Structural formulae of (a) the major sex steroids, and (b) progesterone and synthetic progestins used in oral contraceptives and contraceptive progestins.

hormone (GH), an activator of lipolysis (Ruby & et al., 1997). These actions of oestrogens on sub- Robergs, 1994). Recently, transdermal oestradiol strate metabolism could potentially enhance has also been shown to modify glucose metabo- sports performance, particularly for endurance lism at rest and during moderate exercise as a and ultra-endurance events. result of decreased gluconeogenesis, adrenaline Effects on blood glucose and lactate produc- secretion and changes in glucose transport (Ruby tion are less well characterized. However, it is 42 physiology of the female athlete

known that oestradiol can precipitate glucose although it is likely that in more fit individuals intolerance as a result of insulin insensitivity the effects of training mitigate this to some (Diamond et al., 1988). With increasing doses of degree. oestrogen or administration of synthetic oestro- gens in OCs, the secondary effects of oestrogens Effects on fluid balance (primarily an increase in corticosteroid activity) predominate, leading to deterioration in glucose Fluid dynamics are also altered under the simul- tolerance and insulin resistance (Godsland, taneous influence of progesterone and/or oestro- 1996). In addition, the metabolism of energy gen, depending upon the ratio of the two substrates probably varies with the subnormal hormones. Progesterone antagonizes the effects levels of gonadotrophic hormones that occur sec- of aldosterone, which then leads to increased ondary to menstrual dysfunction in female excretion of water and sodium from the kidney. athletes. This natriuresis in turn stimulates the Another essential action of oestrogen is the renin–angiotensin system, which paradoxically facilitation of calcium uptake into bone. Women increases aldosterone secretion and promotes an with oligomenorrhoea or amenorrhoea may increase in antidiuretic hormone, thought to have a chronic oestrogen deficiency state similar contribute to postovulatory fluid retention. to that of postmenopausal women and are sus- Although it would seem that premenstrual ceptible to premature osteoporosis. Current symptoms might somehow be associated with clinical guidelines suggest the therapeutic use of these changes in fluid dynamics, a recent study replacement hormones such as OCs or various was not able to correlate subjective breast tender- combinations of oestrogen and progesterone for ness and bloating with sodium retention in the protection of bone density in these populations. luteal phase of the cycle (Olson et al., 1996). In this group of athletic women, the potential for hormonal effects on substrates for sports perfor- Metabolic effects mance is a critical issue. In terms of substrate metabolism, progestins actions of progesterone cause a shift towards a greater dependence on fat. This is evidenced by lower RER values, lower In many ways, the progestin group of hormones blood lactate levels during submaximal exercise have ‘anti-oestrogenic’ effects that seem to be (Dombovy et al., 1987) and higher circulating proportional to their androgenicity. They can FFA (Reinke et al., 1972). With special relevance significantly modify body composition, ther- for the population of female athletes, medroxy- moregulation, cardiorespiratory function and progesterone acetate (Depo-Provera), adminis- haemodynamics. Core body temperature is ele- tered intramuscularly (150mg every 3 months) vated by 0.3–0.5°C during the luteal phase of for contraception, has been found to cause deteri- a normal menstrual cycle, giving the classic oration of glucose tolerance or hyperinsuli- ‘biphasic’ curve characteristic of ovulation. naemia or both, possibly because of its glucocorticoid-like actions (Godsland, 1996). Godsland (1996) has also summarized the Respiratory effects research findings on the metabolic actions of the Minute ventilation and the hypercapneic and synthetic progestogens. The synthetic gonane hypoxic respiratory drives are increased during progestogen levonorgestrel has been shown to the luteal phase (England & Fahri, 1976; Schoene induce deterioration in glucose tolerance and et al., 1981). In untrained subjects, this subjective increased insulin levels when taken at a dose sense of dyspnoea has been demonstrated to of 75mg daily as a progestogen-only OC. The impair sports performance (Schoene et al., 1981), oestrane progestogens, ethynodiol diacetate menstrual cycle and oral contraceptives 43

and norethisterone (or norethindrone), appear to peripheral serotonin levels decrease causing an have little effect on glucose and insulin levels. increase in migraines (Marcus, 1995). In post- There is insufficient information on the newer menopausal women, oestrogen has been noted progestogens, desogestrel, gestodene and in a number of studies to have a beneficial effect norgestimate, regarding their impact on glucose on cognitive function and verbal memory, which tolerance and insulin responses. may be modulated through alterations in the concentration and availability of neurotransmit- ters, including serotonin, in the brain. Oestrogen Hormones and cognitive functions is also thought possibly to be protective against During the course of an ovulatory menstrual early onset of Alzheimer’s dementia (Sherwin, cycle, the luteal phase increase in both oestrogen 1996). It is interesting to speculate on potential and progesterone can cause a variety of symp- future psychiatric implications of a prolonged toms collectively termed molimina. These hypooestrogenic state during the reproductive include fluid retention, lateral breast tenderness, years in amenorrhoeic athletes. and appetite and mood changes. In moderation, this is a normal phenomenon and serves as a clin- Early studies of menstrual cycle ical indicator that the neuroendocrine axis is and performance functioning adequately and that ovulation is occurring (Magyar et al., 1979). In most healthy Early anecdotal and retrospective studies on the young women these hormone-induced somatic effects of cycle phase on performance are incon- changes are not accompanied by marked affec- sistent, although athletes generally reported tive aberrations (Laessle et al., 1990). In some their performances to be ‘best’ in the intermen- women, however, these symptoms are more strual or immediate postmenstrual phase and troublesome and are termed premenstrual syn- ‘worst’ during the premenstrual phase (Erdelyi, drome (PMS) (Mortola, 1996). Menstruation 1962; Zaharieva, 1965; Bale & Davies, 1983; itself generally leads to relief from these symp- Lebrun, 1993, 1994). Some postulated mediators toms but can be accompanied by dysmenorrhoea of these effects of the menstrual cycle include or significant menstrual cramps in association self-expectancies, a negative attitude towards with prostaglandin-mediated uterine contrac- menstruation, cultural restrictions and myths, tions. Both PMS and dysmenorrhoea can be dis- and the coexistence of disturbing menstrual or ruptive to optimal sports performance on a premenstrual symptoms (Wells, 1991). Never- cyclical basis. Fortunately, there is evidence that theless, world records have been set and gold these symptoms can be somewhat ameliorated medals won by women in any phase of the cycle. by regular physical exercise (Prior et al., 1987; The major underlying fault of these early Cowart, 1989). Antiprostaglandin medications surveys, in addition to the known shortcomings are commonly prescribed for treatment of the of retrospective studies, was a failure adequately discomfort of dysmenorrhoea. to identify the phase of the cycle. Basal body tem- There are other cognitive impacts of the female perature (BBT) curves have been shown to be hormones, oestrogen in particular, that may also inaccurate in establishing cycle phase (Bauman, theoretically impair or enhance performance but 1981). Quantitative analysis of BBT curves is which have not been systematically researched slightly more efficacious in predicting the timing in athletes. In premenopausal women, changes of ovulation and length of the luteal phase (Prior in oestrogen levels are positively correlated with et al., 1990). More recently, urine testing to detect serotonin levels, serotonin being involved in the the mid-cycle LH surge has proved useful for pathway for neurovascular headache. In low- estimation of the time of ovulation (Miller & oestrogen states (such as during menses, the Soules, 1996); however, adequate characteriza- placebo week of OCs or the postpartum period), tion of follicular, ovulatory and luteal phases of 44 physiology of the female athlete

the cycle demands accurate documentation by of female athletes to these cyclical hormonal serum hormonal measurements (Abraham et al., changes. 1974). These measurements must be made before exercise, as levels of both oestrogen and proges- Menstrual cycle and cardiovascular variables terone are thought to rise with exercise via alterations in hormone secretion or metabolic As previously discussed, both oestrogen and clearance (Jurkowski et al., 1978; Bonen et al., progesterone can influence the cardiovascular 1979). In contrast, Montagnani et al. (1992) found system with different effects predominating at an increase in metabolic clearance rate with a different phases of the cycle. Decreasing levels of 2-hour continuous treadmill test, leading to a oestrogen, such as seen in amenorrhoeic athletes, decrease in hormone concentrations with exer- may increase peripheral resistance and decrease cise. It is probable that the wide circadian varia- exercising muscle blood flow. During the men- tion in hormonal secretion in normal women strual cycle, changes in both oestrogen and prog- contributes to the incongruity of these results. esterone levels have been shown to alter forearm The first attempts to quantify scientifically skin blood flow and vascular reactivity (Bungum these perceived differences in athletic perfor- et al., 1996), although the exact mechanisms mance were also flawed by numerous problems. remain speculative. Sita and Miller (1996) noted Discrepancies in the timing of testing, inaccurate that higher oestradiol levels at different phases documentation of cycle phase, the use of small of the menstrual cycle contribute to a lowering numbers of untrained subjects and a variety of of the cardiovascular responses to stress, most physiological tests make accurate interpretation likely through an effect on arterial wall tone as of the results difficult if not impossible. Testing well as a decrease in b-receptor sensitivity to protocols have generally used either a treadmill catecholamines. · or cycle ergometer and have measured VO2max or On the other hand, progesterone may increase submaximal oxygen uptake. Field studies exam- cardiac excitability by its opposing effects on ining the performance of adolescent swimmers oestrogen. Rosano et al. (1996) documented an found it best in the postmenstrual or menstrual increase in the number and duration of episodes phase and worst in the premenstrual phase or at of paroxysmal supraventricular tachycardia the beginning of menses (Bale & Nelson, 1985; during the late luteal phase that was positively Brooks-Gunn et al., 1986), while similar testing in correlated with plasma progesterone levels and older swimmers did not reveal any performance inversely correlated with plasma oestradiol changes (Quadagno et al., 1991). A study of cross- levels. Birch and Reilly (1997) examined cyclic country skiers, using BBT and cervical mucus to variations in physiological responses to repeated pinpoint cycle phase, showed performance to be lifting. They found that the heart rate response best in the postovulatory and postmenstrual was elevated by approximately 10beatsmin–1 phases (Fomin et al., 1989). Others have observed during the postovulatory phase of cycle. Other a higher incidence of injuries in female soccer investigators have also demonstrated a higher players during the premenstrual and menstrual heart rate during this phase and have suggested phases, especially in those women with signi- that greater cardiovascular strain occurs at this ficant premenstrual symptoms (Möller-Nielson time (Schoene et al., 1981; Hessemer & Bruck, & Hammar, 1989). Dalton (1960) hypothesized 1985b; Pivarnik et al., 1992). These fluctuations in lowered judgement and slower reaction time as functional capacity are also associated tempo- causative factors for an increased accident rate rally with body temperature and body mass during these phases. The results of these early increases, so it is difficult to pinpoint the cause studies are summarized in further detail else- with any certainty. where (Lebrun, 1993, 1994). There appears to be Oestrogen-related vasodilation, increased great interindividual variability in responses capillary membrane permeability/reactivity and menstrual cycle and oral contraceptives 45

possible shifts in plasma volume in the luteal tion varies with menstrual phase, being twice as phase may require cardiovascular compensation. great in the progesterone phase as in the oestro- The only study that has examined this in any gen phase (Coburn, 1970). detail did not use serum progesterone measure- Endurance-trained athletes exhibit decreased ments (Gaebelein & Senay, 1982). A more recent hypoxic and hypercapneic respiratory drives study, utilizing menstrual diaries and BBT both at rest and during exercise and this is changes only, noted transient increases in plasma thought to be a factor in their success. Therefore, volume during the menstrual cycle that reached any menstrual-cycle changes that affect respira- an initial peak within 2 days of the estimated day tory drives have the potential to interfere with of ovulation and progressively increased during performance. The increase in hypercapneic ven- the luteal phase, peaking 2–3 days prior to men- tilatory response is believed to be due to the struation (Fortney et al., 1994). Van Beek et al. ability of progesterone to lower the threshold of (1996) studied peripheral haemodynamics and the medullary respiratory centre and increase its renal function during the follicular and luteal excitability. The higher ventilatory rate during phases of the cycle in nine ovulatory subjects. the luteal phase of the cycle is associated with a Arterial blood pressure, vascular tone and blood greater oxygen demand as well as subjective dys- flow to forearm and kidneys were similar, but the pnoea. However, Schoene et al. (1981) reported blood flow to the skin was consistently lower and no significant cycle-phase differences in exercise the glomerular filtration rate higher during the performance in eumenorrhoeic athletes in con- luteal phase of the cycle. Any changes in haemo- trast to non-athletes, who had a greater per- globin concentration that have been documented ceived exertion during the luteal phase. over the menstrual cycle are small and probably A recent phenomenon that has been identified due to shifts in plasma volume. Given the over- is hormonal interaction and airway dysfunc- riding adaptations of the cardiovascular system tion in a subgroup of female asthmatic patients. to exercise, it is doubtful that these cycle- The effect appears to be greater in severe com- phase alterations in haemodynamics signifi- pared with mild asthma (Gibbs et al., 1984). Pre- cantly affect exercise performance. menstrual aggravation of asthma can be seen in 15–20% of female patients with asthma, although on many occasions the women themselves are Menstrual cycle and respiratory function unaware of this variation. Pauli et al. (1989) mon- Under the influence of higher progesterone itored the effect of cycle phase documented by levels, minute ventilation and maximal exercise hormonal measurements on daily records of response are increased during the luteal phase, asthma symptoms and measurements of peak as is respiratory drive (Schoene et al., 1981; expiratory flow rate in 11 asthmatic and 29 Dombovy et al., 1987; Dutton et al., 1989). Respi- control subjects. The authors found an increase in ratory muscle endurance is also affected by cycle asthma symptoms from the follicular to the phase, being greatest in the luteal phase (Chen & luteal phases and a decrease in morning peak Tang, 1989). It has been suggested that the pul- flows. Nevertheless, there were no correlations monary diffusing capacity of carbon monoxide between changes in spirometry, airway reactivity

(DLCO) is lowest on the third day of menstrual as measured by a methacholine challenge test flow (9% decrease) when progesterone and and absolute levels of either circulating proges- oestrogen levels are low and highest just prior to terone or oestrogen. In another study, only 5 of 14 menses, with no associated changes in haemo- women reported premenstrual worsening of globin or carboxyhaemoglobin (Sansores et al., asthma symptoms at the time of enrolment, but 1995). However, this particular study did not use all 14 had >20% decrease in peak expiratory flow serum progesterone levels to measure cycle rate and/or increase in symptoms premenstru- phase. Endogenous carbon monoxide produc- ally during the study itself (Chandler et al., 1997). 46 physiology of the female athlete

Administration of exogenous oestradiol resulted onset of a sudomotor, vasomotor and shivering in a significant improvement in asthma symp- response appears to be moderated by changes in toms and dyspnoea index scores, an effect that either the central thermoreceptor cycle with no did not appear to be related to b2 receptors. changes in either the thermosensitivity or the The relevance of these findings remains specu- slope of the response (Kolka & Stephenson, 1989; lative. In addition, it is thought that ventilation at Stephenson & Kolka, 1993). rest is controlled by central and peripheral In terms of sports performance, there are some chemoreceptors, while during exercise neuro- hypothetical disadvantages for women perform- genic factors predominate. The changing hor- ing prolonged exercise in the heat during the monal patterns during the menstrual cycle may luteal phase of their cycle. Some investigators affect ventilatory control mechanisms differen- have demonstrated the variation in core tem- tially. It would be interesting to focus on the perature but no differences in response to short- population of female athletes with asthma and term exercise or heat exposure (Wells & Horvath, more specifically those women with exercise- 1973, 1974; Stephenson et al., 1982; Hessemer & induced asthma. Bruck, 1985a,b). Others have found an increase in heart rate and rating of perceived exertion (RPE) at the same intensity of exercise during the luteal Menstrual cycle and thermoregulation phase (Schoene et al., 1981; Hessemer & Bruck, The most obvious parameter to change through- 1985b; Pivarnik et al., 1992; Birch & Reilly, 1997) out an ovulatory menstrual cycle is core body and theorized a greater degree of cardiovascular temperature, due to the central thermogenic strain. Differences in the thresholds for shivering action of progesterone. Carpenter and Nunneley and sweating have also been corroborated (1988), among others, have documented the without any measurable impact on performance luteal-phase increase in core body temperature (Hessemer & Bruck, 1985a). along with a slight fall in temperature around the time of ovulation. The exact dynamics of these Menstrual cycle and metabolic rate shifts have been the basis of many studies; however, it is extremely difficult to separate ther- Energy and macronutrient intakes vary across moregulation from fluid volume or cardiovascu- the course of an ovulatory menstrual cycle as lar regulation. Frascarolo et al. (1990) measured does energy expenditure. Basal and sleeping metabolic heat production by indirect calorime- metabolic rates are elevated during the postovu- try and total heat loss by direct calorimetry and latory or luteal phase and are lowest just before did not observe any significant changes between ovulation (Solomon et al., 1982; Bisdee et al., follicular and luteal phases (as documented by 1989). The putative cause is thought to be the progesterone levels). They postulated that a increase in progesterone levels, but the associ- decrease in thermal conductance allowed for ated temperature changes may also be a factor. maintenance of a higher internal temperature. Greater 24-hour energy expenditure has also Grucza et al. (1993) reported a greater tempera- been noted during the luteal phase (Webb, 1986). ture threshold and larger gains for sweating In a study by Dalvit (1981), energy intakes during the luteal phase compared with the were approximately 2.1kJ·day–1 (0.5kcal·day-1) follicular phase. Hirata et al. (1986) did not higher during the 10 days before the onset of find any menstrual-phase differences in finger menses than after, but there were no hormonal blood flow during exercise, and proposed measurements to substantiate cycle phase or that the thermoregulatory vasodilator response examine correlations. Barr et al. (1995) also was attenuated by increasing exercise-induced found that spontaneous energy intakes varied vasoconstrictor tone in proportion to exercise according to the phase of the cycle, being greater intensity. During the luteal phase, the shift to a during the luteal phase. Interestingly, anovula- higher core or mean body temperature for the tory women did not show any differences. menstrual cycle and oral contraceptives 47

ties of submaximal treadmill exercise (10min at Menstrual cycle and substrate metabolism · 35%, 10min at 60% and 10min at 75% VO2max) As both oestrogen and progesterone promote in nine eumenorrhoeic women. Cycle phases glycogen uptake and storage and modify glyco- were determined by measurements of BBT but gen utilization, theoretically energy metabolism substantiated by urinary total oestrogen and should be more efficient during the luteal phase pregnanediol (progesterone metabolite). At the when both oestrogen and progesterone levels are low and moderate exercise intensities, carbohy- high. Muscle biopsy data have revealed an drate utilization and oxidation rates were lower increase in muscle glycogen storage during this during the mid-luteal phase in association with time (Nicklas et al., 1989) that was associated greater lipid utilization and oxidation. At the with a non-significant trend towards improved highest exercise intensity, no differences in sub- endurance times on a cycle ergometer at 70% strate metabolism were discernible between · VO2max. Another study found that resting muscle testing phases. However, a more recent study glycogen was highest during the time of ovula- (also using BBT in association with urinary tion (Hackney, 1990). There is also thought to be hormone levels) did find a difference in lactate greater protein catabolism during exercise in the levels at 3 and 30min into recovery following luteal phase as measured by increased urea nitro- an incremental treadmill run to exhaustion gen excretion (Lamont et al., 1987). (McCracken et al., 1994). There were no differ- Blood lactate levels during different phases of ences between mid-follicular and mid-luteal the menstrual cycle are contradictory. Eston and phases in either resting blood lactate levels or Burke (1984) studied exercise responses in 21 running time to exhaustion in the nine athletes in physical education students and did not find any this study. Recovery lactate levels, however, were difference in lactate or RPE values or any other significantly lower during the luteal phase, again physiological parameters. However, the luteal suggesting a preferential metabolism of lipid phase was only documented by an increase in and a reduction in the degree of carbohydrate BBT of 0.4°C. Of the studies utilizing hormonal metabolized. measurements, several have suggested a luteal- Investigations in this area are greatly influ- phase decrease in lactate production associated enced by the level of training and relative fitness with an increase in endurance time (Jurkowski et of the individual. Subjects should also be car- al., 1978, 1981; Dombovy et al., 1987; Lavoie et al., bohydrate replete in order to minimize any bias 1987). Others have not replicated this enhanced due to compromised nutrition. There appears to luteal-phase performance (Lebrun, 1995). Many be a deterioration in carbohydrate metabolism other authors have been unable to demonstrate during the luteal phase of the menstrual cycle. any significant differences in lactate during the The complex metabolic effects of the female sex menstrual cycle (Bonen et al., 1983; Lamont, 1986; steroids lead to elevated glucose levels, increased De Souza et al., 1990; Kanaley et al., 1992; Bemben area under the curve of a glucose tolerance test et al., 1995). This may be due to discrepancies and glycosuria, although again nutritional status in testing protocol, exercise intensity or pre- is a confounding variable. Other investigators exercise nutritional status. have not shown a substantial change in blood Some investigators have documented a lower glucose during the cycle (Nicklas et al., 1989; RER during the luteal phase, suggesting an Bonen et al., 1991; Kanaley et al., 1992). increased reliance on FFA for fuel, while others have not. One author documented greater fat Menstrual cycle and strength utilization and oxidation at ovulation under the influence of higher oestrogen levels (Hackney, Investigators have looked at various indices such 1990). In another study, Hackney et al. (1994) as handgrip strength, strength and endurance of further examined the responses of substrate knee flexion and extension, leg press and bench metabolism to progressively increasing intensi- press throughout the menstrual cycle. The major- 48 physiology of the female athlete

ity of these studies have not noted any significant receptors it is possible that oestrogen has a effects of menstrual phase, although they have delayed onset of action. The magnitude of the been carried out without hormonal documenta- change is about 10–11%, and in one study was tion (Higgs & Robertson, 1981; Dibrezzo et al., accompanied by a significant slowing of relaxa- 1991; Quadagno et al., 1991). The only prospec- tion and increase in fatiguability at mid-cycle tive study of this nature using hormonal mea- (Sarwar et al., 1996). Progesterone does not surements (Lebrun, 1995) did not find any appear to have any substantial effects on muscle variation in isokinetic strength of knee flexion strength or function. and extension between follicular and luteal Other investigators have demonstrated oestro- phases. gen and progesterone receptors localized to syn- Several of the earliest studies have shown oviocytes in the synovial lining of the knee, slight but contradictory variations. For example, fibroblasts in the stroma of the anterior cruciate the best achievement in hip strength (flexion and ligament and cells in the blood vessel walls of extension) and standing broad jump in a group the ligaments in both males and females (Liu of collegiate volleyball and basketball players et al., 1996). There are potential implications for was found during the premenstrual phase increased laxity of the anterior cruciate ligament (Wearing et al., 1972). One study (using BBT only) during the luteal phase. This may be one mecha- demonstrated a decrease in isometric hand- nism explaining the increased incidence of ante- grip endurance of forearm contraction during rior cruciate ligament injuries in female soccer the luteal phase (Petrofsky et al., 1976), with the and basketball players compared with males at highest value in the ovulatory phase and the the same competitive level (Arendt & Dick, lowest midway through the luteal phase. There 1995), although other neuromuscular perfor- was no difference over the menstrual cycle in the mance characteristics, such as gender differences isometric strength of the forearm muscles. Wirth in muscle strength, recruitment order and peak and Lohman (1982) found that maximal volun- torque production, are probably of more impor- tary contraction of handgrip was significantly tance (Huston & Wojtys, 1996). greater during the follicular phase. Davies et al. (1991) investigated changes in handgrip strength Menstrual cycle and aerobic performance and standing long jump during the menstrual, ovulatory and luteal phases. They found a sig- In general, maximal oxygen capacity and sub- nificantly stronger handgrip during the men- maximal exercise responses do not appear to be strual phase and attributed this to lower altered during a regular ovulatory menstrual oestrogen and progesterone levels, despite the cycle (De Souza et al., 1990; Bemben et al., 1995). fact that they did not have any supportive The results of research using hormonal docu- evidence from blood measurements. mentation of cycle phase are summarized in Testosterone has the potential to play a role in Table 3.2. One study of 16 élite athletes did find a · the variation in strength during the menstrual slight decrement in VO2max of borderline statisti- cycle because testosterone receptors are present cal significance during the luteal phase (Lebrun, in muscle, and blood levels of this hormone are 1995). Some investigators have found a luteal- increased at the time of ovulation. However, phase increase in oxygen consumption that was there is also a suggestion that strength peaks abolished by subsequent exercise (Wells & during the follicular phase just before ovulation Horvath, 1974). Others have measured a 5.2% · (Phillips et al., 1996) or at mid-cycle (Sarwar et al., increase in VO2 during exercise associated with a 1996) due to the stimulatory effect of oestrogen. 5.6% increase in metabolic rate and a 5.3% There was no direct correlation with oestradiol decrease in net efficiency during the luteal phase levels in the study by Phillips et al. (1996), but if (Hessemer & Bruck, 1985b). the mechanism is through the classic steroid Running economy, defined as the rate of menstrual cycle and oral contraceptives 49

Table 3.2 Effects of menstrual-cycle phase on sports performance: studies with hormonal documentation of cycle phase. (Adapted from Lebrun, 1993)

No. of . o Reference subjects V 2max Performance tests Results . -1 o Bemben et al. 5 ~ 3.0l·min V 2max (treadmill), No significant differences (1995) incremental to exhaustion between early/late follicular and. mid-luteal o phases in V 2max, maximum ventilation, post-exercise lactate and time to exhaustion. However relative ventilatory threshold at higher. percentage of o V 2max in early-follicular compared with mid- luteal and late-follicular phases . -1 -1 o De Souza et al. 8 (N, T) 53.4ml·kg ·min V 2max (treadmill) No. significant differences -1 -1 o (1990) 8 (A, T) 55.4ml·kg ·min Submaximal. test: 40min at in V 2max or in any o 80% V 2max submaximal tests in either group or between phases . -1 -1 o Dombovy 8 (U) 34.4ml·kg ·min V 2max (bicycle ergometer); No. significant differences o et al. (1987) then constant load for 4min in V 2max, maximum above and below anaerobic exercise duration, work threshold efficiency or maximum workload

-1 -1 Hackney et al. 9 (T) 46.0 ± 2.6ml·kg ·min 30-min graded treadmill. run: No. signi. ficant. differences o e o co (1994) 1–10min, ~ 35% .V 2max in V , V 2 or V 2 o 11–20min, ~ 60 V 2max between phases; mean .o 21–30min, ~ 75% V 2max RER at 35% and 60% intensities is lower in mid-luteal compared with mid-follicular phase

-1 Hessemer & 4 (U) 2.81l·min Bicycle ergometer: 15min at 5.2%. increase in mean o Bruck (1985b) 6 (T) 18°C between 03.00 and V 2, 5.6% increase in 04.00 metabolic rate and 5.3% decrease in net efficiency during luteal phase . -1 -1 o Horvath & 4 (T) 39.0ml·kg ·min Treadmill. walk at 30% Highest resting V 2max o Drinkwater V 2max at 28, 35 and 48°C during luteal phase. (1982) Greater relative decrease in plasma volume during luteal phase following exercise at 48°C

-1 -1 Jurkowski 9 (T) 41.8ml·kg ·min Bicycle ergometer:. Time to exhaustion o et al. (1981) 20min at 30–35% V. 2max longer in luteal phase o 20min at. 60–66% V 2max (1.57 ± 0.32 vs. 2.97 ± o 85–90% V 2max to exhaustion 0.63min)

Continued p. 50 50 physiology of the female athlete

Table 3.2 (Continued)

No. of . o Reference subjects V 2max Performance tests Results . . -1 -1 o o Lebrun (1995) 16 (T) 53.7ml·kg ·min V 2max (treadmill); time. to Slight decrease in V 2max -1 o 3.19l·min exhaustion at 90% V 2max; in luteal phase (P = 0.04), anaerobic endurance no other significant differences

-1 -1 McCracken 9 (T) 46.0 ± 2.6ml·kg ·min Treadmill run:. No differences in running o et al. (1994) 1–10min at 35% V. 2max time to exhaustion or in o 11–20min at 60% V. 2max resting lactate levels; but o 21–30min at 75%. V 2max recovery lactates at ~ 3 o then at ~ 90% V 2max to and 30min after exercise exhaustion lower in luteal phase Nicklas 6 (T) 44.9ml·kg-1·min-1 Bicycle ergometer: Borderline increase in et al. (1989) exercise to exhaustion,. endurance time during o 90min at 60% V 2max luteal phase (P < 0.07), followed by four. 1-min associated with increased o sprints at 100% V 2max muscle glycogen 3 days rest, 60% carbohydrate diet, exercise time. to fatigue at 70% o V 2max, muscle biopsies for glycogen

-1 -1 Pivarnik 9 (T) 43.2ml·kg ·min Bicycle. ergometer: 60min at No significant differences o et al. (1992) 65% V 2max in performance, but an increase in cardiovascular strain and RPE during luteal phase

Robertson & 14 12-min. submaximal run at Endurance performance o Higgs (1983) 90% V. 2max; all-out run at decreased in early menses o 100% V 2max compared with mid- follicular phase and increased in mid-luteal phase . -1 -1 o Schoene et al. 6 (U) 35.2ml·kg ·min V 2max (bicycle ergometer): Maximal exercise (1981) 6 (N, T) 49.6ml·kg-1·min-1 exercise time to exhaustion response better in 6 (A, T) follicular phase in non- athletes only . -1 -1 o Williams and 8 (T) 50.7 ± 2.8ml·kg ·min At rest and running on Resting V 2 and Krahenbuhl treadmill. at speeds of 55 and ventilation higher in mid- o (1997) 80% of V 2max; five cycle luteal compared with phases mid-follicular phase; running. economy at 55% o V 2max not. different, but o at 80% V 2max, economy significantly less in mid- luteal phase

A, amenorrhoeic; N, eumenorrhoeic; T, trained; U, untrained. RER, respiratory exchange ratio; RPE, rating of perceived exertion. menstrual cycle and oral contraceptives 51

· oxygen consumption (VO2) during a given management of dysmenorrhoea and PMS as well submaximal steady-state running speed, is as for protection of bone density (Haberland et probably a more accurate indicator of perfor- al., 1995). In the absence of medical contraindica- mance than maximal oxygen capacity. Williams tions (Table 3.3), they can now be safely adminis- and Krahenbuhl (1997) studied eight eumenor- tered to women from either the age of 16 or 3 rhoeic runners at rest and at speeds correspond- years past menarche (Committee on Sports ing to 55% and 80% of their maximal oxygen Medicine, American Academy of Pediatrics, · consumption. Measurements of VO2, proges- 1989) until the perimenopausal years. Despite terone and mood scores were taken at five dif- the known health benefits of OCs (Table 3.4), ferent phases of the cycle: early follicular, late many athletes still fear alterations in their sports follicular, early luteal, mid-luteal and late luteal. performance. Given that a wide age range of At 80%, but not at 55%, of maximal speed, physically active females may be taking these running economy was significantly less during medications, it is somewhat surprising that rela- the mid-luteal compared with the early-follicular tively little is known in this area. phase. There were associated changes in ven- tilatory drives and fluctuations in mood state (Williams & Krahenbuhl, 1997). Table 3.3 Contraindications to oral contraceptives

Absolute contraindications Oral contraceptives Thromboembolic disorders Cerebrovascular accident Contraceptive options for the female athlete Coronary occlusion Impaired liver function Athletic women during their reproductive Oestrogen-dependent neoplasia years frequently require contraception. ‘Natural’ Undiagnosed vaginal bleeding family planning is not usually a viable option Carcinoma of the breast because of the high prevalence of menstrual- Relative contraindications cycle alterations in this physically active popula- Hypertension [diastolic blood pressure > 90mmHg tion. Spermicides and barrier methods, such as (> 12kPa)] Hyperlipidaemia the condom, diaphragm or cervical cap, are Abnormal glucose tolerance popular due to lack of side-effects, including any Renal, hepatic or gallbladder disease perceived impact on performance. In addition, Migraine headaches they provide protection from sexually trans- Depression mitted diseases; however, they are less reliable Recent major elective surgery than other methods and demand responsibility and consistency of use. The intrauterine device is more effective in preventing pregnancy but has the disadvantage of increasing menstrual Table 3.4 Health benefits of oral contraceptives cramping and monthly blood loss, both of which may adversely affect the competitive female Elimination or reduction in dysmenorrhoea athlete. Reduction in menstrually induced iron-deficiency anaemia Previous estimates have suggested that Reduced risk of endometrial and ovarian cancer 12–42% of female athletes preferentially use OCs Reduced incidence of benign breast lesions, pelvic (Shangold & Levine, 1982; Jarrett & Spellacy, inflammatory disease, ovarian cysts, ectopic 1983). This proportion is somewhat lower than pregnancy, rheumatoid arthritis in the general population but has probably Reduced risk of endometrial hyperplasia Prevention of premature osteoporosis in amenorrhoeic increased in recent years. OCs are prescribed not athletes only for contraception but also for cycle control, 52 physiology of the female athlete

Side-effects of oral contraceptives Oral contraceptives and the cardiovascular system Early contraceptive preparations consisted of much higher dosages than those in current use: As previously discussed, the steroid hormones contemporary OCs have a threefold to fourfold can precipitate certain alterations in the haema- decrease in oestrogen content and a 10-fold tological and cardiovascular systems, although decrease in progestin. In addition, the develop- there is not universal agreement on any corre- ment of the second- and third-generation prog- sponding impact on performance. Research in estins has further attenuated adverse androgenic this area is complicated by multiple factors, effects such as weight gain and fluid retention. including the wide range of OCs on the market, As a result, it is likely that any significant the fitness level of the subjects, testing protocols changes in athletic performance are also and exercise-induced shifts in plasma volume. lessened. Antithrombin III, which accounts for at least 50% For both the younger and more mature athlete, of the anticoagulant activity of the blood, is pri- beneficial side-effects include a reduction in dys- marily affected in a dose-dependent fashion by menorrhoea, PMS, menorrhagia and iron- the oestrogen component of the pill. Oestrogen deficiency anaemia secondary to excessive also causes enhanced platelet aggregation and an monthly blood loss. The frequency of dysfunc- increase in various coagulation factors. Formu- tional uterine bleeding, common in both adoles- lations containing 35mg or less of ethinyloestra- cents and perimenopausal women, is diminished diol theoretically have a lower thrombogenic (Burkman, 1994). A decrease in functional potential, and there is evidence that administra- ovarian cysts and benign breast disease may also tion of such an OC containing norethindrone did contribute to improved quality of active daily life not have any adverse effects on haemostatic for training and competition (Grimes, 1992). mechanisms in moderately active women Reports of significant adverse effects, such as (Notelovitz et al., 1987). mood and libido changes, headache, melanoma, Regular physical activity has many health ben- gallbladder disease, liver tumours, exacerbation efits in terms of prevention of coronary artery of sickle-cell disease, teratogenesis and ‘postpill’ disease and atherosclerosis. Are female athletes amenorrhoea or infertility, have largely been dis- who take OCs introducing a significant cardio- proved by better analysis of the existing data vascular risk factor that may negate the advan- (Goldzieher & Zamah, 1995). Of more concern tages of their improved fitness levels? Exercise are potential cardiovascular and thrombotic itself has an anticoagulatory effect and has been complications, including myocardial infarction, observed to act synergistically with some OCs to embolic stroke and venous thrombosis (Carr & increase fibrinolytic activity (Huisveld et al., Ory, 1997). Healthy non-smoking women who 1982, 1983). A more recent paper reported that are current or past users of OCs do not appear to the changes in the fibrinolytic system induced have an increased risk of either myocardial by physical exercise are not affected by OCs (De infarction or stroke. In fact, the oestrogen in OCs Paz et al., 1995). Detrimental changes in serum may have direct cardioprotective effects on the triglycerides, cholesterol and blood pressure are walls of the coronary vessels. The oestrogen com- minimized by OCs containing the newer prog- ponent of OCs also exerts a favourable action on estins, but are still detectable. In addition, regular lipoproteins, which may be opposed by the non- conditioning exercise appears to attenuate any beneficial effect of the progestin component. observed impact on plasma lipids (Gray et al., 1983; Merians et al., 1985). Increases in blood pressure are usually mani- fest during the first few months of use, may diminish over time and are generally reversible menstrual cycle and oral contraceptives 53

· on discontinuation of the pill. The postulated tidal volume, total minute ventilation and VCO2 mechanism is related to increased liver synthesis that were greater at 3 months than at 6 months, of angiotensinogen, a precursor of angiotensin, suggesting some degree of accommodation to and decreased renin secretion from the kidney. this effect. A different study with another Exercise itself also causes physiological stimula- monophasic OC measured an increase in oxygen tion of the renin–angiotensin system, an effect consumption for standardized workloads on a that has been shown in at least one study to be cycle ergometer (McNeill & Mozingo, 1981). If suppressed in women taking OCs (Huisveld et ventilation increases, then there may be a con- al., 1985). Recent data suggest that administra- comitant increase in the work of breathing and tion of combination OCs may be associated hence oxygen consumption. However, two with an increase in systolic blood pressure of recent studies that demonstrated a slight decre- between 2 and 7mmHg (0.26–0.93kPa) and in ment in aerobic capacity with administration of a diastolic pressure of between 1 and 3mmHg low-dose OC did not document any associated (0.13–0.4kPa). For the majority of women on ventilatory changes (Notelovitz et al., 1987; C.M. OCs, these small changes do not have any clinical Lebrun et al., unpublished observation). An implications. alternative explanation for increased oxygen Theoretical cardiovascular advantages, such consumption in women using OCs may be as increases in preload and stroke volume of the differences in the metabolic cost of releasing heart due to fluid retention, may augment the energy from various substrates, such as FFA and effective cardiac output and enhance perfor- glycogen. mance. Seaton (1972) documented a higher pul- monary capillary blood volume in women on Oral contraceptives and energy metabolism a variety of OCs, comparable to values in the second half of the cycle in a control group. A The interaction of OCs with systems regulating higher cardiac output has been demonstrated energy metabolism are somewhat more complex with several higher dosage combination pills, (Table 3.5). The oestrogen dose, as well as the both at rest and during exercise, either with or type and dose of the progestin, modulate the without concomitant alterations in blood pres- overall metabolic impact of a given OC combina- sure and vascular volume (Walters & Lim, 1969; tion. Glucose production, both at rest and during Littler et al., 1974; Lehtovirta et al., 1977). Low- exercise, is primarily determined by insulin, oestrogen monophasic OCs containing lev- although other hormones such as thyroxine, onorgestrel have also been reported to increase the catecholamines, cortisol and GH can have blood pressure depending on the dose of lev- a counter-regulatory effect. GH levels can be onorgestrel, although triphasic preparations and increased by high doses of oestrogen and OCs with the newer progestins appear to have decreased by progestins. Progesterone causes little effect. For the most part, heart rate at rest reduced insulin binding secondary to a decrease and during exercise has not been shown to in insulin receptor concentration, both in the change significantly with administration of luteal phase of the cycle and when administered OCs. in a combination OC. The more androgenic prog- estins have the greatest detrimental impact on glucose transport and insulin secretion. Oral contraceptives and the respiratory system Norgestrel and levonorgestrel are the most Ventilatory changes have been documented in potent in this regard (Sondheimer, 1991). Depot users of two different monophasic OCs. Montes medroxyprogesterone acetate also increases the et al. (1983) studied 12 women taking two differ- insulin response, but norethindrone alone does · ent OCs and found no changes in VO2, either at not appear to have any significant effects. rest or during exercise. There were increases in Oestrogens and progesterone in combination 54 physiology of the female athlete

Table 3.5 Factors influencing substrate metabolism half-life, or by direct opposition, as with during endurance exercise megestrol. There are no conclusive detrimental or benefi- Endurance training and cardiorespiratory fitness Exercise intensity and duration cial effects on energy metabolism and sports per- Muscle morphology and histology formance. Some studies have shown an increase Fibre distribution type and enzyme activity in FFA levels during mild exercise and lower Succinate dehydrogenase blood glucose levels at rest and during exercise Malate dehydrogenase in OC users (Bonen et al., 1991). Women on OCs Hormones Stress hormones have an elevated GH response to exercise as well Catecholamines as lower glucose and carbohydrate use, with a Cortisol shift more towards FFA metabolism (Bemben et Growth hormone al., 1992). There is an overall glycogen-sparing Insulin effect of the OCs and, theoretically, therapy with Somatotrophin Thyroid hormones the ‘right’ OC might potentially provide a com- Gonadotrophic hormones petitive advantage during prolonged intense Testosterone exercise. Bemben (1993) has proposed a theo- Oestrogen retical model for the potential impact of OCs on Progesterone hormonal responses and substrate utilization Cellular mechanisms Insulin receptors during prolonged exercise (Fig. 3.3). Glucose transporters (GLUT-4) Results are complicated by many other vari- Diet and nutrition ables, including pre-exercise nutritional status Glycogen status and the interaction of endogenous opioids Before event released during exercise, which can also be inde- During exercise Blood glucose homeostasis pendently affected by the steroid components in OCs. Greater ability to spare carbohydrate may be advantageous for prolonged exercise, but lower blood glucose levels may reflect decreased hepatic output (Bemben et al., 1992). OCs lead to a relatively consistent impairment of Alternatively, stimulation of lipolysis by GH glucose tolerance and varying degrees of hyper- might be a compensatory response to low blood insulinaemia. Fasting glucose concentrations are glucose levels. To investigate these metabolic also reduced in OC users. Postulated causative effects further, substrate turnover studies, con- factors include reduced insulin receptor concen- trolling for all other variables, would be ideal. trations, increased FFA levels, increased GH concentrations, changes in alimentary absorp- Oral contraceptives and sports performance tion of glucose, increased glucocorticoid activity and disturbances in tryptophan metabolism Investigations reported in the literature are not in (Godsland, 1996). The latter action is mainly complete agreement about the potential physio- mediated through increased activity of the logical impacts of these synthetic sex steroids enzyme tryptophan pyrrolase (increased by on athletic performance. Anecdotally, Bale and oestrogens), leading to a deficiency in vitamin Davies (1983) noted a performance enhancement

B6. By inference, there may be potential for im- in 8% of women on OCs. Some studies have provement in glucose tolerance in OC users by documented fewer musculoskeletal injuries in administration of pyridoxine. The progestogen women taking OCs, probably secondary to an component may modify these oestrogen- amelioration of symptoms of PMS and dysmen- induced changes by decreasing oestrogen elimi- orrhoea (Möller-Nielson & Hammar, 1989, 1991). nation, via alterations in lipolytic rate or insulin In élite athletes, the menstrual cycle can be menstrual cycle and oral contraceptives 55

Hormone changes with OC use

Growth hormone Insulin sensitivity Insulin:glucagon ratio

Lipolysis Blood glucose Hepatic glucose Gluconeogenesis uptake release Triglyceride synthesis Adipose tissue Liver

Free fatty Blood acids Carbohydrate triglycerides utilization Free fatty acid availability

Skeletal muscle

Fig. 3.3 Theoretical model for the potential impact of oral contraceptive (OC) use on hormonal responses and sub- strate utilization during prolonged exercise. (From Bemben, 1993 with permission.)

manipulated around the time of important com- native methods of birth control must be used to petitions by extending the duration of active pills protect against unwanted pregnancy. or the highest dose in a triphasic preparation. It is less clear if there are any significant physi- This can usually stave off menstruation success- ological performance-altering effects of steroid fully for at least 7–10 days, although Sulak et al. contraceptives. An early study by Daggett et al. (1997) were able prospectively to stabilize 37 of (1983) demonstrated a detrimental impact on · 50 patients (74%) on an extended regimen of 6–12 VO2max with administration of a higher-dose OC weeks of consecutive days with active OCs. for 2 months that was reversible on discontinua- Therapeutically, this may decrease the frequency tion of the drug. There was an associated and alter the timing of menstrual-related prob- decrease in mitochondrial citrate, suggesting a lems, including dysmenorrhoea, menorrhagia, possible cellular mechanism. Notelovitz et al. premenstrual-type symptoms and menstrual (1987) studied women on a lower-dose migraines. For the athlete concerned with per- monophasic OC, containing 0.4mg norethin- formance, a better option might be to shorten drone, for 6 months. They also found a slight but · the cycle progressively over a few months by significant change, with a 7% decrease in VO2max decreasing the number of pills, so that the com- and an 8% deterioration in exercise performance petition will occur after menstruation has fin- as measured by oxygen pulse. C.M. Lebrun et al. ished, i.e. in the pill-free interval, in order to (unpublished observations) studied seven diminish any potential hormonal side-effects. women taking a lower-dose triphasic OC for 2 The OC can also be stopped 10 days in advance months compared with a similar group on · of the anticipated competition. Of course, alter- placebo and found a decrement in VO2max that 56 physiology of the female athlete

was not evident in the placebo group. Neither population group for this study consisted of 16 anaerobic capacity nor aerobic endurance were women on eight different OCs and testing in the altered in this study. Recently, Bryner et al. (1996) 10 normal control subjects was determined by prospectively randomized 10 moderately trained the calendar method. In another study of only women to either placebo (n=3) or an OC contain- seven women (three of whom were on different ing 1mg norethindrone and 35µg ethinyloestra- OCs), isometric endurance varied sinusoidally diol (n=7) for 21 days. Subjects were tested twice during the cycle (determined by BBT), with a during a control menstrual cycle, performing a peak value midway through the ovulatory phase · VO2max test and then 48 hours later a treadmill and the lowest value midway through the luteal run to exhaustion at 80% of maximal heart rate. phase; the women on OCs did not show any vari- Testing was repeated during the first and third ation in their test results across the cycle (Petrof- weeks of the treatment month. Serial trans- sky et al., 1976). In another study, isokinetic abdominal ultrasonography of the ovary was strength and endurance of knee flexors used to identify cycle phases in the placebo and extensors did not seem to be affected by group. Neither the cycle phase nor the low- administration of a low-dose triphasic OC dose OC had any significant adverse effects on (C.M. Lebrun et al., unpublished observation). ventilatory frequency or athletic performance Although Sarwar et al. (1996) found menstrual- during the maximal treadmill test or endurance cycle variation of muscle strength, relaxation rate run. and fatiguability in 10 ovulatory women, they did not find any significant changes in a matched group taking a combined monophasic OC. Oral contraceptives and strength Phillips et al. (1996) also found significant Previously it was thought that the androgenic changes in menstruating subjects with no change component of the pill might have an ergogenic in women on OCs. action. In fact, in 1987 the International Olympic Committee seriously considered placing com- Conclusion and recommendations for pounds containing norethindrone on the list of future research banned drugs, on the premise that they might potentially give an unfair advantage in terms of This is a complex and fascinating field for clini- muscle strength and/or because of the possibil- cians, scientists, coaches and athletes alike. ity of masking other anabolic agents. Fortunately Although significant progress has been made in this ruling was successfully overturned by a the understanding of the unique physiology of group of determined physicians and scientists. the female athlete during her reproductive years, More recently, women in the 1994 World there are still many unanswered questions. Are Master’s Games in Australia tested positive for there inherent biological factors that limit the steroids secondary to hormonal replacement ability of women to transport and utilize oxygen therapy containing small amounts of testos- or does the difference represent some factor terone in addition to the oestrogen. This has also amenable to training and sport experience? What been challenged and eliminated as a problem. are the most appropriate and accurate methods The thermogenic effect of progesterone seen of matching male and female subjects on the during the luteal phase of the cycle is minimized fitness factor for comparative studies of oxygen by OCs (Grucza et al., 1993), although with some delivery and utilization systems? of the biphasic or triphasic pills there may be a The evidence points to some influence of slight variation throughout the cycle. This may endogenous female sex steroids on various car- be the basis for the detrimental impact in forearm diovascular, respiratory and metabolic factors. isometric endurance and muscle force output These changes probably have minimal impact on seen by Wirth and Lohman (1982); however, the the ability of most recreational athletes to partici- menstrual cycle and oral contraceptives 57

pate in and enjoy their sport, but may have more and soccer: NCAA data and review of literature. significant impact at the élite level. Is it possible American Journal of Sports Medicine 23, 694–701. Bale, P. & Davies, J. (1983) Effect of menstruation and to clarify further the relationship between contraceptive pill on the performance of physical peripheral concentrations of the steroid hor- education students. British Journal of Sports Medicine mones and their biological actions? What are the 17, 46–50. actions at the end-organ level and how can they Bale, P. & Nelson, G. (1985) The effects of menstruation be quantified? What additional effects can be on performance of swimmers. Australian Journal of Science and Medicine in Sport 17, 19–22. accounted for by plasma volume shifts or Barr, S.I., Janelle, K.C. & Prior, J.C. (1995) Energy changes in production or clearance of the hor- intakes are higher during the luteal phase of ovula- mones? Are the physiological responses linked to tory menstrual cycles. American Journal of Clinical exercise intensity and/or duration with a certain Nutrition 61, 39–43. ‘threshold’? Bauman, J.E. (1981) Basal body temperature: unreliable method of ovulation detection. Fertility and Sterility For female athletes who choose OCs as a 36, 429–433. method of birth control or who may need to take Bemben, D.A. (1993) Metabolic effects of oral contra- them for therapeutic reasons, it is likely that any ceptives. Implications for exercise responses of pre- potential repercussions are lessened by use of the menopausal women. Sports Medicine 16, 295–304. lower-dose triphasic pills and the newer prog- Bemben, D.A., Boileau, R.A., Bahr, J.M., Nelson, R.A. & Misner, J.E. (1992) Effects of oral contraceptives on estins. However, it is necessary to acknowledge hormonal and metabolic responses during exercise. that there may be marked individual effects in Medicine and Science in Sports and Exercise 24, 434– some women. Although these may not achieve 441. statistical significance, they may be of critical Bemben, D.A., Salm, P.C. & Salm, A.J. (1995) Ventila- importance to the affected athlete. More large- tory and blood lactate responses to maximal tread- mill exercise during the menstrual cycle. Journal of scale, prospective, randomized clinical trials are Sports Medicine and Physical Fitness 35, 257–262. required to delineate any advantage of one Birch, K.M. & Reilly, T. (1997) The effect of eumenor- preparation over another. These must be carried rheic menstrual cycle phase on physiological out in trained individuals, using accurate hor- responses to a repeated lifting task. Canadian Journal monal measurements, particularly in the control of Applied Physiology 22, 148–160. groups not on OCs, in order to estimate the phase Bisdee, J.T., James, W.P. & Shaw, M.A. (1989) Changes in energy expenditure during the menstrual cycle. of the menstrual cycle precisely. The biggest British Journal of Nutrition 61, 187–199. benefit of OCs in the athletic population may be Bonen, A., Ling, W.Y., MacIntyre, K.P., Neil, R., maintenance of a predictable hormonal milieu McGrail, J.C. & Belcastro, A.N. (1979) Effects of exer- for training and competition. cise on serum concentrations of FSH, LH, proges- As funding for research in women’s issues terone, and estradiol. European Journal of Applied Physiology 42, 15–23. hopefully continues to increase, there should be Bonen, A., Haynes, F.W., Watson-Wright, W. et al. (1983) many more valid scientific studies addressing Effect of menstrual cycle on metabolic responses to these and other critical problems. The next few exercise. Journal of Applied Physiology 55, 1506–1513. decades should bring a plethora of interesting Bonen, A., Haynes, F.W. & Graham, T.E. (1991) Sub- perspectives to the participation of women in strate and hormonal responses to exercise in women using oral contraceptives. Journal of Applied Physiol- sport and physical activity. ogy 70, 1917–1927. Brooks-Gunn, J., Gargiulo, J.M. & Warren, M.P. (1986) References The effect of cycle phase on the performance of ado- lescent swimmers. Physician and Sportsmedicine 14, Abraham, G.E., Maroulis, G.B. & Marshall, J.R. (1974) 182–192. Evaluation of ovulation and corpus luteum function- Bryner, R.W., Toffle, R.C., Ullrich, I.H. & Yeater, R.A. ing using measurements of plasma progesterone. (1996) Effect of low dose oral contraceptives on exer- Obstetrics and Gynecology 44, 522–525. cise performance. British Journal of Sports Medicine 30, Arendt, E. & Dick, R. (1995) Knee injury patterns 36–40. among men and women in collegiate basketball Bungum, L., Kvernebo, K., Øian, P. & Maltau, J.M. 58 physiology of the female athlete

(1996) Laser Doppler-recorded reactive hyperemia in Diamond, M.P., Wentz, A.C. & Cherrington, A.D. (1988) the forearm skin during the menstrual cycle. British Alterations in carbohydrate metabolism as they Journal of Obstetrics and Gynaecology 103, 70–75. apply to reproductive endocrinology. Fertility and Bunt, J.C. (1990) Metabolic actions of estradiol: signifi- Sterility 50, 387–397. cance for acute and chronic exercise responses. Dibrezzo, R., Fort, I.L. & Brown, B. (1991) Relation- Medicine and Science in Sports and Exercise 22, 286– ships among strength, endurance, weight and body 290. fat during three phases of the menstrual cycle. Burkman, R.T. Jr (1994) Noncontraceptive effects of Journal of Sports Medicine and Physical Fitness 31, hormonal contraceptives: bone mass, sexually trans- 89–94. mitted disease and pelvic inflammatory disease, car- Dombovy, M.L., Bonekat, H.W., Williams, T.J. & Staats, diovascular disease, menstrual function and future B.A. (1987) Exercise performance and ventilatory fertility. American Journal of Obstetrics and Gynecology response in the menstrual cycle. Medicine and Science 170, 1569–1575. in Sports and Exercise 19, 111–117. Carpenter, A.J. & Nunneley, S.A. (1988) Endogenous Dutton, K., Blankskby, B.A. & Morton, A.R. (1989) CO2 hormones subtly alter women’s response to heat sensitivity changes during the menstrual cycle. stress. Journal of Applied Physiology 65, 2313–2317. Journal of Applied Physiology 67, 517–522. Carr, B.R. & Ory, H. (1997) Estrogen and progestin com- England, S.J. & Farhi, L.E. (1976) Fluctuations in alveo- ponents of oral contraceptives: relationship to vascu- lar CO2 and in base excess during the menstrual lar disease. Contraception 55, 267–272. cycle. Respiratory Physiology 26, 157–161. Chandler, M.H., Schuldheisz, S., Phillips, B.A. & Muse, Erdelyi, G.J. (1962) Gynecological survey of female ath- K.N. (1997) Premenstrual asthma: the effect of estro- letes. Journal of Sports Medicine and Physical Fitness 2, gen on symptoms, pulmonary function, and beta2- 174–179. receptors. Pharmacotherapy 17, 224–234. Eston, R.G. & Burke, E.J. (1984) Effects of the menstrual Chen, H.-I. & Tang, Y.-R. (1989) Effects of the menstrual cycle on selected responses to short constant-load cycle on respiratory muscle function. American exercise. Journal of Sports Sciences 2, 145–153. Review of Respiratory Disease 140, 1359–1362. Fomin, S.K., Pivovarova, V.I. & Voronova, V.I. (1989) Coburn, R.F. (1970) Endogenous carbon monoxide Changes in the special working capacity and mental production. New England Journal of Medicine 282, stability of well-trained women skiers at various 207–209. phases of the biological cycle. Sports Training Medi- Committee on Sports Medicine, American Academy of cine and Rehabilitation 1, 89–92. Pediatrics (1989) Amenorrhea in adolescent athletes. Fortney, S.M., Turner, C., Steinmann, L., Driscoll, T. & Pediatrics 84, 394–395. Alfrey, C. (1994) Blood volume responses of men and Cowart, V.S. (1989) Can exercise help women with women to bed rest. Journal of Clinical Pharmacology 34, PMS? Physician and Sportsmedicine 17, 169–178. 434–439. Daggett, A., Davies, B. & Boobis, L. (1983) Physiological Frascarolo, P., Schutz, Y. & Jéquier, E. (1990) Decreased and biochemical responses to exercise following oral thermal conductance during the luteal phase of the contraceptive use (abstract). Medicine and Science in menstrual cycle in women. Journal of Applied Physiol- Sports and Exercise 15, 174. ogy 69, 2029–2033. Dalton, K. (1960) Menstruation and accidents. British Gaebelein, C.J. & Senay, L.C. Jr (1982) Vascular volume Medical Journal 2, 1425–1426. dynamics during ergometer exercise at different Dalvit, S.P. (1981) The effect of the menstrual cycle on menstrual phases. European Journal of Applied Physiol- patterns of food intake. American Journal of Clinical ogy 50, 1–11. Nutrition 34, 1811–1815. Gibbs, C.J., Coutts, I.I., Lock, R., Finnegan, O.C. & Davies, B.N., Elford, J.C.C. & Jamieson, K.F. (1991) Vari- White, R.J. (1984) Premenstrual exacerbation of ations in performance of simple muscle tests at dif- asthma. Thorax 39, 833–836. ferent phases of the menstrual cycle. Journal of Sports Godsland, I.F. (1996) The influence of female Medicine and Physical Fitness 31, 532–537. sex steroids on glucose metabolism and insulin De Paz, J.A., Villa, J.G., Vilades, E., Martin-Nuño, M.A., action. Journal of Internal Medicine 240 (Suppl. 738), 1– Lasierra, J. & Gonzalez-Gallego, J. (1995) Effects of 60. oral contraceptives on fibrinolytic response to exer- Goldzieher, J.W. & Zamah, N.M. (1995) Oral contracep- cise. Medicine and Science in Sports and Exercise 27(7), tive side effects: where’s the beef? Contraception 52, 961–966. 327–335. De Souza, M.J., Maguire, M.S., Rubin, K. & Maresh, Gray, D.P., Harding, E. & Dale, E. (1983) Effects of oral C.M. (1990) Effects of menstrual cycle phase and contraceptives on serum lipid profiles of women amenorrhea on exercise responses in runners. Medi- runners. Fertility and Sterility 39, 510–514. cine and Science in Sports and Exercise 22, 575–580. Grimes, D.A. (1992) The safety of oral contraceptives: menstrual cycle and oral contraceptives 59

epidemiologic insights from the first 30 years. performance characteristics in elite female athletes. American Journal of Obstetrics and Gynecology 166, American Journal of Sports Medicine 24, 427–436. 1950–1954. Jarrett, J.C. & Spellacy, W.N. (1983) Contraceptive prac- Grucza, R., Pekkarinen, H., Titov, E., Kononoff, A. tices of female runners. Fertility and Sterility 37, & Hänninen, O. (1993) Influence of the menstrual 374–375. cycle and oral contraceptives on thermoregulatory Jurkowski, J.E.H., Jones, N.L., Walker, W.E., Younglai, responses to exercise in young women. European E.V. & Sutton, J.R. (1978) Ovarian hormonal re- Journal of Applied Physiology 67, 279–285. sponses to exercise. Journal of Applied Physiology 44, Haberland, C.A., Seddick, D., Marcus, R. & Bachrach, 109–114. L.K. (1995) A physician survey of therapy for Jurkowski, J.E.H., Jones, N.L., Toews, C.J. & Sutton, J.R. exercise-associated amenorrhea: a brief report. Clini- (1981) Effects of menstrual cycle on blood lactate, O2 cal Journal of Sport Medicine 5, 246–250. delivery and performance during exercise. Journal of Hackney, A.C. (1990) Effects of the menstrual cycle on Applied Physiology 51, 1493–1499. resting muscle glycogen content. Hormone and Meta- Kanaley, J.A., Boileau, R.A., Bahr, J.A., Misner, J.E. & bolic Research 22, 647. Nelson, R.A. (1992) Substrate oxidation and GH Hackney, A.C., McCracken-Compton, M.A. & responses to exercise are independent of menstrual Ainsworth, B. (1994) Substrate responses to submax- phase and status. Medicine and Science in Sports and imal exercise in the midfollicular and midluteal Exercise 24, 873–880. phases of the menstrual cycle. International Journal of Kolka, M.A. & Stephenson, L.A. (1989) Control of Sport Nutrition 4, 299–308. sweating during the human menstrual cycle. Euro- Hessemer, V. & Bruck, K. (1985a) Influence of men- pean Journal of Applied Physiology 58, 890–895. strual cycle on shivering, skin blood flow and sweat- Laessle, R.G., Tuschl, R.J., Schweiger, U. & Pirke, K.M. ing responses measured at night. Journal of Applied (1990) Mood changes and physical complaints Physiology 59, 1902–1910. during the normal menstrual cycle in healthy young Hessemer, V. & Bruck, K. (1985b) Influence of men- women. Psychoneuroendocrinology 15, 131–138. strual cycle on thermoregulatory, metabolic and Lamont, L.S. (1986) Lack of influence of the menstrual heart rate responses to exercise at night. Journal of cycle on blood lactate. Physician and Sportsmedicine Applied Physiology 59, 1911–1917. 14, 159–163. Higgs, S.L. & Robertson, L.A. (1981) Cyclic variations Lamont, L.S., Lemon, P.W.R. & Brust, B.C. (1987) Men- in perceived exertion and physical work capacity in strual cycle and exercise effects on protein catabo- females. Canadian Journal of Applied Sport Sciences 6, lism. Medicine and Science in Sports and Exercise 192, 191–196. 106–110. Hirata, K., Nagasaka, T., Hirai, A., Hirashita, M., Taka- Lavoie, J.M., Dionne, N., Helie, R. & Brisson, G.R. hata, T. & Nunomura, T. (1986) Effects of human (1987) Menstrual cycle phase dissociation of blood menstrual cycle on thermoregulatory vasodilation glucose homeostasis during exercise. Journal of during exercise. European Journal of Applied Physiol- Applied Physiology 62, 1084–1089. ogy 54, 559–565. Lebrun, C.M. (1993) Effect of the different phases of the Horvath, S.M. & Drinkwater, B.L. (1982) Thermoregu- menstrual cycle and oral contraceptives on athletic lation and the menstrual cycle. Aviation Space and performance. Sports Medicine 16, 400–430. Environmental Medicine 53, 790–794. Lebrun, C.M. (1994) The effect of the phase of the Huisveld, I.A., Hospers, A.J.H., Bernink, M.J.E., Bier- menstrual cycle and the birth control pill on steker, M.W.A., Erich, W.B.M. & Bouma, B.N. (1982) athletic performance. Clinics in Sports Medicine 13, Oral contraceptives and fibrinolysis among female 419–441. cyclists before and after exercise. Journal of Applied Lebrun, C.M. (1995) Effects of menstrual cycle phase on Physiology 53, 330–334. athletic performance. Medicine and Science in Sports Huisveld, I.A., Hospers, J.E.H., Bernink, M.J.E., Erich, and Exercise 27, 437–444. W.B.M. & Bouma, B.N. (1983) The effect of oral con- Lehtovirta, P., Kuikka, J. & Pyorala, T. (1977) Hemody- traceptives and exercise on hemostatic and fibri- namic effects of oral contraceptives during exercise. nolytic mechanisms in trained women. International International Journal of Gynaecology and Obstetrics 15, Journal of Sports Medicine 4, 97–103. 35–37. Huisveld, I.A., Derkx, F.M.H., Bouma, B.N., Erich, Lindholm, C., Hagenfeldt, K. & Ringertz, B.-M. (1994) W.B.M. & Schalekap, M.A.D.H. (1985) Renin– Pubertal development in elite juvenile gymnasts. angiotensin system: oral contraception and exercise Effects of physical training. Acta Obstetricia et Gyneco- in healthy female subjects. Journal of Applied Physiol- logica Scandinavica 73, 269–273. ogy 59, 1690–1697. Littler, W.A., Bojorges-Bueno, R. & Banks, J. (1974) Car- Huston, L.J. & Wojtys, E.M. (1996) Neuromuscular diovascular dynamics in women during the men- 60 physiology of the female athlete

strual cycle and oral contraceptive therapy. Thorax liminary report. American Journal of Obstetrics and 29, 567–570. Gynecology 156, 591–598. Liu, S.H., Al-Shaikh, R., Panossian, V. et al. (1996) Olson, B.R., Forman, M.R., Lanza, E. et al. (1996) Rela- Primary immunolocalization of estrogen and tion between sodium balance and menstrual cycle progesterone target cells in the human anterior symptoms in normal women. Annals of Internal Medi- cruciate ligament. Journal of Orthopaedic Research 14, cine 125, 564–567. 526–533. Pauli, B.D., Reid, R.L., Munt, P.W., Wigle, R.D. & McCracken, M., Ainsworth, B. & Hackney, A.C. (1994) Forkert, L. (1989) Influence of the menstrual cycle on Effects of menstrual cycle phase on the blood lactate airway function in asthmatic and normal subjects. responses to exercise. European Journal of Applied American Review of Respiratory Disease 140, 358–362. Physiology and Occupational Physiology 69, 174–175. Petrofsky, J.S., LeDonne, D.M., Rinehart, J.S. & Lind, McNeill, A.W. & Mozingo, E. (1981) Changes in the A.R. (1976) Isometric strength and endurance during metabolic cost of standardized work associated with the menstrual cycle. European Journal of Applied Physi- the use of an oral contraceptive. Journal of Sports Med- ology 35, 1–10. icine 21, 238–244. Phillips, S.K., Sanderson, A.G., Birch, K., Bruce, S.A. & Magyar, D.M., Boyers, S.P., Marshall, J.R. & Abraham, Woledge, R.C. (1996) Changes in maximal voluntary G.E. (1979) Regular menstrual cycles and premen- force of human adductor pollicis muscle during the strual molimina as indicators of ovulation. Obstetrics menstrual cycle. Journal of Physiology 496, 551–557. and Gynecology 53, 411–414. Pivarnik, J.M., Marichal, C.J., Spillman, T. & Morrow, Marcus, D.A. (1995) Interrelationships of neurochemi- J.R. Jr (1992) Menstrual cycle phase affects tempera- cals, estrogen and recurring headache. Pain 62, ture regulation during endurance exercise. Journal of 129–139. Applied Physiology 72, 543–548. Merians, D.R., Haskell, W.L., Vranizan, K.M., Phelps, J., Plowman, S.A., Liu, N.Y. & Wells, C.L. (1991) Body Woods, P.D. & Superko, R. (1985) Relationship of composition and sexual maturation in premenar- exercise, oral contraceptive use and body fat to con- cheal athletes and nonathletes. Medicine and Science centrations of plasma lipids and lipoprotein choles- in Sports and Exercise 23, 23–29. terol in young women. American Journal of Medicine Prior, J.C., Vigna, Y.M., Sciarretta, D., Alojado, N. & 78, 913–919. Schultzer, M. (1987) Conditioning exercise decreases Miller, P.B. & Soules, M.R. (1996) The usefulness of a premenstrual symptoms: a prospective, controlled urinary LH kit for ovulation prediction during men- 6-month trial. Fertility and Sterility 47, 402–408. strual cycles of normal women. Obstetrics and Gyne- Prior, J.C., Vigna, Y.M., Schultzer, M., Hall, J.E. & cology 87, 13–17. Bonen, A. (1990) Determination of luteal phase Möller-Nielson, J. & Hammar, M. (1989) Women’s length by quantitative basal temperature methods: soccer injuries in relation to the menstrual cycle and validation against the midcycle LH peak. Clinical and oral contraceptive use. Medicine and Science in Sports Investigative Medicine 13, 123–131. and Exercise 21, 126–129. Quadagno, D., Faquin, L., Lim, G.-N., Kuminka, W. & Möller-Nielson, J. & Hammar, M. (1991) Sports injuries Moffatt, R. (1991) The menstrual cycle: does it affect and oral contraceptive use. Is there a relationship? athletic performance? Physician and Sportsmedicine Sports Medicine 12, 152–160. 19, 121–124. Montagnani, C.F., Arena, B. & Maffuli, N. (1992) Estra- Reinke, U., Ansah, B. & Voigt, K.D. (1972) Effect of the diol and progesterone during exercise in healthy menstrual cycle on carbohydrate and lipid metabo- untrained women. Medicine and Science in Sports and lism in normal females. Acta Endocrinologica 69, Exercise 24, 764–768. 762–768. Montes, A., Lally, D. & Hale, R.W. (1983) The effects of Robertson, L.A. & Higgs, L.S. (1983) Menstrual cycle oral contraceptives on respiration. Fertility and Steril- variations in physical work capacity, post-exercise ity 39, 515–519. lactate, and perceived exertion (abstract). Canadian Mortola, J.F. (1996) Premenstrual syndrome. Trends in Journal of Applied Sports Sciences 8, 220. Endocrinology and Metabolism 7, 184–189. Rosano, G.M.C., Leonardo, F., Sarrel, P.M., Beale, C.M., Nicklas, B.J., Hackney, A.C. & Sharp, R.L. (1989) The De Luca, F. & Collins, P. (1996) Cyclical variation in menstrual cycle and exercise: performance, muscle paroxysmal supraventricular tachycardia in women. glycogen and substrate responses. International Lancet 347, 786–788. Journal of Sports Medicine 10, 264–269. Ruby, B.C. & Robergs, R.A. (1994) Gender differences in Notelovitz, M., Zauner, C., McKenzie, L., Suggs, Y., substrate utilisation during exercise. Sports Medicine Fields, C. & Kitchens, C. (1987) The effect of low-dose 17, 393–410. contraceptives on cardiorespiratory function, coagu- Ruby, B.C., Robergs, R.A., Waters, D.L., Burge, M., lation, and lipids in exercising young women: a pre- Mermier, C. & Stolarczyk, L. (1997) Effects of estra- menstrual cycle and oral contraceptives 61

diol on substrate turnover during exercise in amen- Kuehl, T.J. (1997) Extending the duration of active orrheic females. Medicine and Science in Sports and oral contraceptive pills to manage hormone with- Exercise 29, 1160–1169. drawal symptoms. Obstetrics and Gynecology 89, Sansores, R.H., Abboud, R.T., Kennell, C. & Haynes, N. 179–183. (1995) The effect of menstruation on the pulmonary Tarnopolsky, L.J., MacDougall, J.D., Atkinson, S.A., carbon monoxide diffusing capacity. American Tarnopolsky, M.A. & Sutton, J.R. (1990) Gender dif- Journal of Respiration and Critical Care Medicine 152, ferences in substrate for endurance exercise. Journal 381–384. of Applied Physiology 68, 302–308. Sarwar, R., Niclos, B.B. & Rutherford, O.M. (1996) Turley, K.R. & Wilmore, J.H. (1997) Cardiovascular Changes in muscle strength, relaxation rate and responses to submaximal exercise in 7- to 9-yr-old fatiguability during the human menstrual cycle. boys and girls. Medicine and Science in Sports and Exer- Journal of Physiology 493, 267–272. cise 29(6), 824–832. Schoene, R.B., Robertson, H.T., Pierson, D.J. & Peter- Van Beek, E., Houben, A.J.H.M., Van Es, P.N. et al. son, A.P. (1981) Respiratory drives and exercise in (1996) Peripheral haemodynamics and renal func- menstrual cycles of athletic and nonathletic women. tion in relation to the menstrual cycle. Clinical Science Journal of Applied Physiology 50, 1300–1305. 91, 163–168. Seaton, A. (1972) Pulmonary capillary blood volume in Walters, W.A.W. & Lim, Y.L. (1969) Cardiovascular women: normal values and the effect of oral contra- dynamics in women receiving oral contraceptive ceptives. Thorax 27, 75–79. therapy. Lancet ii, 879–881. Shangold, M.M. & Levine, H.S. (1982) The effect of Wearing, M.P., Yuhasz, M., Campbell, R. & Love, E. marathon training upon menstrual function. Ameri- (1972) The effect of the menstrual cycle on tests of can Journal of Obstetrics and Gynecology 143, 862–869. physical fitness. Journal of Sports Medicine and Physical Shangold, M.M. & Mirkin, G. (eds) (1994) Women and Fitness 12, 38–41. Exercise: Physiology and Sports Medicine, 2nd edn. F.A. Webb, P. (1986) Twenty-four hour energy expenditure Davis, Philadelphia. and the menstrual cycle. American Journal of Clinical Sherwin, B.B. (1996) Hormones, mood, and cognitive Nutrition 44, 614–619. functioning in postmenopausal women. Obstetrics Wells, C.L. (1991) Effects of the menstrual cycle on and Gynecology 87, 20S–26S. physical performance. In C.L. Wells (ed.) Women, Sita, A. & Miller, S.B. (1996) Estradiol, progesterone Sport and Performance: A Physiological Perspective, and cardiovascular response to stress. Psychoneuroen- pp. 75–84. Human Kinetics Publishers, Champaign, docrinology 21, 339–346. Illinois. Solomon, S.J., Kurzer, M.S. & Calloway, D.H. (1982) Wells, C.L. & Horvath, S.M. (1973) Heat stress Menstrual cycle and basal metabolic rate in women. responses related to the menstrual cycle. Journal of American Journal of Clinical Nutrition 36, 611–616. Applied Physiology 35, 1–5. Sondheimer, S.J. (1991) Update on the metabolic effects Wells, C.L. & Horvath, S.M. (1974) Responses to exer- of steroidal contraceptives. Endocrinology and Metab- cise in a hot environment as related to the menstrual olism Clinics of North America 20, 911–923. cycle. Journal of Applied Physiology 36, 299–302. Stager, J.M., Wigglesworth, J.K. & Hatler, L.K. (1990) Williams, T.J. & Krahenbuhl, G.S. (1997) Menstrual Interpreting the relationship between age of menar- cycle phase and running economy. Medicine and che and prepubertal training. Medicine and Science in Science in Sports and Exercise 29, 1609–1618. Sports and Exercise 22, 54–58. Winget, C.M., DeRoshia, C.W. & Holley, D.C. (1985) Stephenson, L.A. & Kolka, M.A. (1993) Thermoregula- Circadian rhythms and athletic performance. Medi- tion in women. Exercise and Sport Sciences Reviews 21, cine and Science in Sports and Exercise 17, 498–516. 231–262. Wirth, J.C. & Lohman, T.G. (1982) The relationship of Stephenson, L.A., Kolka, M.A. & Wilkerson, J.E. (1982) static muscle function to use of oral contraceptives. Metabolic and thermoregulatory responses to exer- Medicine and Science in Sports and Exercise 14, 16–20. cise during the human menstrual cycle. Medicine and Zaharieva, E. (1965) Survey of sportswomen at the Science in Sports and Exercise 14, 270–275. Tokyo Olympics. Journal of Sports Medicine and Physi- Sulak, P.J., Cressman, B.E., Waldrop, E., Holleman, S. & cal Fitness 5, 215–219. Chapter 4

Environmental Challenges

EMILY M. HAYMES

Introduction Physiological responses to environmental challenges Many female athletes participate in competitive events that are held under various environmen- This section focuses on the physiological tal conditions. Examples include the heat of the responses to exercise in three types of environ- 1992 and 1996 Summer Olympics in Barcelona ments: warm (both humid and dry), cold and and Atlanta, the cold of the 1994 Winter altitude (hypobaric). The section begins with a Olympics in Lillehammer and the hypoxia due to brief description of the physiological responses an altitude of 2300m at the 1968 Summer to each environment. Observed differences in the Olympics in Mexico City. Each of these environ- responses of females and males to specific envi- ments can provide challenges not only to the ronmental challenges are then discussed. physiological responses of the individual athlete but also may affect the athlete’s performance. Warm environments An example is the reduction in barometric pres- sure at altitude that reduces both oxygen trans- Exercise in warm environments presents a port in the blood and performance in endurance challenge to the body’s thermoregulatory events. system: to dissipate the metabolic heat produced Much of the research that has been conducted when energy is released by the contracting on the effects of different environments on the muscles. The amount of heat produced is directly physiological responses to exercise used male proportional to the intensity of the exercise. This subjects. Because the average female is smaller heat must be transported by the blood to and has a higher proportion of body fat, some of the body’s surface where heat dissipation the physiological responses to environmental will occur. As the blood temperature increases challenges may be different in female athletes. and circulates through the anterior hypothala- Furthermore, female reproductive hormones mus of the brain, neurones in the thermoregula- influence thermoregulatory responses to warm tory centre stimulate blood vessels in the skin to and cold environments. The purpose of the dilate and the sweat glands to secrete sweat. In present chapter is to examine the physiological thermoneutral environments, a large thermal responses of females to the environmental chal- gradient exists between the temperatures of the lenges most commonly experienced by competi- skin and air that facilitates the loss of dry heat. tive and recreational athletes. Heat is also lost from the skin by evaporation of sweat. As air temperature rises in warm envi- ronments the gradient between skin and air diminishes, which reduces the amount of dry 62 environmental challenges 63

heat loss from the skin. Evaporation of sweat ties in hot (39–48°C) dry environments (Wells, must increase in order to maintain thermal 1980; Frye & Kamon, 1981). balance in warm environments. This is accom- It has been suggested that females may be at a plished by increasing the sweat rate and is disadvantage in hot dry environments because assisted by increasing blood flow to the skin. the average woman has a smaller plasma volume In warm humid environments, evaporation of and a lower percentage of body water than the sweat is limited because the air is saturated average man. The ratio of total body water to with water vapour. When the air temperature body weight is 50–55% in women and 55–60% in exceeds skin temperature (approximately 35°C), men (Van Loan & Boileau, 1996), while plasma the body gains heat from the environment. The volume is 13% less in women (Fortney, 1996). If only avenue of heat loss at higher air tempera- male and female athletes lose sweat at the same tures is through the evaporation of sweat. Hot rate, the rate of dehydration would be greater in humid environments are particularly stressful the females because they are losing a higher pro- because evaporative heat loss is limited. At air portion of their body water and plasma volume. temperatures of 35°C or higher and relative It is recommended that female athletes consume humidity of 60% or above, runners are not able fluids as frequently as males in order to replace to achieve thermal balance because not enough the disproportionate loss of body fluids (Fortney, sweat can evaporate (Nielsen, 1996). Failure to 1996). achieve thermal balance results in rising body core temperatures and increased risk of heat tropical environments exhaustion. Repeated exposure to warm environments In the warm humid environments typical of the increases an athlete’s heat tolerance. Adaptations tropics, females appear to tolerate exercise better occur in several physiological responses that than males. Several studies have reported that allow heat loss to begin earlier in the exercise unacclimatized females had lower rectal temper- bout and that reduce body temperatures and car- atures, heart rates and sweat rates (Paolone et al., diovascular strain. This process, known as heat 1978; Avellini et al., 1980; Shapiro et al., 1980a) acclimatization, includes lower core tempera- and were able to exercise longer than unacclima- tures for the onset of both sweating and vasodila- tized males (Avellini et al., 1980). Following 10 tion, increased plasma volume, lower core and days’ acclimatization to a hot humid environ- skin temperatures, and a lower heart rate during ment, both rectal temperature and heart rate exercise in the heat. were still significantly lower in females com- pared with males (Avellini et al., 1980). On the desert environments other hand, males have significantly higher sweat rates than females after acclimatization to The physiological responses of well-trained a hot humid environment (Avellini et al., 1980). males and females to exercise in warm tempera- Acclimatization to humid heat also increases the tures with low relative humidity are very similar. sweat rate of females, but the increase (15%) is Although some early studies reported males less than that observed in males (35%). Much of were more tolerant of exercise in the heat than the males’ additional sweat may have been females, it appears that trained males were com- wasted because high humidity limits evapora- pared with sedentary females in some of these tion. Lower sweat rates in humid environments studies (Shapiro et al., 1980a, b). When heat- would appear to be advantageous because body acclimatized male and female subjects were fluid and plasma volume losses would be matched for fitness status, there were no differ- reduced. ences in rectal temperature, heart rate or sweat Several recent studies comparing male and rate during exercise at low and moderate intensi- female athletes competing in warm humid envi- 64 physiology of the female athlete

ronments have reported that males lose signifi- 1500 cantly more sweat than females (Bergeron et al., 1995; Millard-Stafford et al., 1995). Female dis- tance runners had lower sweat rates and smaller changes in plasma volume than male runners during a 40-km run (Millard-Stafford et al., 1995). ) –1 1000 h Over the last 10km of the run the female runners . also had lower rectal temperatures. A study of tennis players reported that females had signifi- cantly lower sweat rates than males during midday singles matches (Bergeron et al., 1995). There were no significant differences in fluid 500 replacement between males and females in either Fluid loss/intake (ml the 40-km run or tennis match. In both the runners and tennis players fluid intake did not replace fluid losses. Similar results have been reported for soccer and basketball players during 0 training and competition in warm humid envi- Running Tennis Soccer Basketball ronments (Broad et al., 1996). Failure to replace Sport fluid losses during competition and training results in dehydration. The rate of fluid loss Fig. 4.1 Fluid loss (sweat rate, ) and fluid intake ( ) of female athletes during competitive events in warm replacement among the female athletes ranged weather. (Data from Bergeron et al., 1995; Millard- from 47% for the distance runners to 76% for the Stafford et al., 1995; Broad et al., 1996.) tennis players (Fig. 4.1). In some sports, like soccer and field hockey, fluid intake during com- petition is limited. Athletes in these sports should consume 500ml of fluid prior to the aerobic fitness levels maintain lower heart rates match and at least 400ml at half-time (Broad et and higher stroke volumes during prolonged al., 1996). During tennis matches, fluid replace- exercise in the heat compared with non-athletes ment should occur at each change-over at a rate (Drinkwater et al., 1976, 1977). Although there are of 120–240ml (Bergeron et al., 1995). Female no differences in sweat rate, female athletes are runners should consume up to 1litre of fluid in better able to maintain their plasma volumes the hour prior to distance runs in warm environ- during exercise due to a greater influx of pro- ments and 150–300ml every 15min during the teins into the plasma (Drinkwater et al., 1977). run (American College of Sports Medicine, 1996). Increases in plasma volume and total plasma Even female athletes competing and training protein have been observed in females after an in indoor environments (e.g. basketball, volley- aerobic training programme (Fortney & Senay, ball) need to replace fluids at the rate of 600– 1979). An expanded plasma volume is an advan- 1000ml·h–1 (Broad et al., 1996). tage because central blood volume, and therefore stroke volume, can be better maintained during effects of training exercise in warm environments. It has also been observed that female athletes Female athletes are able to tolerate exercise in hot appear to be partially acclimatized on their first dry environments better than untrained females day of exposure to the heat (Fein et al., 1975). Fol- (Fein et al., 1975; Drinkwater et al., 1976, 1977). lowing an interval training programme, trained There are several possible reasons why training females were observed to acclimatize to the heat improves heat tolerance. Athletes with higher at a faster rate than untrained females (Cohen & environmental challenges 65

Gisolfi, 1982). The onset of sweating has been higher in the luteal phase and perceived exertion observed to occur earlier during an exercise bout was significantly greater near the end of exercise in trained females (Araki et al., 1981). Threshold (Pivarnik et al., 1992). Although core tempera- core temperature for the onset of sweating tures were higher during the luteal phase in both decreases in females after training (Roberts studies, no adverse effects on exercise perfor- et al., 1977). Because sweating begins earlier in mance were observed. exercise, less heat will be stored and body tem- Plasma volume shifts during heat exposure peratures will be lower. In warm humid environ- and exercise have been observed to change ments, trained women’s sweat rates were also during the menstrual cycle. Passsive heating pro- found to decline (hidromeiosis) during pro- duced a greater decrease in plasma volume longed exercise (Araki et al., 1981). It has been (haemoconcentration) during the luteal phase, suggested that training improves the efficiency while high-intensity exercise produced a greater of sweating in females by reducing wasteful decrease in plasma volume during the follicular sweating. phase (Stephenson & Kolka, 1988). Greater decreases in plasma volume in the follicular influence of the menstrual cycle phase have been observed during low-intensity exercise as well (Gaebelein & Senay, 1982). The normal menstrual (ovarian) cycle is divided However, no adverse effect on endurance was into two phases: the follicular phase, which observed in either study. The effect of menstrual- begins on the first day of the menses and lasts cycle phase on fluid replacement following exer- until ovulation; and the luteal phase, which cise has been examined in a recent study begins immediately following ovulation and (Maughan et al., 1996). After exercising in a warm lasts until the next menses. During the follicular environment to reduce body weight by 1.8%, phase, oestrogens are produced by the ovary in female subjects ingested enough carbohydrate– increasing amounts until shortly before ovula- electrolyte drink to replace 150% of the weight tion. In the luteal phase, both oestrogens and lost over a 60-min period. The investigators progesterone are produced by the corpus found that there were no significant differences luteum. After ovulation, the rising levels of prog- in fluid balance or urine volume in the different esterone are associated with a significant rise phases of the menstrual cycle (Maughan et al., (0.3–0.6°C) in core and skin temperatures (Hesse- 1996). It should be noted, however, there have mer & Bruck, 1985a; Stephenson & Kolka, 1985). been no studies examining voluntary fluid Thresholds for the onset of both sweating and replacement during the different phases of the cutaneous vasodilation are increased during the menstrual cycle. luteal phase of the menstrual cycle (Hessemer & Bruck, 1985b; Stephenson & Kolka, 1985). The heat illness prevention effect of these shifts to higher thresholds on ther- moregulatory responses during exercise has Dehydration is fairly common in many sports been the subject of several studies. events during the warm months of the year. As a Higher core and skin temperatures were result of dehydration, the athlete’s body core observed during the luteal phase throughout temperature is elevated and may reach the prolonged low-intensity exercise in a hot dry hyperthermic range (≥ 39°C). Heat exhaustion environment, but there was no impairment of and heat stroke are the two illnesses most likely heat tolerance and all subjects were able to com- to occur among athletes. Female athletes may plete the exercise bout (Carpenter & Nunneley, experience heat illness in many sports, including 1988). During moderate-intensity exercise in a running, soccer, field hockey, softball and tennis. thermoneutral environment (22°C), both core Previous reports of the incidence of heat illness temperature and heart rate were significantly among athletes suggest that the rates for females 66 physiology of the female athlete

and males are approximately the same (England 45 110 et al., 1982; Elias et al., 1991). The risk of heat illness can be reduced in ath-

F) 40 Very high 100 C) º letes through the use of several strategies. One of º the most important ways of preventing heat illness is to acclimatize athletes to the heat prior 35 High 90 to competition. Allowing adequate time for full acclimatization (about 2 weeks) reduces the risk 30 Moderate 80 of heat illness and leads to improved perfor- mance in endurance events. During the first few Dry bulb temperature ( Low Dry bulb temperature ( days of acclimatization, athletes should reduce 25 70 the intensity of training and the amount of time Dry Wet spent in the heat. Partial acclimatization to the 20 60 0 20 40 60 80 100 heat occurs over the first 4–5 days, during which Relative humidity (%) time heart rate and core and skin temperatures decrease and tolerance for exercise increases. Fig. 4.2 Risk of heat exhaustion or heat stroke while Another important strategy for reducing the racing in hot environments. (From American College of risk of heat illness is to ensure adequate hydra- Sports Medicine, 1996 with permission.) tion. This should include consumption of fluids before exercise, at regular intervals during exer- cise and adequate amounts of fluids after exer- between the skin and air facilitates the loss of cise to replace sweat losses. Weighing athletes heat produced by the contracting muscles. If the before and after practice each day is often used to rate of heat loss exceeds metabolic heat produc- identify individual athletes who are not replac- tion, the decrease in core and skin temperatures ing fluid losses. stimulates vasoconstriction of the superficial Especially during the summer, scheduling blood vessels, which shunts more blood into the training and competitive events during the core and into deeper blood vessels in the extrem- cooler parts of the day (e.g. early in the morning ities. The bloodless skin and subcutaneous fat or later in the evening) reduces the risk of heat serve as insulation against heat loss, helping to illness (Fig. 4.2). The American College of Sports conserve body heat. Shivering, stimulated by a Medicine (1996) recommends that distance further drop in core temperature, increases meta- running events be rescheduled when the wet bolic heat production (thermogenesis). bulb globe temperature (WBGT) reaches 28°C. Most studies of the physiological responses to The combination of air temperature and relative cold environments have been conducted with humidity equivalent to a WBGT of 28°C is shown male subjects. There is some evidence, however, in Fig. 4.2 by the line separating the high and that females may be able to work and even very high risks of heat illness. Athletes in many survive in cold environments better than males endurance events (e.g. soccer, field hockey) (Pugh, 1966; Hong et al., 1986). It has been sug- would reduce their risk of heat illness by follow- gested that only females dive in the cold waters ing these same environmental stress guidelines of Korea because they are better insulated recommended for runners. against the cold than males (Hong et al., 1986). After examining incidents of hypothermia in walkers, climbers and campers, Pugh (1966) con- Cold environments cluded that females were more likely to survive In cold environments, exercise presents much cold exposure leading to hypothermia compared less of a challenge to the thermoregulatory with males. Theoretically, females might be system because the large thermal gradient better insulated against the cold because the environmental challenges 67

average female has a greater subcutaneous fat at –5 and +5°C (Graham & Lougheed, 1985; thickness than the average male. Fat is an excel- Stevens et al., 1987). During the latter stages of lent insulator against the cold: thickness of the prolonged intermittent periods of exercise and subcutaneous fat layer is significantly related to rest, the metabolic rate increased significantly in maximal tissue insulation during cold exposure the males (Graham & Lougheed, 1985). In a sub- (Hong et al., 1986). It has been observed that sequent study, no significant difference in rectal females have greater tissue insulation during temperatures was observed between males and cold exposure than males (Rennie et al., 1962). females exercising at the same absolute intensity Body size is also an important factor determin- in cold environments ranging from –10 to +10°C ing heat loss. More heat is stored in a large body (Walsh & Graham, 1986). However, the females mass than a small body mass; however, the ratio had lower metabolic rates during the latter part of surface area to body mass (SA/M) determines of the exercise compared with the males. Eleva- the rate of heat loss from the body. Individuals tion of the metabolic rate suggests that thermo- with large SA/M lose heat more rapidly than genesis was stimulated in the males but not the individuals with small SA/M. Prepubertal females. swimmers have larger SA/M than adolescents Prolonged endurance events in cold environ- and cool more rapidly in cold water (Sloan & ments may present more of a challenge to female Keatinge, 1973). The average female has a larger athletes. In a study comparing males and females SA/M than the average male and should, based exercising at the same relative intensity (e.g. · on geometrical considerations, lose heat more same percentage of VO2max) in a –5°C environ- rapidly than males. The female’s larger SA/M ment, the females’ rectal temperatures decreased may negate part of the advantage provided significantly during the third hour of exercise by thicker subcutaneous fat layers in cold (Graham, 1983). Heat production was signifi- environments. cantly lower for the females who were exercising at a lower absolute intensity than the males. exercise in cold environments During the third hour of exercise net heat loss was significantly greater for the females. In a cold Gender differences in response to exercise in cold environment, a higher metabolic rate is advanta- environments are complicated to study. When a geous in offsetting heat loss. Exercising in the person exercises, the metabolic rate is elevated in wind further increases heat loss. Males and proportion to the exercise intensity and heat pro- females wearing cross-country skiing uniforms duction rises. If males and females exercise at the were unable to maintain core temperatures when same absolute intensity, the rate of heat produc- exercising at the same relative intensity in a tion is equivalent. In exercise bouts at the same 15km·h–1 wind at –20°C (Haymes et al., 1982). absolute intensity, the amount of heat produced Exercise in cold water presents even more of a is the same in both sexes and body temperatures challenge to the athlete. Because water is an will rise more rapidly in the females. If the excellent conductor of heat, heat loss occurs more · women have a lower VO and are exercising at rapidly in water than air at the same tempera- 2max · the same relative intensity (e.g. 70% VO2max) as ture. During exercise in cold water (20°C), both the men, the rate of heat production will be lower lean (9% body fat) and average (17% body fat) for the women. This latter situation exists in males increased their metabolic rates, while lean winter sports like cross-country skiing, where (18.5% body fat) females maintained relatively females ski at the same relative intensity but at constant metabolic rates (McArdle et al., 1984). slower speeds than males. Decline in rectal temperature was greatest in the When males and females exercise at the same lean males after 1hour of exercise, followed by absolute intensity, females have been observed to the average males, lean females and average have higher rectal temperatures in environments (25% body fat) females (Fig. 4.3). Similar results 68 physiology of the female athlete

1 C) º Av. women 0 Lean women

–1 Av. men Fig. 4.3 Change in rectal temperature of lean men (9% fat), Rectal temperature ( Lean men average men (17% fat), lean women (18.5% fat) and average –2 women (25% fat) after exercise in 5 10 15 20 25 30 water at 20°C for 1 hour. (Data Body fat (%) from McArdle et al., 1984.)

have been observed in younger males and rhoeic females. The investigators concluded females swimming in cold water (Sloan & from their results that amenorrhoeic females are Keatinge, 1973). The rate of body cooling while less sensitive to cold than males or eumenor- swimming was greater in males with less subcu- rhoeic females (Graham et al., 1989). Many of the taneous fat than in females with more subcuta- earlier studies comparing females and males did neous fat. not report any information concerning the men- strual status of their subjects. Onset of shivering influence of the menstrual cycle thermogenesis in females who are amenorrhoeic may be delayed. Menstrual status and cycle Thermoregulatory responses to the cold are phase should be controlled in future studies influenced by the phase of the menstrual cycle. comparing females and males. Not only were resting core temperatures sig- nificantly higher during the luteal phase but influence of iron deficiency skin temperatures decreased at a faster rate (Hessemer & Bruck, 1985a). The threshold for Iron depletion without anaemia is relatively shivering thermogenesis occurred at higher core common among female athletes, with the temperatures in the luteal phase when the female reported incidence ranging from 20% to 47% subjects were exposed to cold. However, the (Clarkson & Haymes, 1995). Iron-deficiency metabolic rate increased during shivering at the anaemia is less common among athletes but is same rate in both phases. more prevalent in female than male athletes. Because many female athletes are amenor- Anaemia reduces the oxygen-carrying capacity rhoeic, the inclusion of female subjects who are of the blood and results in a greater cardiac amenorrhoeic may influence the responses to output in order to supply oxygen to the tissues. cold in comparison with males and eumenor- Iron deficiency may deplete the tissues of iron- rhoeic females. Amenorrhoeic females (less than containing cellular enzymes (e.g. cytochromes) one menstrual cycle per year) had significantly and impair cellular metabolism (e.g. thermogen- lower resting core temperatures than eumenor- esis). When anaemic males and females were rhoeic females; however, the menstrual-cycle compared with subjects who were iron deficient phase was not controlled in the eumenorrhoeic or had normal iron status, the decline in body females (Graham et al., 1989). During resting temperature during exposure to cold water was exposure to 5°C, amenorrhoeic females had 0.9°C in the anaemic subjects, 0.5°C in the iron- lower metabolic rates than males and eumenor- deficient subjects and 0.2°C in the normal sub- environmental challenges 69

jects (Martinez-Torres et al., 1984). During expo- exposed to 10°C for 2 weeks had a delayed sure to cold, metabolic rate was significantly onset of shivering and a reduced thermogenic higher in the anaemic and iron-deficient subjects response following acclimatization (Silami- compared with the normal subjects. Iron-defi- Garcia & Haymes, 1989). There were no signifi- cient and anaemic subjects also had higher cant changes in rectal or skin temperature plasma noradrenaline levels than the normal reponses to cold following acclimatization. subjects, which was the probably stimulus of the Reductions in the shivering response have also elevated metabolic rates. been reported in males acclimatized to 10°C for 3 The effects of iron depletion and iron repletion weeks (Mathew et al., 1981). Body temperature in on responses to cold exposure were examined in the males did not drop as much during cold a group of females. The females began shivering exposure after 3 weeks of acclimatization. The earlier during cold exposure following an 80-day males’ resting metabolism was elevated follow- period of iron depletion compared with 100 days ing acclimatization, a response similar to the ele- of iron repletion (Lukaski et al., 1990). Iron defi- vated basal metabolic rates of the acclimatized ciency resulted in lower core and skin tempera- diving females in Korea (Hong et al., 1986). Due tures and metabolic rates were depressed even to insufficient data on cold acclimatization it is though noradrenaline levels were elevated. not possible to say whether females and males Thyroid hormones were slightly, but not signifi- acclimatize to cold at the same rate. However, it cantly, lower in response to cold stimulus when appears that a delay in the onset of shivering and the females were iron deficient. It appears that a reduction in shivering thermogenesis are the females who are iron deficient cannot produce as earliest responses seen in both sexes. much heat during cold exposure due to a depressed thermogenic response. These results preventing cold illnesses could have significant implications for female endurance athletes who compete in cold envi- Hypothermia and frostbite are the cold illnesses ronments (e.g. cross-country skiers). that athletes training and competing in cold environments are most likely to experience. The acclimatization to the cold cause of hypothermia (core temperature <36°C) is failure of the metabolic rate to generate enough The most comprehensive studies of cold acclima- heat to counterbalance heat losses. Symptoms tization were conducted on female divers in that suggest the onset of hypothermia include Korea. Acclimatization to cold water reduced the fatigue, weakness, inability to maintain pace, core temperature at which these women began stumbling and falling (Pugh, 1966). Factors that to shiver and increased their maximal tissue contribute to the development of hypothermia in insulation (Hong et al., 1986). The female divers athletes are wet clothing, inadequate clothing, allowed their core temperatures to drop to 35°C extreme cold, wind and low exercise intensities. before terminating a diving session. These obser- The insulation provided by clothing is greatly vations were made when the females wore only reduced when it is wet. Athletes training and cotton suits during diving. Similar responses are competing in the rain and snow can reduce the likely to occur in female swimmers who train in risk of hypothermia by wearing an outer layer cold water. After the Korean female divers of clothing made of water-repellant material switched to wet suits in 1977, cold acclimatiza- (Haymes & Wells, 1986). Although inadequate tion was gradually lost over the next 5 years clothing is a factor in very cold environments, too (Hong et al., 1986). much clothing may stimulate sweating during Most of the studies of acclimatization to cold exercise and the inner layers of clothing become air environments have been conducted with wet. It is recommended that athletes wear multi- male subjects. Females who were repeatedly ple layers of lightweight clothing when training 70 physiology of the female athlete

in the cold, as it is the air trapped between the oxygen pressure (PO2) decreases. The higher layers of clothing that is the best insulator. the altitude, the greater the decrease in PO2. Because heat loss increases as wind speed Reduction in PO2 of the air leads to a lower PO2 in increases, the risk of hypothermia also increases. the lungs and blood, which results in less oxygen Wearing outer garments made of wind-resistant being transported to the muscles. Thus, the per- materials (e.g. nylon) reduces heat loss from formance of endurance athletes is more likely to the skin. be negatively affected at altitude. The risk of hypothermia is greater when envi- On the other hand, some athletes may actually ronmental temperatures are below 0°C; however, perform better at altitude. For example, at the hypothermia can occur at temperatures below 1968 Summer Olympics in Mexico City (altitude 10°C, especially in athletes wearing inadequate 2300m), new world records were set in most of clothing (American College of Sports Medicine, the sprinting events. The decline in air density 1996). Athletes at greatest risk of developing as altitude increases results in a reduction in hypothermia are the slower runners and skiers in air resistance. Reductions in air resistance are endurance events (e.g. marathon, 50-km ski race) particularly beneficial to athletes in sprinting, because their exercise intensity is too low to gen- cycling, skiing and speed skating. erate enough heat to offset heat loss. Frostbite occurs when the skin temperature physiological responses falls below 0°C and fluids in the skin freeze. The risk of frostbite increases when the windchill Exercise at altitude at the same absolute intensity index, a combination of air temperature and as at sea level (e.g. running at 16km·h–1) can wind speed, exceeds –31°C. Coaches and ath- put great strain on the cardiovascular system letes should monitor the windchill index when because the oxygen content of the blood will be training in cold environments, especially when reduced. This is especially true at altitudes of the ambient temperature is –10°C or below. At 2200m and above. Although the PO2 of the blood higher racing speeds in cross country skiing, decreases linearly with altitude, the amount of the windchill is greater and races are postponed oxygen bound to haemoglobin declines very if the temperature is below –20°C (American little at low altitudes. At higher altitudes, cardiac College of Sports Medicine, 1996). Frostbite output increases to compensate for the decrease occurs most frequently on the exposed areas of in the blood oxygen content. The increase in the face, fingers and toes. In fact, some athletes cardiac output is due to increased heart rate. may not realize that frostbite has occurred until When males and females exercise at the same · they remove their gloves and boots. The skin is relative intensity (50% VO2max), similar increases numb because sensory neurones are blocked by in heart rate have been observed as altitude the cold. When the risk of frostbite is increased, increases (Elliott & Atterbom, 1978). companions should check for signs of frostbite When females exercised at the same intensity · on exposed areas of the face. The wearing of hats relative to their VO2max at each altitude, heart rate, that cover the ears and bandanas or ski masks stroke volume and cardiac output were the same reduces the risk of frostbite to the face. at altitudes ranging from sea level to 4270m (Wagner et al., 1980). However, the respiratory exchange ratio (RER) was higher at altitude, Altitude indicating greater reliance on carbohydrates for Many athletes find exercise at altitude to be par- energy, and blood lactate levels were elevated at · ticularly challenging because of the earlier onset 3050 and 4270m. VO2max was reduced in females of fatigue. As altitude increases, barometric by 10% and 13% at 2130 and 3050m respectively pressure decreases. Although the percentage of (Miles et al., 1980). During maximal exercise at · oxygen in the air remains constant (20.93%), the 4100m, females had significantly lower VO2max, environmental challenges 71

110 may have been due to low iron stores in the females. One recent study found that male and female runners with low ferritin levels, an indi- 100 cation of depleted iron stores, exhibited very little increase in red cell volume during 4 weeks’ 90 acclimatization to 2500m (Stray-Gunderson et al., 1992). Because many female athletes

at sea level (%) have low ferritin levels (Clarkson & Haymes, 80 1995), increases in red cell volume may occur 2max O

. more slowly during acclimatization in these V 70 athletes. Following several weeks of acclimatization, 60 subjects are less dependent on muscle glycogen 0 1000 2000 3000 4000 5000 as a source of energy for exercise and are better Altitude (m) able to use fatty acids as an energy source (Young · et al., 1982). This shift in substrate utilization Fig. 4.4 Decline in VO2max at altitude in females ( ) and males () compared with the predicted decline () is a result of several adaptations that occur in of 1% per 100 m for altitudes above 1500 m. (Data from muscle tissue during acclimatization, including Drinkwater et al., 1979; Miles et al., 1980; Squires & increases in myoglobin concentration, mitochon- Buskirk, 1982; Young et al., 1982.) dria and capillaries (Levine & Stray-Gunderson, 1992). maximal heart rate, RER and time to exhaustion training at altitude but higher blood lactate compared with values at sea level (Drinkwater et al., 1979). The decrease in Prior to the 1968 Olympics in Mexico City, a · VO2max for the females (26.7%) at this altitude was number of studies were conducted on the effects similar to that reported for males (27%) (Young of training at altitude on performance at altitude. · et al., 1982). The reduction in VO2max at altitude Results from several of these studies suggest in females is very similar to the predicted decline improved performance following several weeks of 1% for every 100m above 1500m (Fig. 4.4). of training at altitude (Buskirk et al., 1967; Pugh, 1967; Saltin, 1967). However, performance at alti- acclimatization to altitude tude in the endurance events was reduced com- pared with the athletes’ performance at sea level. The initial response to altitude is a decrease in Furthermore, the intensity of training had to be plasma volume that results in an increase in reduced at altitude because of the reduction in · · haemoglobin concentration over the first few VO2max. Significant reductions in VO2max have days. As a result, the oxygen content of the blood been observed in trained males at altitudes of increases proportionately. On the other hand, the 1200m and above (Squires & Buskirk, 1982) and increased haemoconcentration also increases in competitive athletes at altitudes as low as resistance to blood flow. After several weeks at 900m (Terrados, 1992). altitude, stroke volume decreases due to the Some élite athletes train at altitudes of reduction in plasma volume. Red cell volume 2000–2500m for competitive events that will increases gradually due to the hypoxic stimulus occur near sea level. The advantages of this alti- of altitude. At altitudes above 5000m, smaller tude training have recently been questioned increases in haemoglobin concentration have (Levine & Stray-Gunderson, 1992). When male been observed in females compared with those and female runners trained at altitudes of 1200 or reported for males (Drinkwater et al., 1982). This 2500m for 4 weeks, the improvement in 5-km run 72 physiology of the female athlete

times at sea level were similar; however, blood the different phases of the menstrual cycle as lactate levels and heart rate during submaximal well as between females and males. Because exercise decreased more in the runners who many female athletes have depleted iron stores, trained at 1200m (Levine & Stray-Gunderson, more research is needed on the effects of iron 1992). This was most probably due to the runners deficiency on performance in the cold. More training at a lower percentage of their sea-level studies are also needed on acclimatization in · VO2max and the lower running speeds at 2500m female athletes who compete in cold environ- compared with 1200m (Stine et al., 1992). On the ments (e.g. skiers, speed skaters). For example, it other hand, when athletes trained at the same would be interesting to know if performance absolute intensity at 2300m and sea level, signifi- improves following cold acclimatization. cant increases in skeletal muscle myoglobin and Although information is available on the · aerobic enzyme activity and greater increases in effects of different altitudes on VO2max in females, endurance were observed after 4 weeks of alti- more research is needed on the acute and chronic tude training (Terrados, 1992). The results of effects of altitude on performance. This informa- these studies suggest that training at altitudes tion is especially needed in female athletes who of 2300–2500m is more likely to enhance per- are iron depleted. Studies should be conducted formance at sea level if the athletes can main- also on the effects of iron supplementation tain their sea-level training intensity (speed) at during acclimatization. Research on the effects of altitude. menstrual status and cycle phase on the physio- logical responses to altitude is also desirable. Recommendations for future research References It is apparent that more research is needed on the effects of different environments on the physio- American College of Sports Medicine (1996) Position logical responses and performance of female stand: heat and cold illnesses during distance subjects. In warm environments, studies involv- running. Medicine and Science in Sports and Exercise 28(12), i–x. ing females should be conducted at higher exer- Araki, T., Matsushita, K., Umeno, K., Tsujino, A. & cise intensities that simulate competition in Toda, Y. (1981) Effect of physical training on exercise- various sports (e.g. running, cycling). Although induced sweating in women. Journal of Applied Physi- there have been numerous studies that have ology 51, 1526–1532. examined thermoregulatory responses in differ- Avellini, B., Kamon, E. & Krajewski, J. (1980) Physio- logical responses of physically fit men and women to ent phases of the menstrual cycle, most have acclimation to humid heat. Journal of Applied Physiol- been conducted during low- and moderate- ogy 49, 254–261. intensity exercise. Voluntary fluid replacement Bergeron, M., Maresh, C., Armstrong, L. et al. (1995) following exercise should also be examined Fluid–electrolyte balance associated with tennis during different phases of the menstrual cycle. match play in a hot environment. International Journal of Sport Nutrition 5, 180–193. The effects of heat stress on the physiological Broad, E., Burke, L., Cox, G., Heeley, P. & Riley, M. responses of amenorrhoeic female athletes need (1996) Body weight changes and voluntary fluid to be compared with those of eumenorrhoeic ath- intakes during training and competition sessions in letes in different phases of the menstrual cycle. team sports. International Journal of Sport Nutrition 6, There is very little information available on the 307–320. Buskirk, E., Kollias, J., Picon-Reatigue, E., Akers, R., exercise responses to cold environments during Prokop, E. & Baker, P. (1967) Physiology and perfor- the different phases of the menstrual cycle. Car- mance of track athletes at various altitudes in the bohydrates appear to be the preferred source of United States and Peru. In R.F. Goddard (ed.) Interna- energy in cold environments, at least in males. tional Symposium on the Effects of Altitude on Physical Similar studies should be conducted with female Performance, pp. 65–72. Athletic Institute, Chicago. Carpenter, A.J. & Nunneley, S.A. (1988) Endogenous subjects, comparing substrate utilization during environmental challenges 73

hormones subtly alter women’s responses to heat of the thermal responses to mild exercise in a cold stress. Journal of Applied Physiology 65, 2313–2317. environment. Human Biology 55, 463–476. Clarkson, P. & Haymes, E. (1995) Exercise and mineral Graham, T. & Lougheed, M. (1985) Thermal responses status of athletes: calcium, magnesium, phosphorus, to exercise in the cold: influence of sex differences and iron. Medicine and Science in Sports and Exercise and alcohol. Human Biology 57, 687–698. 27, 831–843. Graham, T., Viswanathan, M., Van Dijk, J., Bonen, A. & Cohen, J. & Gisolfi, C. (1982) Effects of interval training George, J. (1989) Thermal and metabolic responses to on work–heat tolerance of young women. Medicine cold by men and by eumenorrheic and amenorrheic and Science in Sports and Exercise 14, 46–52. women. Journal of Applied Physiology 67, 282–290. Drinkwater, B., Denton, J., Kupprat, I., Talag, T. & Haymes, E. & Wells, C. (1986) Environment and Human Horvath, S. (1976) Aerobic power as a factor in Performance. Human Kinetics Publishers, Cham- women’s response to work in hot environments. paign, Illinois. Journal of Applied Physiology 41, 815–821. Haymes, E., Dickinson, A., Malville, N. & Ross, R. Drinkwater, B., Kupprat, I., Denton, J. & Horvath, S. (1982) Effects of wind on the thermal and metabolic (1977) Heat tolerance of female distance runners. responses to exercise in the cold. Medicine and Science Annals of the New York Academy of Sciences 301, in Sports and Exercise 14, 41–45. 777–792. Hessemer, V. & Bruck, K. (1985a) Influence of men- Drinkwater, B., Folinsbee, L., Bedi, J., Plowman, S., strual cycle on shivering, skin blood flow, and sweat- Loucks, A. & Horvath, S. (1979) Response of women ing responses measured at night. Journal of Applied mountaineers to maximal exercise during hypoxia. Physiology 59, 1902–1910. Aviation, Space and Environmental Medicine 50, Hessemer, V. & Bruck, K. (1985b) Influence of men- 657–662. strual cycle on thermoregulatory, metabolic, and Drinkwater, B., Kramar, P., Bedi, J. & Folinsbee, L. heart rate responses to exercise at night. Journal of (1982) Women at altitude: cardiovascular responses Applied Physiology 59, 1911–1917. to altitude. Aviation, Space and Environmental Medicine Hong, S., Rennie, D. & Park, Y. (1986) Cold acclimatiza- 53, 472–477. tion and deacclimatization of Korean women divers. Elias, S., Roberts, W. & Thorson, D. (1991) Team sports Exercise and Sport Sciences Reviews 14, 231–268. in hot weather: guidelines for modifying youth Levine, B. & Stray-Gunderson, J. (1992) A practical soccer. Physician and Sportsmedicine 19, 67–80. approach to altitude training: where to live and train Elliott, P. & Atterbom, H. (1978) Comparison of exercise for optimal performance enhancement. International responses of males and females during acute expo- Journal of Sports Medicine 13, S209–S212. sure to hypobaria. Aviation, Space and Environmental Lukaski, H., Hall, C. & Nielsen, F. (1990) Thermogene- Medicine 49, 415–418. sis and thermoregulatory function of iron-deficient England, A., Fraser, D., Hightower, A. et al. (1982) Pre- women without anemia. Aviation, Space and Environ- venting severe heat injury in runners: suggestions mental Medicine 61, 913–920. from the 1979 Peachtree road race experience. Annals McArdle, W., Magel, J., Spina, R., Gergley, T. & Toner, of Internal Medicine 97, 196–201. M. (1984) Thermal adjustment to cold-water expo- Fein, J., Haymes, E. & Buskirk, E. (1975) Effects of daily sure in exercising men and women. Journal of Applied intermittent exposures on heat acclimation of Physiology 56, 1572–1577. women. International Journal of Biometeorology 19, Martinez-Torres, C., Cubeddu, L., Dillmann, E. et al. 41–52. (1984) Effect of exposure to low temperature on Fortney, S. (1996) Hormonal control of fluid balance in normal and iron-deficient subjects. American Journal women during exercise. In E.R. Buskirk & S.M. Puhl of Physiology 246, R380–R383. (eds) Body Fluid Balance: Exercise and Sport, pp. Mathew, L., Purkayastha, S., Jayashankar, A. & Nayar, 231–258. CRC Press, Boca Raton, Florida. H. (1981) Physiological characteristics of cold Fortney, S. & Senay, L. (1979) Effects of training and acclimatization in man. International Journal of Biome- heat acclimation on exercise responses of sedentary teorology 25, 191–198. females. Journal of Applied Physiology 47, 978–984. Maughan, R., McArthur, M. & Shirreffs, S. (1996) Influ- Frye, A. & Kamon, E. (1981) Responses to dry heat of ence of menstrual status on fluid replacement after men and women with similar aerobic capacities. exercise induced dehydration in healthy young Journal of Applied Physiology 50, 65–70. women. British Journal of Sports Medicine 30, 41–47. Gaebelein, C. & Senay, L. (1982) Vascular volume Miles, D., Wagner, J., Horvath, S. & Reyburn, J. (1980) dynamics during ergometer exercise at different Absolute and relative work capacity in women at menstrual phases. European Journal of Applied Physiol- 758, 586, and 523 torr barometric pressure. Aviation, ogy 50, 1–11. Space and Environmental Medicine 51, 439–444. Graham, T. (1983) Alcohol ingestion and sex differences Millard-Stafford, M., Sparling, P., Rosskopf, L., Snow, 74 physiology of the female athlete

T., DiCarlo, L. & Hinson, B. (1995) Fluid intake in acute exposure to simulated altitude, 914–2286 male and female runners during a 40-km field run in meters. Medicine and Science in Sports and Exercise 14, the heat. Journal of Sports Sciences 13, 257–263. 36–40. Nielsen, B. (1996) Olympics in Atlanta: a fight against Stephenson, L. & Kolka, M. (1985) Menstrual cycle physics. Medicine and Science in Sports and Exercise 28, phase and time of day alter reference signal control- 665–668. ling arm blood flow and sweating. American Journal Paolone, A., Wells, C. & Kelly, G. (1978) Sexual varia- of Physiology 249, R186–R191. tions in thermoregulation during heat stress. Avia- Stephenson, L. & Kolka, M. (1988) Plasma volume tion, Space and Environmental Medicine 49, 715–719. during heat stress and exercise in women. European Pivarnik, J., Marichal, C., Spillman, T. & Morrow, J. Journal of Applied Physiology 57, 373–381. (1992) Menstrual cycle phase affects temperature Stevens, G., Graham, T. & Wilson, B. (1987) Gender dif- regulation during endurance exercise. Journal of ferences in cardiovascular and metabolic responses Applied Physiology 72, 543–548. to cold and exercise. Canadian Journal of Physiology Pugh, L. (1966) Accidental hypothermia in walkers, and Pharmacology 65, 165–171. climbers, and campers: report to the medical com- Stine, T., Levine, B., Taylor, S., Schultz, W. & Stray- missions on accident prevention. British Medical Gunderson, J. (1992) Quantification of altitude train- Journal 1, 123–129. ing in the field. Medicine and Science in Sports and Pugh, L. (1967) Athletes at altitude. Journal of Physiology Exercise 24, S103. 192, 619–646. Stray-Gunderson, J., Alexander, C., Hochstein, A., Rennie, D., Covino, B., Howell, B., Song, S., Kang, B. & deLemos, D. & Levine, B. (1992) Failure of red cell Hong, S. (1962) Physical insulation of Korean diving volume to increase at altitude exposure in iron defi- women. Journal of Applied Physiology 17, 961–966. cient runners. Medicine and Science in Sports and Roberts, M., Wenger, C., Stolwijk, J. & Nadel, E. (1977) Exercise 24, S90. Skin blood flow and sweating changes following Terrados, N. (1992) Altitude training and muscular exercise training and heat acclimation. Journal of metabolism. International Journal of Sports Medicine Applied Physiology 43, 133–137. 13, S206–S209. Saltin, B. (1967) Aerobic and anaerobic work capacity at Van Loan, M. & Boileau, R. (1996) Age, gender, and an altitude of 2250 meters. In R.F. Goddard (ed.) fluid balance. In E.R. Buskirk & S.M. Puhl (eds) Body International Symposium on the Effects of Altitude on Fluid Balance: Exercise and Sport, pp. 215–230. CRC Physical Performance, pp. 97–102. Athletic Institute, Press, Boca Raton, Florida. Chicago. Wagner, J., Miles, D. & Horvath, S. (1980) Physiological Shapiro, Y., Pandolf, K., Avellini, B., Pimental, N. & adjustments of women to prolonged work during Goldman, R. (1980a) Physiological responses of men acute hypoxia. Journal of Applied Physiology 49, and women to humid and dry heat. Journal of Applied 367–373. Physiology 49, 1–8. Walsh, C. & Graham, T. (1986) Male–female responses Shapiro, Y., Pandolf, K. & Goldman, R. (1980b) Sex dif- in various body temperatures during and following ferences in acclimation to a hot-dry environment. exercise in cold air. Aviation, Space and Environmental Ergonomics 23, 635–642. Medicine 57, 966–973. Silami-Garcia, E. & Haymes, E. (1989) Effects of Wells, C. (1980) Responses of physically active and repeated short-term cold exposure on cold induced acclimatized men and women to exercise in a desert thermogenesis of women. International Journal of Bio- environment. Medicine and Science in Sports and Exer- meteorology 33, 222–226. cise 12, 9–13. Sloan, R. & Keatinge, W. (1973) Cooling rates of young Young, A., Evans, W., Cymerman, A., Pandolf, K., people swimming in cold water. Journal of Applied Knapik, J. & Maher, J. (1982) Sparing effect of chronic Physiology 35, 371–375. high-altitude exposure on muscle glycogen utiliza- Squires, R. & Buskirk, E. (1982) Aerobic capacity during tion. Journal of Applied Physiology 52, 857–862. PART 3

TRAINING THE FEMALE ATHLETE

Chapter 5

Physiological Aspects of Training

MARY L. O’TOOLE

Introduction ranging from 7 to 12km. Cardiorespiratory and muscle endurance are of obvious import. Of this Women athletes have been competing in total distance, however, up to 12% has been esti- Olympic events since the Second Olympiad mated to occur at sprint speed interspersed on (1900) of the modern Games. At that time, only a the continuous motion (Reilly & Thomas, 1976; few women contestants participated in just three Mayhew & Wenger, 1985; Zeederberg et al., 1996). sports: tennis, golf and yachting. In the 1996 Additionally, accelerations from standing to Summer Games, 36% of competing athletes were maximal effort occur 40–62 times per game with women. These women athletes were contestants pace and/or direction being changed approxi- in a broad range of sporting events, most of mately every 5s (Kirkendall, 1985). These bursts which were identical to the corresponding men’s require muscular power, reaction time, agility events. For example, the marathon was a 42.2-km and flexibility. road race, the freestyle swim was 100m long, a Understanding the physiological bases for basketball game consisted of two 20-min halves, training to become ‘Swifter, Higher, Stronger’ a soccer game two 45-min halves, etc. The physi- can help the athlete develop appropriate training ological demands of the events were therefore programmes aimed at making adaptations to the same for women as for men. meet the physiological demands of the sport. The components of success in competition (i.e. Thus, the movement requirements of each sport- winning) for men and women athletes can be ing event (e.g. fast or slow, high intensity or low summarized succinctly by the motto of the intensity, short or prolonged) determine the car- modern Olympic Games: ‘Citius, Altius, Fortius’ diovascular and metabolic requirements for that or its translation ‘Swifter, Higher, Stronger’. Each sport. Training type, intensity and duration of these components is based on capacities of the should mirror these requirements. Resultant athlete for cardiorespiratory endurance, muscle improvement in the capacity for energy transfor- endurance, muscle strength, power, flexibility, mation (aerobic and anaerobic), aspects of neuro- agility and speed. The extent to which each of physiological function (e.g. coordination, skill, these components is important for success reaction time) as well as the capacity for strength depends on an analysis of the requirements of and power generation are all important for an each event. Although a detailed analysis of the athlete’s performance. components of each of the Olympic events is Training for competition fits the same general beyond the scope of this chapter, a general look at model as training to improve health or fitness. what happens during a soccer game serves to This can be described as a stimulus–response illustrate this point. Players are continuously model, in which the stimulus is the training active for two 45-min halves covering distances overload and the response is the physiological 77 78 training the female athlete

adaptation that allows the athlete to go faster, Table 5.1 Women’s Olympic track and field records jump higher or be stronger. Although evidence for the adaptive responses of women athletes to Distance Time Year of record training is not as voluminous as that for male 100m 10.62s 1988 athletes, existing evidence does suggest that men 200m 21.34s 1988 and women respond to the same training with 400m 48.25s 1996 the same adaptations (Wells, 1991; Plowman & 800m 1min 53.43s 1980 Smith, 1997). Much is known about the physio- 1500m 3min 53.96s 1988 5000m 14min 59.88s 1996 logical adaptations that occur during the initial 10000m 31min 01.64s 1996 stages of exercise training. These are discussed in 42.2km 2hours 24min 52s 1984 Chapter 2. Much less is known about the adapta- tions that occur in athletes to improve perfor- mance by very small amounts (often the difference between winning an event and finish- all but the shortest of athletic events. For optimal ing out of medal contention). Since most serious performance, the fastest rates of ATP resynthesis athletes have been training for many years and that can be sustained for the length of the race have made the initial physiological adaptations must result from optimal functioning of the long ago, training must include stimuli aimed at energy pathways best equipped to meet these improving particular aspects of performance in demands. Training methods should be aimed at accord with the specific demands of the competi- overloading the energy pathways that will be tive event. Large amounts of training, while necessary during competition. For example, a avoiding the pitfalls of overtraining, may be nec- 100-m sprinter needs a very fast rate of energy essary to produce very small improvements in transformation for a short period of time (9–10s). performance. These small improvements are, of She will reach her potential if she can optimize necessity, based on some underlying physiologi- energy transfer via ATP and phosphocreatine cal adaptations. The purpose of this chapter is to systems. An 800-m runner can improve her per- discuss some of the training techniques com- formance by optimizing ATP, phosphocreatine monly used, their physiological bases and the and anaerobic glycolytic energy transfer. At the expected adaptations that result in improved other end of the energy spectrum are the needs of performance. a marathon runner. Her main energy require- ments must be met with aerobic metabolism with adjuncts from the anaerobic glycolytic system for Swifter: training to optimize energy surges throughout the course of the race and for a transformation finishing kick. These examples are straightfor- Most sports events contain some element of ward since the outcome of the race is determined swiftness or speed. Speed is ultimately limited by the swiftness with which the athlete can cover by rate of energy transformation. Maximal speed the required distance. Less clear are the swiftness (exercise intensity) sustainable is directly related demands of sports events that require some com- to the length of time the athlete must be in bination of energy transformation pathways for motion (race or event duration). Table 5.1 shows optimal performance. A thorough analysis of the record times for running races with distances requirements of each sports event is necessary to from 100m to 42.2km. Quite clearly, exercise develop an appropriate training plan for specific intensity (speed) and duration are inversely events. Such an analysis is beyond the scope of related. The ultimate source of energy for move- this chapter. The section below reviews some of ment is adenosine triphosphate (ATP). Since only the commonly used training techniques, as well a small amount of ATP is stored in the body, the as their physiological bases, for improving the rate of ATP resynthesis is the limiting factor for various types of energy transfer. The translation physiological aspects of training 79

of this general information into specific training tained distance running, transport (cardiovascu- plans is left to the athlete and her coach. lar) and utilization (metabolic) systems are stressed. Additional stresses on the athlete include elevation of body temperature, loss of Aerobic energy transformation fluid and electrolytes in sweat, repeated micro- Aerobic metabolism is governed by oxygen and trauma to joints and muscles, and the need to nutrient transport as well as by muscle respira- maintain energy balance. tory capacity. According to the training The second commonly used training tech- principles of specificity and overload, training nique for improving aerobic metabolism is the to improve aerobic energy transformation use of aerobic interval training. During aerobic should therefore stress the physiological systems interval training, workouts consist of repeated involved in transport and use of oxygen and sub- exercise periods (usually lasting 5–15min) inter- strate by muscles involved in the tasks specific to spersed with short rest periods (5–15s). With this the competitive event. type of training pattern, more absolute work can be done during a workout session than with sus- training methods tained distance training. Although neither circu- lation nor oxygen uptake has time to recover to There are two commonly used methods to train any appreciable amount during the relatively the aerobic energy transformation systems: sus- short recovery intervals, the musculoskeletal tained distance training and aerobic interval system gets brief respites from continuous strain. training (Wells & Pate, 1988). During sustained As with sustained distance training, the specific distance training, workouts are bouts of continu- length of the exercise interval depends on the ous rhythmical activity lasting for relatively long exercise mode and the length of the competitive periods of time and done at a comfortable pace event. For example, a 10-km runner might incor- (also called long slow distance). The specific dis- porate 800–1600-m repeats into her workout tance is somewhat arbitrary and may vary con- plan. Repetitions may be as few as five per siderably depending on the length and type of session or as many as 20. The longer the exercise the competitive event; 8km of running or at least interval in relation to the event length (greater 30min of continuous swimming have been proportion of the whole race), the fewer the repe- reported for rowers and swimmers respectively titions (Costill, 1986). The pace should be slightly (Kearney, 1996), while marathon runners have below the lactate threshold pace, but faster than been reported to run for 2–3 hours and cyclists to the pace for sustained distance training. Intensity ride 130–250km for sustained distance training can be guided by keeping RPE within the ‘some- (Wells & Pate, 1988). The pace of these training what hard to hard’ range (RPE = 13–15), with sessions should be one that can easily be per- heart rates kept in a range that represents slightly formed for the specified time. Exercise intensity less than lactate threshold. It is commonly recom- can be monitored by the athlete during these mended that these intervals be done no more workouts by using the rating of perceived exer- than 1–3 days per week because of risk of injury tion (RPE) or by monitoring heart rates. RPE (Costill, 1986). The same benefits to transport and during this type of workout should be ‘fairly utilization systems occur as with sustained dis- light to light’ (RPE = 10–12). If information is tance training, but additional benefits accrue as available from an incremental exercise test, heart well. The movement patterns are more similar to rates representing a pace well below the lactate competitive event patterns, thus potentially threshold (see below) can be used to guide pace. improving movement economy (see below) and Heart rate monitors (on which lower and upper relative proportions of substrate used (fat vs. car- limits can be set) are useful for guiding the bohydrate). Additionally, lactate may increase athlete to maintain appropriate pace. During sus- during the workout, stressing systems involved 80 training the female athlete

in tolerating higher lactate levels and those size and left ventricular mass are common find- involved in removing lactate. ings in female as well as male endurance-trained The physiological adaptations that account for athletes over a wide age range from a variety of improvement in aerobic energy transformation sports (Pollack et al., 1987; Douglas et al., 1988; are reflected in the functional capacities of the Douglas & O’Toole, 1992; Pelliccia et al., 1996). cardiovascular and metabolic systems. Adapta- The increased wall thickness allows a reduction tions to the cardiovascular system include the in the tension applied to each individual fibre, as variety of cardiac adaptations that allow greater wall stress is distributed across a greater mass efficiency in the performance of the heart’s of myocardium (Douglas, 1989). Additionally, primary function, that of a muscular pump, as preload is increased, in part because of an well as those involving more efficient distribu- increase in total blood volume (particularly tion of blood volume (Harrison, 1985). Adap- plasma volume) (Oscai et al., 1968), and results in tations to the metabolic system include more an increase in stroke volume via the Frank– efficient utilization of substrate via improved Starling mechanism. The increased left and right functioning of energy transfer systems. ventricular end-diastolic volumes allow a similar volume of blood to be ejected with less shorten- cardiovascular adaptations ing and less friction but with increased tension. Endurance training appears to result also in an · Initially VO2max, often used as the ‘gold standard’ increased left ventricular compliance that to judge capacity for aerobic energy transfer, enhances preload at maximal exercise (Levine et increases because of training-induced increases al., 1991). Studies of male and female ultra- in maximal cardiac output directly attributable endurance triathletes have shown enhanced to increased stroke volume (Clausen, 1977; diastolic function at rest (altered diastolic filling Blomqvist & Saltin, 1983). Traditional wisdom pattern with increased early filling), which pre- has been that during incremental exercise stroke sumably would result in increased preload volumes of women as well as men reach during maximal exercise (Douglas, 1989). Others maximum at exercise intensities of 40–50% have also reported enhanced diastolic function, maximal capacity and that training will increase with measured peak filling rates up to 71% the height of the plateau. Endurance athletes greater than control subjects at matched heart were simply thought to have larger stroke rates (Gledhill et al., 1994). In longitudinal volumes at each exercise intensity and higher studies, training has also been documented to plateaus than untrained or less well-trained result in improved cardiac filling in younger and individuals (Saltin, 1969). Recently, however, older subjects both at rest and during exercise Gledhill et al. (1994) confirmed earlier reports (Levy et al., 1993). Others have reported resting (Ekblom & Hermanson, 1968; Vanfraechem, diastolic performance to be an independent · 1979; Crawford et al., 1986) of continued increase determinant of VO2max in both sedentary individ- in stroke volume throughout an incremental uals and athletes (Vanoverschelde et al., 1991), exercise test to maximal effort in highly trained although our studies in triathletes have not con- male cyclists. The resultant slower heart rates at firmed this relationship (P.S. Douglas & M.L. submaximal exercise intensities would reduce O’Toole, unpublished observations). myocardial oxygen demand. While similar infor- The effects of endurance training on contrac- mation is not available for female athletes, they tile function are less clear, since contractile func- have been demonstrated to exhibit many of the tion is increased during maximal exercise in physiological changes that could potentially con- untrained as well as highly trained athletes. tribute to increased stroke volume. Gledhill et al. (1994) demonstrated a progressive Several factors can contribute to an increased increase in peak left ventricular emptying rates stroke volume. Increased left ventricular cavity with maximal exercise testing in cyclists that was physiological aspects of training 81

not seen in control subjects and a longer left ven- can contribute as much as 50% to the initial tricular ejection time, suggesting that augmenta- improvement in the ability to extract and use tion of systolic function during exercise is a oxygen during the aerobic resynthesis of ATP mechanism by which athletes are able to enhance (Holloszy, 1975; Clausen, 1977). Gollnick et al. performance. It has been postulated that the (1972) demonstrated that these adaptations in athlete’s ability to enhance systolic function males were specific to the mode of exercise stim- leads to a smaller end-systolic volume which, by ulus (e.g. the patterns of enzyme activities in arm virtue of suction, would enhance early diastolic and leg muscles of swimmers were clearly differ- filling. ent from those of cyclists). Both fat and carbohy- Peripherally, aerobic training results in drate metabolism is enhanced (Gollnick et al., increased capillary density; a close correlation 1972; Holloszy & Coyle, 1984). The time course of · has been shown between VO2max and number of these adaptations appears to be somewhat vari- capillaries per muscle fibre in both women and able, although Hamel et al. (1986) reported adap- men athletes (Saltin et al., 1977). Endurance tation of skeletal muscle enzymes to be near training has also been associated with reduced maximal trainability after 15 weeks. systolic and diastolic blood pressures and total Interindividual differences in movement peripheral resistance, thereby enabling the economy occur in highly trained élite athletes endurance athlete to achieve high cardiac (Daniels, 1985). As has been shown for male outputs at maximal exercise with afterload runners, Pate et al. (1987) demonstrated that élite · similar to that of sedentary subjects with much female runners had lower VO2 (better movement lower cardiac outputs. Additionally, a close economy) at two different submaximal running relationship between submaximal exercise blood speeds (230 and 248m·min–1) compared with pressures and left ventricular mass has been non-élite runners. Morgan and Craib (1992) have reported for male and female ultra-endurance suggested that these differences are the result of triathletes (Douglas et al., 1986). differences in muscle fibre type. However, All these findings suggest a more efficiently Williams and Cavanagh (1987) reported no dif- functioning cardiovascular system in highly ference in fibre type among trained runners with trained athletes. Although some of this informa- good, medium and poor running economy. Simi- tion, including the work of Gledhill et al. (1994), larly, Costill et al. (1987) confirmed that muscle has been derived from studies of male athletes, fibre characteristics and enzyme activities in both Douglas and colleagues and Pelliccia and female runners were directly related to the length colleagues have included women athletes and of the competitive event but not to skill level. have found no gender-related differences in Women marathon runners had a greater percent- these responses. The time course of these adapta- age of type I fibres than middle distance runners, tions in athletes is unknown as are the limits to but muscle enzyme activities were similar in élite adaptation in any single athlete. and non-élite runners at matched distances (Costill et al., 1987). metabolic adaptations Both muscle and liver glycogen reserves are increased with this type of training. Studies have Adaptive changes in the muscular system that shown that with training, the relative contribu- occur in response to sustained distance or tion of fat compared with carbohydrate as sub- aerobic interval training improve the efficiency strate is increased (Gollnick, 1985). Thus, at the of substrate utilization (Saltin & Rowell, 1980; same absolute workload (i.e. same running Klausen et al., 1981). These metabolic adaptations speed), muscle and liver glycogen are metabo- (increases in myoglobin, size and number of lized at a slower rate than before training (Hol- mitochondria, and levels of various enzymes and loszy & Coyle, 1984; Gollnick et al., 1986; transfer agents that enhance aerobic metabolism) Abernathy et al., 1990). The advantage of this is a 82 training the female athlete

delay in glycogen depletion, which not only balance must be maintained daily. During sus- allows activity to proceed at a particular pace for tained distance and aerobic interval training, the a longer time but also allows brief spurts of athlete metabolizes a combination of fat and car- higher intensity activity that is reliant on gly- bohydrate for prolonged periods. Since fat stores colytic energy sources. However, the oxygen cost are essentially unlimited, the focus of energy of burning fat is greater than that of burning car- balance should be on the consumption of ade- bohydrate. Therefore, one could hypothesize quate calories and enough carbohydrate to keep that it would be to the advantage of the success- glycogen stores replete. It is generally accepted ful athlete to be able not only to conserve muscle that 8–10g·kg–1 (600–650g) of carbohydrate daily glycogen but also to oxidize exogenous carbohy- are necessary to maintain maximally full glyco- drate. No studies have specifically addressed this gen stores (Sherman & Lamb, 1988). How well issue in female athletes. female athletes comply with these recommenda- Sustained distance training and aerobic tions may depend on the specific sport for which interval training alter lactate thresholds by they are training. For example, caloric intakes of decreasing lactate production and/or improving triathletes have been reported to be appropriate clearance rates at submaximal exercise intensi- for the amount and type of training, with carbo- ties. Lactate thresholds, when expressed as per- hydrate intake quite close to recommended · –1 centage VO2max, are similar for equally well- amounts, ranging between 6.7 and 8.8g·kg trained men and women athletes. The relation- daily (Burke & Read, 1987; Khoo et al., 1987; ship of lactate threshold to successful perfor- Applegate, 1989). Conversely, female cross- mance has been shown to be as important for the country runners, for whom thinness may be per- woman athlete as the man (O’Toole et al., 1989; ceived as more important, were reported to fall Laurenson et al., 1993; O’Toole & Douglas, 1995). short of both caloric and carbohydrate require- Élite marathon runners have been reported to run ments (Tanaka et al., 1995). The effect on perfor- their races at an average pace equivalent to 86% mance of women athletes who do not follow · VO2max, a pace that represents 93% of their lactate these recommendations is not clear in the light of threshold of 4mmol·l–1 (Sjodin & Svedenhag, evidence that women athletes demonstrate 1985). Slower marathon runners reportedly run greater lipid and less carbohydrate or protein · at 65% VO2max. There is some evidence to suggest metabolism during moderate-intensity exercise that in highly trained male and female athletes compared with equally trained male athletes · who have reached their genetic ceiling for VO2max (Tarnopolsky et al., 1990). through hard training, continued improvement In addition to daily energy/carbohydrate in performance results from continual improve- balance, many endurance athletes also follow ment in lactate threshold. Kohrt et al. (1989) carbohydrate-loading regimens before impor- reported increases of 6% and 10% in lactate tant competitions. During typical carbohydrate thresholds for female as well as male triathletes loading, dietary carbohydrate is increased to 75% for cycling and running, respectively, during the of energy intake for 4 days before competition. course of a triathlon season. No increases in Recent research, however, has cast doubt on the · VO2max occurred. Neither the time course nor the usefulness of this practice for female athletes. optimal training stimulus for continual improve- Tarnopolsky et al. (1995) reported that while men ment of thresholds in athletes is known. increased muscle glycogen concentration by 41% following such a routine, no change in glycogen other considerations concentration was seen in women athletes. In men, this resulted in a 45% improvement in · To derive optimal training benefits from sus- cycling performance at 85% VO2max, while in tained distance and aerobic interval training, women there was no change in performance. energy balance as well as fluid and electrolyte Confirmation of these apparent gender differ- physiological aspects of training 83

ences is needed in larger groups of women can be used to monitor training (Dwyer & Bybee, athletes and in different exercise modes. 1983; Gilman & Wells, 1993). Since lactate thresh- Another major consideration is the mainte- olds may vary according to exercise mode, heart nance of fluid and electrolyte balance. To main- rates that have been measured in the particular tain body temperature within tolerable limits, training mode should be used. For example, in the high rate of heat production that occurs with both men and women athletes, lactate thresholds aerobic exercise training and competition must (4mmol·l–1) have been reported to be 72–88% · · be balanced by a high rate of heat loss. This VO2max for cycling but 80–85% VO2max for running requires a high sweat rate and therefore loss of (Kohrt et al., 1989; O’Toole et al., 1989). Because both fluids and electrolytes (Nadel, 1988). Both the pace is above the threshold, lactate accumu- sustained distance training and aerobic interval lates in the muscle during the exercise part of the training, particularly when performed in a interval. During the recovery intervals ATP and hot environment, place large thermoregulatory phosphocreatine are replenished, allowing the demands on the female athlete. Tolerance to fluid athlete to maintain the high intensity at the consumption during endurance exercise appears beginning of the next exercise interval. However, to be a trainable phenomenon and should be only some of the lactate is removed and metabo- incorporated into sustained distance and aerobic lized via aerobic metabolism, causing the athlete interval training (Sparling et al., 1993) (see to try to maintain pace despite a more acidic local Chapter 4 for a more thorough discussion of muscle environment (Plowman & Smith, 1997). gender-related differences in thermoregulatory Thus pace training stimulates and causes adap- capacities of athletes). tive responses in both aerobic and anaerobic energy systems. Since many sports require inter- mittent anaerobic activity over a long period of Aerobic and anaerobic energy transformation time, this type of training can be particularly Just as the metabolic systems do not operate in useful. Following a training session, approxi- isolation, some types of training improve both mately 50% of the lactate is removed with 15– aerobic and anaerobic metabolism. Pace or 20min of rest and levels are nearly back to resting tempo training is a perfect example. Pace train- levels within 1 hour. Lactate removal can be ing is continued for long enough periods of time accelerated by continuous jogging for about to stress the oxidative energy systems (see above) 20min at a comfortable pace just below the but also at a sufficient intensity that there is a lactate threshold. However, the continuous large anaerobic component as well. jogging may delay the resynthesis of muscle glycogen and therefore may not be beneficial to training methods all athletes, e.g. one who has repeated heats in a middle-distance event. Pace training involves exercise performed at a pace slightly faster than lactate threshold pace physiological bases and adaptations (Wells & Pate, 1988). Intervals of 3–10min are interspersed with 30–90s periods of slower The benefits of pace training include many of the paced activity. The number of intervals per- adaptations described above for sustained dis- formed during any exercise session depends on tance and aerobic interval training. Additionally, the exercise mode and the length of the competi- pace training effectively stimulates an increase in tion. During the exercise intervals, the RPE the lactate threshold by increasing the capacity to should represent subjective feelings of ‘hard to remove lactate, increasing the tolerance to high very hard’ exercise (RPE = 15–17). Heart rates levels of lactate, enhancing the capacity for that represent an exercise intensity approxi- glycolytic energy transfer (increased glycolytic mately 5% greater than that at lactate threshold enzymes) and increasing the capacity to store 84 training the female athlete

muscle glycogen. Another benefit of pace train- physiological bases and adaptations ing is a muscle-fibre recruitment pattern similar to that in competition, thus contributing to For most contests, other than outright sprints, the improved movement economy. Both male and challenge for the athlete is not to perform only female athletes respond similarly to lactate and one of these intervals but to recover quickly and have similar resting levels and similar levels at perform them repeatedly throughout the course matched relative intensities (Plowman & Smith, of a game, e.g. basketball, tennis, etc. During the 1997). As with aerobic training, neither the time exercise part of the interval, there is marked course nor the upper limits of trainability for depletion of phosphagens (ATP and phosphocre- female athletes is known. atine) along with marked elevations in lactate with the longer intervals. Unlike training with high lactate levels to improve tolerance to low Anaerobic energy transformation pH, there is no benefit to training with depleted High-intensity exercise requires a very fast rate phosphagens. The 2-min recovery interval of energy transfer. This rate can only be met reflects the time it takes to restore the phospha- through anaerobic energy pathways. The limit- gens to near resting levels; half-restoration ing factors for continued energy transformation occurs within 30s (Fox & Mathews, 1974). via anaerobic pathways are mainly substrate Although phosphagen recovery is most effective depletion and the factors associated with accu- with complete rest, unless the exercise interval mulation of lactate as described above. Exercise has been limited to 10s or less some lactate has time is severely limited, from seconds to a few accumulated as well. Low-intensity exercise minutes, when anaerobic metabolism is the sole would then be the most appropriate recovery energy source. Anaerobic interval training, with technique. For most athletes, intervals should intervals of varying lengths, is useful for enhanc- have a specific metabolic goal. They should be ing power for short events such as the 100-m either very short so as to minimize the contribu- sprint and for spurts in many game activities. tion of lactate or long enough to include a lactate These short intervals, often called speed training, contribution. The specific combination of are as effective for women athletes as for men intervals should be guided by the competition (Weltman et al., 1978). demands on each athlete. Although the efficiency of splitting ATP is not changed by this or any training methods other type of training (Plowman & Smith, 1997), trained muscle contains more ATP and phospho- Very short exercise intervals are performed at or creatine as well as enzymes to increase the rate of · above the pace associated with VO2max (Weltman breakdown. The specific contribution of these et al., 1978; Wells & Pate, 1988). Exercise intervals increased resting levels to movement and speed last between 30s and 4min with recovery inter- in particular is not known. vals about 2min long; 5–20 such intervals may be repeated during a training session. Subjective Higher: training to optimize RPE should be ‘very, very hard’ (RPE=18–20). neurophysiological aspects Heart rates can be monitored but are probably of movement unnecessary for this type of training. ATP and phosphocreatine systems are the main targets for In order to soar or jump higher, an athlete needs the shorter intervals, with the anaerobic gly- the capacity for optimal energy transformation colytic system being an additional target during (see above) and optimal strength and power intervals lasting longer than a few seconds. This (see below). However, these capacities will not type of training is very demanding and should produce winning efforts in most sports contests be used judiciously and interspersed with train- unless neurophysiological aspects of movement ing of other energy systems. are also functioning at optimal levels. There is physiological aspects of training 85

general agreement that motor skills, including clubs. This type of equipment is best for isolating agility, balance, reaction time and quickness, are muscles around a particular joint. Because all important for success in sports. However, muscle groups are isolated, with little effect on there is not general agreement about training adjacent groups, the athlete must be careful to methods or underlying physiological changes avoid creating imbalances in strength around a that contribute to improvement of these parame- joint. ‘Free-form’ weights are mainly free weights ters. However, since it is known that motor skills that require synergistic muscle action to main- are acquired through practice with appropriate tain balance and to keep the movement in the feedback (Fox et al., 1996), most athletes train appropriate plane. This type of training has the with repetition of the specific movement patterns most relevance for sports. As with increasing · of the competitive event. Neither the time course VO2max, the main increases in strength should be for skill development nor the final skill level can accomplished before the competitive season; be predicted for an individual athlete. It is strength training during the season should be beyond the scope of this chapter to explore the used for maintenance. Although some contro- concepts of motor learning for the athlete. versy continues to exist regarding concurrent strength and endurance training (Dudley & Djamil, 1985; Callister et al., 1990; Chromiak & Stronger: training to optimize Mulvaney, 1990), most of the available studies strength and power suggest that concurrent training shows little Most sports contests require a certain element of effect on aerobic capacity but may decrease strength and/or power. As with training for strength and power. For example, Callister et al. optimal energy utilization and neuromuscular (1990) documented decreases in speed and function, strength/power training should be jumping power following a mixed training specific to the goals of the individual athlete. A regimen. In addition to the resistance applied, gymnast may require a great deal of strength, the velocity of movement also seems to be impor- long jumpers a great deal of power and athletes tant in training for power (Perrin, 1993). Slow- in most other sports a combination of these two velocity training has been shown to increase qualities. As in other types of training, the torque only at the training velocity. Fast-velocity response of the female athlete is qualitatively training seems to have the added advantage of similar to that of the male athlete, so that while increasing torque at the training velocity and at the male athlete is typically stronger than the movement speeds slower than training velocity. female athlete, both will respond to resistance Since angular velocities for most sports move- training with similar patterns of strength gains ments are greater than commonly used and similar changes in muscle cross-sectional isokinetic training velocities, it makes intuitive area (Wilmore, 1974; Weltman et al., 1978; sense that the athlete should train at the highest Cureton et al., 1988; Tesch, 1992). velocity possible for a given power requirement. As with other types of training, the intensity of the stimulus (amount of weight or resistance) Training methods determines the response (strength gain). There- fore near-maximal resistance is used to produce During resistance training, the components that the greatest gains in strength. For the female are manipulated to produce the required stimu- athlete, strength requirements are a part of the lus are the load, number of repetitions, number physiological demands necessary for success in a of sets and length of rest periods. Of these, load sport or event, rather than a separate event such seems to be most important for the development as weight-lifting for men. Typically, two types of of strength. No single combination of these com- equipment are used to improve strength. ‘Fixed- ponents has been documented to produce the form’ equipment includes the various types of best results. Research has shown that resistance weight machines commonly found at fitness must be at least 60% of maximum in order to 86 training the female athlete

make strength gains. However, most commonly, heavy-resistance free weights are moved as 80–90% maximal capacity (1 repetition maxi- rapidly as possible through the range of motion. mum, RM) is lifted for three to six repetitions The momentum created from the accelerating per set for three to five sets (Fleck & Kramer, mass must be decelerated at the end of the range. 1987). Many athletes quantify and manipulate Newton et al. (1996) have shown this to be coun- the volume of training (number of repetitions ¥ terproductive in the development of power as set ¥ load) per session to make optimal improve- judged by training-induced decreases, rather ment without undue fatigue (Tesch, 1992). If than increases, in bench press power. Kraemer muscular endurance, i.e. the ability continually and Nindl (1997) suggest that power training to repeat submaximal efforts as in tennis strokes, would best be done with weights that can be is the desired outcome, a lower resistance can be released at the end of the range of motion, e.g. used. Gains in muscular endurance have been medicine balls. Plyometrics, another technique reported with resistance as low as 30% of used by athletes to develop power, is a training maximal capacity if repetitions are continued technique that employs eccentric contractions until the muscle group is fatigued (Cureton et al., immediately followed by concentric contrac- 1988). The length of the rest periods is also tions. For example, one typical routine involves important. Relatively long rest periods of several the athlete trying to rebound and attain greater minutes between sets are used when the goal is heights after jumping from a box or platform that increasing strength. Conversely, shorter rest is higher than floor or ground level. The quadri- periods of less than 1min between sets should be ceps undergoes rapid eccentric contraction fol- used for training muscular endurance (Fleck & lowed immediately by a concentric contraction. Kramer, 1987). Training 2–4 days a week is This type of training is used by hurdlers, high thought by weight-lifters to be the most effective. jumpers and by other athletes, such as basketball However, they frequently emphasize only one players, who must jump higher to improve per- muscle group during a workout. This muscle formance. The role of plyometric training for group is then rested for 48–72hours before either male or female athletes has not been another strength-training session. Whether this clearly proved at this time (Bobbert, 1990). is an appropriate way to strength train athletes, other than competitive resistance athletes, is Physiological bases and adaptations unknown. Once the athlete has achieved the desired level of strength, usually within 1 year of Strength gains accrue within a few weeks of serious training, this level can be maintained initiation of a resistance training programme. with as little as one session per week or multiple Initial strength gains are attributed to neural sessions with reduced volume as long as the adaptations that include increased neural drive, resistance load is maintained. increased synchronization of motor units and Training methods to improve power are less release of the inhibitory effects of Golgi tendon clear and not supported by good research studies organs (Fleck & Kramer, 1987). These neural (Wilmore & Costill, 1994). A given power adaptations result in improved coordination and requirement can be met by training with a high- increased activation of the prime movers for any velocity/low-resistance regimen or a slower- muscle action. With continued training, muscle velocity/higher-resistance regimen. Fleck and hypertrophy occurs as a result of increased Kramer (1987) suggest that the load should amounts of contractile protein, increased size be similar to that during strength training. and number of myofibrils per muscle fibre and However, the choice of exercise equipment may an increase in the amount of surrounding con- be important in the development of power. One nective tissue (Rogers & Evans, 1993). One study technique that athletes have used is ‘speed reps’ of heavy-resistance training in men reported that with free weights. During this type of training, a 28% increase in strength was accompanied by physiological aspects of training 87

significant increases in the muscle’s resting levels year is divided into blocks of time periods of ATP, phosphocreatine, free creatine and glyco- ranging from days to weeks to months. During gen (MacDougal et al., 1977). Although similar each of these blocks, a particular aspect of train- studies using female athletes as subjects have not ing is emphasized. been reported, there is no reason to believe that The longest blocks of time are called macrocy- their responses would be different. cles and usually last 2–4 months; there may be Speed is a more difficult component than three to four macrocycles per year. Smaller strength to change. In large measure, the physio- blocks called mesocycles are organized within logical changes that allow the athlete to increase each macrocycle; a mesocycle typically lasts 8–10 her power are much the same as those for weeks. In turn, microcycles, usually 1 week each, increased strength. The physiological mecha- make up each of the mesocycles. Training nisms underlying the improved jumping perfor- volumes and intensities are varied by cycle. In its mance following plyometric training are not well simplest form, volume and intensity are varied understood. Both the stretch–shortening cycle, inversely. However, the exact make-up of each which relies on the elastic properties of muscle cycle depends on the specific demands of the and connective tissue, and the activation of competitive event and includes a primary focus muscle spindles during the eccentric part of the and several secondary ones. For example, during jump are thought to potentiate the subsequent the first macrocycle of a training period (fre- concentric contraction. However, these mecha- quently referred to as the preparatory phase), nisms have not yet been substantiated for either high-volume/low-intensity workouts are em- male or female athletes (Bobbert, 1990). phasized as the primary focus. For an endurance athlete, this means that sustained distance and aerobic interval training should make up the Other considerations for bulk of the training, with perhaps some supple- optimal performance mental weight training done with low resistance Although winning performances require opti- and medium to high volume. For an athlete mization of the above-mentioned training adap- whose event demands mainly strength and tations, other factors may also contribute to the power, such as a high jumper, resistance training outcome. Biomechanical aspects of performance should be emphasized. For this athlete, the are discussed in Chapter 6, psychological aspects primary focus might be high-volume (three to in Chapter 7 and nutrition in Chapter 8. five sets of 8–12 repetitions), low-resistance However, even in terms of the physiological (50–80% 1 RM) weight training with some sus- adaptations, the athlete must optimize these by tained distance or aerobic intervals. As the training sensibly. Periodization and avoidance of athlete progresses towards competition, training overtraining are critical to an athlete’s success. volumes are decreased and intensities increased. The last mesocycle before an important competi- tive event is typically divided into two parts. Periodization During the first part, the emphasis is on maximal Periodization is the purposeful variation in a intensity, sport-specific training based on the training programme over the course of time so strength, power and endurance requirements for that the athlete will approach her optimal adap- that particular sport and is of very short dura- tive potential just before important competitions. tion. The second part of the last mesocycle before Asystematic, sequential approach is used to opti- competition should be the taper. Some form of mize potential for short periods of time by orga- tapering is universally accepted as a means to nizing training into blocks of time. In its simplest optimize performance by allowing adequate form, athletes use a hard–easy pattern for daily recovery from hard training before important workouts. In its more complete form, the training competitions (Wells & Pate, 1988). During a 88 training the female athlete

taper, some combination of training frequency, performance plateaus. The usual response to a intensity and volume is altered to reduce the performance plateau is to increase the amount training stimulus. Most evidence indicates that a and intensity of training. If the reason for the rather drastic reduction of up to 85–90% of usual plateau is indeed undertraining, additional training volume in combination with short training may be of benefit. On the other hand, intense workouts gives the best result (Shepley et if the reason for the plateau is overtraining, al., 1992; Houmard & Johns, 1994). This type of further training will exacerbate the problem and taper has been shown to result in a performance in all likelihood lead to further decrements in improvement of about3% in swimmers and dis- performance. tance runners. Despite this evidence, athletes The maladaptations of overtraining are essen- find the taper a difficult part of training. Typi- tially an imbalance between stimulus and recov- cally, athletes undergo tapering (i.e. reduce train- ery. Multiple signs and symptoms have been ing volume by at least two-thirds) for about 1 associated with overtraining. Fry et al. (1991) week. This may not be long enough to be have compiled a list of the major symptoms of optimal. Costill et al. (1985) have reported a 3–4% overtraining reported in the literature (Table 5.2). improvement in swim times following a 15-day These signs and symptoms may be diffuse in taper where training yardage was reduced by nature, presenting as generalized fatigue with or two-thirds. This work, as well as that of Hickson without more specific physiological symptoms. and Rosenkoetter (1981), shows that training Alternatively, a specific physiological system adaptations can be maintained and perhaps may break down, e.g. failure of some aspect of potentiated by appropriate use of the taper. the musculoskeletal system may result in an Although evaluation of individual periodization overuse injury such as a stress fracture. Some of routines is difficult, shorter mesocycles can be these symptoms are seemingly contradictory, evaluated to determine the efficacy of specific e.g. both increased and decreased resting heart aspects of training. rates have been reported in overtrained runners. Multiple symptoms in any combination, any single symptom or even the absence of physio- Overtraining logical symptoms characterize an overtrained Overtraining is a long-term (weeks to months) athlete. The universal finding in overtrained decrement in performance with or without athletes is a decrease in performance ability. related physiological and psychological signs or However, not all aspects of performance are symptoms and can be a serious problem for the affected simultaneously or to the same degree. competitive athlete (Kreider et al., 1997). To Identification of physiological markers prodro- achieve optimal athletic performance, serious mal to the overtraining syndrome is likewise athletes devote years to hard training. Knowing difficult. that an athlete who does not train hard enough may never reach her full potential, many Conclusion athletes adopt a ‘more is better’ philosophy. Unfortunately, training too often and/or The physiological demands of most sporting too intensely may lead to physiological events are similar for men and women athletes. maladaptations and decreases in performance. Likewise, training methods seem to be similar. Determining the optimal amount of training to Although men athletes may be swifter, able to go optimize performance of individual athletes is higher and are stronger than women athletes in difficult. The amount of training that may be absolute terms, women athletes respond to train- optimal for one athlete may undertrain or over- ing with many of the same physiological adapta- train others. To complicate the issue further, both tions. Although much is known about the initial undertraining and overtraining may result in responses of women to training and about the physiological aspects of training 89

Table 5.2 The major symptoms of overtraining as indicated by their prevalence in the literature. (From Fry et al., 1991 with permission)

Physiological/performance Decreased self-esteem/worsening feelings of self Decreased performance Emotional instability Inability to meet previously attained performance Difficulty in concentrating at work and training standards/criteria Sensitive to environmental and emotional stress Recovery prolonged Fear of competition Reduced toleration of loading Changes in personality Decreased muscular strength Decreased ability to narrow concentration Decreased maximum work capacity Increased internal and external distractability Loss of coordination Decreased capacity to deal with large amounts of Decreased efficiency/decreased amplitude of information movement Gives up when the going gets tough Reappearance of mistakes already corrected Reduced capacity of differentiation and correcting Immunological technical faults Increased susceptibility to and severity of Increased difference between lying and standing heart illness/colds/allergies rate Flu-like illnesses Abnormal T-wave pattern in ECG Unconfirmed glandular fever Heart discomfort on slight exertion Minor scratches heal slowly Changes in blood pressure Swelling of lymph glands Changes in heart rate at rest, exercise and recovery One-day colds Increased frequency of respiration Decreased functional activity of neutrophils Perfuse respiration Decreased total lymphocyte counts Decreased body fat Reduced response to mitogens Increased oxygen consumption at submaximal Increased blood eosinophil count workloads Decreased proportion of null (non-T, non-B) Increased ventilation and heart rate at submaximal lymphocytes workloads Bacterial infection Shift of the lactate curve towards the x axis Reactivation of herpes viral infection Decreased evening post-workout weight Significant variations in CD4:CD8 lymphocytes Elevated basal metabolic rate Chronic fatigue Insomnia with and without night sweats Biochemical Feels thirsty Negative nitrogen balance Anorexia nervosa Hypothalamic dysfunction Loss of appetite Flat glucose tolerance curves Bulimia Depressed muscle glycogen concentration Amenorrhoea/oligomenorrhoea Decreased bone mineral content Headaches Delayed menarche Nausea Decreased haemoglobin Increased aches and pains Decreased serum iron Gastrointestinal disturbances Decreased serum ferritin Muscle soreness/tenderness Lowered total iron-binding capacity Tendinostic complaints Mineral depletion (Zn, Co, Al, Mn, Se, Cu, etc.) Periosteal complaints Increased urea concentrations Muscle damage Elevated cortisol levels Elevated C-reactive protein Elevated ketosteroids in urine Rhabdomyolysis Low free testosterone Increased serum hormone-binding globulin Psychological/information processing Decreased ratio of free testosterone to cortisol of more Feelings of depression than 30% General apathy Increased uric acid production 90 training the female athlete

physiological adaptations (e.g. changes in Daniels, J.T. (1985) A physiologist’s view of running cardiac structure and function) seen in athletes economy. Medicine and Science in Sports and Exercise 17, 332–338. and attributed to training for many years, much Douglas, P.S. (1989) Cardiac considerations in the less is known about the small adaptations that triathlete. Medicine and Science in Sports and Exercise occur in athletes throughout their careers allow- 21 (Suppl.), S214–S218. ing them to reach their full potential. This gap in Douglas, P.S. & O’Toole, M.L. (1992) Aging and physi- knowledge should be addressed with future cal activity determine cardiac structure and function in the older athlete. Journal of Applied Physiology 72, studies of women athletes. 1969–1973. Douglas, P.S., O’Toole, M.L., Hiller, W.D.B. & Reichek, References N. (1986) Left ventricular structure and function by echocardiography in ultraendurance athletes. Abernathy, P.J., Thayer, R. & Taylor, A.W. (1990) Acute American Journal of Cardiology 58, 805–809. and chronic responses of skeletal muscle to endur- Douglas, P.S., O’Toole, M.L., Hiller, W.D.B., Hackney, ance and sprint exercise: a review. Sports Medicine 10, K. & Reichek, N. (1988) Electrocardiographic diagno- 365–389. sis of exercise-induced left ventricular hypertrophy. Applegate, E. (1989) Nutritional concerns of the ultra- American Heart Journal 116, 786–790. endurance athlete. Medicine and Science in Sports and Dudley, G.A. & Djamil, R. (1985) Incompatibility of Exercise 21 (Suppl.), S205–S208. endurance and strength training modes of exercise. Blomqvist, C.G. & Saltin, B. (1983) Cardiovascular Journal of Applied Physiology 59, 1446–1451. adaptations to physical training. Annual Review of Dwyer, J. & Bybee, R. (1983) Heart rate indices of the Physiology 45, 169–189. anaerobic threshold. Medicine and Science in Sports Bobbert, M.F. (1990) Drop jumping as a training and Exercise 15, 72–76. method for jumping ability. Sports Medicine 9, 7–22. Ekblom, B. & Hermanson, L. (1968) Cardiac output in Burke, L.M. & Read, R.S.D. (1987) Diet patterns of elite athletes. Journal of Applied Physiology 25, 619–625. Australian male triathletes. Physician and Sportsmedi- Fleck, S.J. & Kramer, W.J. (1987) Designing Resistance cine 15, 140–155. Training Programs. Human Kinetics Publishers, Callister, R., Callister, R.J., Fleck, S.J. & Dudley, G.A. Champaign, Illinois. (1990) Physiological and performance responses to Fox, E.L. & Mathews, D.K. (1974) Interval Training: Con- overtraining in elite judo athletes. Medicine and ditioning for Sports and General Fitness. W.B. Saunders, Science in Sports and Exercise 22, 816–824. Philadelphia. Chromiak, J.A. & Mulvaney, D.R. (1990) A review: the Fox, P.W., Hershberger, S.L. & Bouchard, T.J. Jr (1996) effects of combined strength and endurance training Genetic and environmental contributions to the on strength development. Journal of Applied Sport acquisition of a motor skill. Nature 384, 356–358. Science Research 4, 55–60. Fry, R.W., Morton, A.R. & Keast, D. (1991) Overtraining Clausen, J.P. (1977) Effect of physical training on in athletes. Sports Medicine 12, 32–65. cardiovascular adjustments to exercise in man. Physi- Gilman, M.B. & Wells, C.L. (1993) The use of heart rates ological Reviews 57, 779–815. to monitor exercise intensity in relation to metabolic Costill, D.L. (1986) Inside Running: Basics of Sport Physi- variables. International Journal of Sports Medicine 14, ology. Benchmark Press, Indianapolis. 3334–3339. Costill, D.L., King, D.S., Thomas, R. & Hargreaves, M. Gledhill, N., Cox, D. & Jamink, R. (1994) Endurance (1985) Effects of reduced training on muscular power athletes’ stroke volume does not plateau: major in swimmers. Physician and Sportsmedicine 13, 94–101. advantage is diastolic function. Medicine and Science Costill, D.L., Fink, W.J., Flynn, M. & Kirwan, J. (1987) in Sports and Exercise 26, 1116–1121. Muscle fiber composition and enzyme activities in Gollnick, P.D. (1985) Metabolism of substrates during elite female distance runners. International Journal of exercise and as modified by training. Federation Pro- Sports Medicine 8, 1031–1036. ceedings 44, 353–357. Crawford, M.H., Petru, M.A. & Rabinowitz, C. (1986) Gollnick, P.D., Armstrong, R.B., Saubert, C.W., Piehl, K. Effect of isotonic exercise training on left ventricular & Saltin, B. (1972) Enzyme activity and fiber compo- volume during upright exercise. Circulation 72, sition in skeletal muscle of untrained and trained 1237–1243. men. Journal of Applied Physiology 33, 312–319. Cureton, K.J., Collins, M.A., Hill, D.W. & McElhannon, Gollnick, P.D., Bayly, W.M. & Hodgson, D.R. (1986) F.M. (1988) Muscle hypertrophy in men and women. Exercise intensity, training, diet, and lactate concen- Medicine and Science in Sports and Exercise 20, 338– tration in muscle and blood. Medicine and Science in 344. Sports and Exercise 18, 334–340. physiological aspects of training 91

Hamel, P., Simoneau, J.-A., Lortie, G., Boulay, M.R. & ing augments diastolic filling at rest and during exer- Bouchard, C. (1986) Heredity and muscle adaptation cise in healthy young and older men. Circulation 88, to endurance training. Medicine and Science in Sports 116–126. and Exercise 18, 690–699. MacDougall, J.D., Ward, G.R., Sale, D.G. & Sutton, J.R. Harrison, M.H. (1985) Effects of thermal stress and (1977) Biochemical adaptation of human skeletal exercise on blood volume in humans. Physiological muscle to heavy resistance training and immobiliza- Reviews 65, 149–199. tion. Journal of Applied Physiology 43, 700–703. Hickson, R.C. & Rosenkoetter, M.A. (1981) Reduced Mayhew, S.R. & Wenger, H.A. (1985) Time–motion training frequencies and maintenance of increased analysis of professional soccer. Journal of Human aerobic power. Medicine and Science in Sports and Movement Studies 11, 49–52. Exercise 13, 13–16. Morgan, D.W. & Craib, M. (1992) Physiological aspects Holloszy, J.O. (1975) Adaptation of skeletal muscle to of running economy. Medicine and Science in Sports endurance exercise. Medicine and Science in Sports and and Exercise 24, 456–461. Exercise 7, 155–164. Nadel, E.R. (1988) Temperature regulation and pro- Holloszy, J.O. & Coyle, E.F. (1984) Adaptations of skele- longed exercise. In D.R. Lamb & R. Murray (eds) Per- tal muscle to endurance exercise and their metabolic spectives in Exercise Science and Sports Medicine, Vol. 1 consequences. Journal of Applied Physiology 56, Prolonged Exercise, pp. 25–47. Benchmark Press, 831–838. Indianapolis. Houmard, J.A. & Johns, R.A. (1994) Effects of taper on Newton, R.U., Kraemer, W.J., Hakkinen, K., swim performance. Practical implications. Sports Humphries, B.J. & Murphy, A.J. (1996) Kinematics, Medicine 17, 224–232. kinetics, muscle activation during explosive upper Kearney, J.T. (1996) Training the Olympic athlete. Scien- body movements. Journal of Applied Biomechanics 12, tific American 274, 52–63. 31–43. Khoo, C.S., Rawson, N.E. & Robinson, M.L. (1987) Oscai, L.B., Williams, B.T. & Hertig, B.A. (1968) Effect of Nutrient intake and eating habits of triathletes. exercise on blood volume. Journal of Applied Physiol- Annals of Sports Medicine 3, 144–150. ogy 26, 622–624. Kirkendall, D.T. (1985) The applied sport science of O’Toole, M.L. & Douglas, P.S. (1995) Applied physiol- soccer. Physician and Sportsmedicine 13, 53–59. ogy of triathlon. Sports Medicine 19, 251–267. Klausen, K., Andersen, L.B. & Pelle, I. (1981) Adaptive O’Toole, M.L., Douglas, P.S. & Hiller, W.D.B. (1989) changes in work capacity, skeletal muscle capilliari- Lactate, oxygen uptake, and cycling performance in zation, and enzyme levels during training and triathletes. International Journal of Sports Medicine 10, detraining. Acta Physiologica Scandinavica 113, 9–16. 413–418. Kohrt, W.M., O’Connor, J.S. & Skinner, J.S. (1989) Lon- Pate, R.R., Sparling, P.B., Wilson, G.E., Cureton, K.J. & gitudinal assessment of responses by triathletes to Miller, B.J. (1987) Cardiorespiratory and metabolic swimming, cycling, and running. Medicine and responses to submaximal and maximal exercise in Science in Sports and Exercise 21, 569–575. elite women distance runners. International Journal of Kraemer, W.J. & Nindl, B.C. (1997) Factors involved in Sports Medicine 8 (Suppl.), 91–95. overtraining for strength and power. In R.B. Kreider, Pelliccia, A., Maron, B.J., Culasso, F., Spataro, A. & A.C. Fry & M.L. O’Toole (eds) Overtraining in Sport, Caselli, G. (1996) Athlete’s heart in women: echocar- pp. 69–86. Human Kinetics Publishers, Champaign, diographic characterization of highly trained elite Illinois. female athletes. Journal of the American Medical Associ- Kreider, R.B., Fry, A.C. & O’Toole, M.L. (eds) (1997) ation 276, 211–215. Overtraining in Sport. Human Kinetics Publishers, Perrin, D.H. (1993) Isokinetic Exercise and Assessment. Champaign, Illinois. Human Kinetics Publishers, Champaign, Illinois. Laurenson, N.M., Fulcher, K.Y. & Korkia, P. (1993) Plowman, S.A. & Smith, D.L. (1997) Exercise Physiology Physiological characteristics of elite and club level for Health, Fitness and Performance. Allyn & Bacon, female triathletes during running. International Boston. Journal of Sports Medicine 14, 455–459. Pollack, S.J., McMillan, S.T., Mumpower, E. et al. (1987) Levine, B.D., Lane, L.D., Buckey, J.C., Friedman, D.B. Echocardiographic analysis of elite women distance & Blomqvist, C.G. (1991) Left ventricular runners. International Journal of Sports Medicine 8 pressure–volume and Frank–Starling relations in (Suppl.), 81–83. endurance athletes: implications for orthostatic Reilly, T. & Thomas, V. (1976) Amotion analysis of work tolerance and exercise performance. Circulation 84, rate in different positional roles in professional foot- 1016–1023. ball match play. Journal of Human Movement Studies 2, Levy, W.C., Cerqueira, M.D.S., Abrass, I.B., Schwartz, 87–97. R.S. & Stratton, J.R. (1993) Endurance exercise train- Rogers, M.A. & Evans, W.J. (1993) Changes in skeletal 92 training the female athlete

muscle with aging: effects of exercise training. Exer- Tesch, P.A. (1992) Training for body building. In P.V. cise and Sport Sciences Reviews 21, 65–102. Komi (ed.) Strength and Power in Sport, pp. 357–369. Saltin, B. (1969) Physiological effects of physical condi- Blackwell Scientific Publications, Oxford. tioning. Medicine and Science in Sports 1, 50–56. Vanfraechem, J.H.P. (1979) Stroke volume and systolic Saltin, B. & Rowell, L.B. (1980) Functional adaptations time interval adjustments during bicycle exercise. to physical acitivity and inactivity. Federation Proceed- Journal of Applied Physiology 46, 588–592. ings 39, 1506–1513. Vanoverschelde, J.L.J., Younis, L.T., Melin, J.A. et al. Saltin, B., Henriksson, J., Nygaard, E. & Andersen, P. (1991) Prolonged exercise induces left ventricular (1977) Fiber types and metabolic potentials of skele- dysfunction in healthy subjects. Journal of Applied tal muscles in sedentary man and endurance Physiology 70, 1356–1363. runners. Annals of the New York Academy of Sciences Wells, C.L. (1991) Women, Sport and Performance: A Phys- 301, 3–29. iological Perspective, 2nd edn. Human Kinetics Pub- Shepley, B., MacDougall, J.D., Cipriano, N. & Sutton, lishers, Champaign, Illinois. J.R. (1992) Physiological effects of tapering in highly Wells, C.L. & Pate, R.R. (1988) Training for performance trained athletes. Journal of Applied Physiology 72, of prolonged exercise. In D.R. Lamb & R. Murray 706–711. (eds) Perspectives in Exercise Science and Sports Medi- Sherman, W.M. & Lamb, D.R. (1988) Nutrition and pro- cine, Vol. 1 Prolonged Exercise, pp. 357–391. Bench- longed exercise. In D.R. Lamb & R. Murray (eds) Per- mark Press, Indianapolis. spectives in Exercise Science and Sports Medicine, Vol. 1 Weltman, A.R., Moffatt, R.J. & Stamford, B.A. (1978) Prolonged Exercise, pp. 213–276. Benchmark Press, Supramaximal training in females: effects on anaero- Indianapolis. bic power output, anaerobic capacity, and aerobic Sjodin, B. & Svedenhag, J. (1985) Applied physiology of power. Journal of Sports Medicine and Physical Fitness marathon running. Sports Medicine 2, 83–99. 18, 237–244. Sparling, P.B., Nieman, D.C. & O’Connor, P.J. (1993) Williams, K. & Cavanagh, P. (1987) Relationship Selected scientific aspects of marathon racing. An between distance running mechanics, running update on fluid replacement, immune function, psy- economy and performance. Journal of Applied Physiol- chological factors and the gender difference. Sports ogy 63, 1236–1245. Medicine 15, 116–132. Wilmore, J.H. (1974) Alterations in strength, body Tanaka, J.A., Tanaka, H. & Landis, W. (1995) An assess- composition, and anthropometric measurements ment of carbohydrate intake in collegiate distance consequent to a 10 week weight training pro- runners. International Journal of Sports Nutrition 5, gramme. Medicine and Science in Sports 6, 133–138. 206–214. Wilmore, J.H. & Costill, D.L. (1994) Physiology of Tarnopolsky, L.J., MacDougall, J.D., Atkinson, S.A., Sport and Exercise. Human Kinetics Publishers, Tarnopolsky, M.A. & Sutton, J.R. (1990) Gender dif- Champaign, Illinois. ferences in substrate for endurance exercise. Journal Zeederberg, C., Leach, L., Lambert, E.V., Noakes, T.D., of Applied Physiology 68, 302–308. Dennis, S.C. & Hawley, J.A. (1996) The effect of car- Tarnopolsky, M.A., Atkinson, S.A., Phillips, S.M. & bohydrate ingestion on the motor skill proficiency of MacDougall, J.D. (1995) Carbohydrate loading and soccer players. International Journal of Sports Nutrition metabolism during exercise in men and women. 6, 348–355. Journal of Applied Physiology 78, 1360–1368. Chapter 6

Biomechanics

JILL A. CRUSSEMEYER AND JANET S. DUFEK

Introduction mance more thoroughly and accurately. Gener- ally, kinematic variables measured in biome- A general definition of biomechanics is the appli- chanics include both linear and angular position, cation of mechanical laws to living organisms. In velocity and acceleration. A coach or teacher this chapter, the concepts of mechanics are knowing the values of these motion descriptors reviewed in order to understand more thor- can provide such information to the athlete in oughly the additional topics covered in this order to improve their performance. For book. Mechanics can be divided into statics and example, if a hurdler continuously hits the dynamics and both are utilized in the study of hurdle with their lead foot, a kinematic analysis biomechanics. Statics deals with the system may show that they are leaving the ground too (athlete, implement or both in combination) close to the hurdle in order to clear it. The coach under zero acceleration, while dynamics focuses can explain this to the athlete and together work on the accelerating system. Understanding on a solution so the hurdle can be successfully statics and dynamics with respect to the athlete is cleared. The hurdler is constrained by the important in order to improve overall perfor- mechanical laws of parabolic motion. Athorough mance and minimize the potential for injury. understanding of the physical laws and mech- The neuromusculoskeletal system is the anical relationships of parabolic motion can lend framework upon which the mechanical laws are insight into performance interventions in order applied. A thorough understanding of functional to optimize performance. anatomy (structure and function of the body) is During any athletic activity the individual uti- crucial when evaluating performances biome- lizes lever systems and attempts to manipulate chanically. This allows for a general picture of or maintain the body’s centre of mass (COM) what is happening in the body as well as what throughout the movement. The body itself can be could happen if something should suddenly viewed as a series of levers or rigid links that change. Anthropometry, the study and evalua- work together to accomplish a goal. Sports tion of body size, also yields vital information equipment such as a diving board can be thought when comparing a variety of individuals trying of as an external lever that the athlete must work to complete the same task. Kinematics, lever with in order to achieve the best possible dive. manipulation and force application are impor- The system’s COM is determined relative to the tant mechanical concepts that one must initially spatial orientation of the levers and the distribu- understand prior to completing a biomechanical tion of the performer’s segment masses. Asimple assessment. kinematic analysis of the COM may also yield Kinematics or position analyses of movement useful information, such as the relationship of an helps to describe and understand the perfor- athlete’s COM to the bar during the high jump. 93 94 training the female athlete

The forces or kinetics that cause motion also Standing height (cm) need to be addressed. It is important to deter- Females Males mine not only the magnitude of the forces acting on the system but also the direction and point of 190 4 application at which they act. This allows the coach and/or performer to determine if one is 5 7 180 applying force appropriately to gain a maximum 2 6 1 performance while minimizing the potential for injury. It is important to understand the relation- 170 ships between kinetics, kinematics and the per- 3 former in an attempt to achieve the best possible 160 performance. Women have been participating in sports for 150 many years, and since the initiation of Title IX Educational Assistance Act of 1972 in the USA 140 the number of female athletes has increased. Coinciding with this increase in number of ath- Fig. 6.1 Standing height ranges of variability (5th and letes, there has been an increase in injury and also 95th percentiles) in males and females of different demand for specialized sporting equipment for nationalities: 1, US civilians; 2, Swedish civilians; 3, the female (Hutchinson & Ireland, 1995). The Japanese civilians; 4, US Air Force fliers; 5, Italian mili- female athlete is not the same as the male athlete tary; 6, Japanese civilians; 7 Turkish military. (Adapted as emphasized throughout this book. Such dif- from Pulat, 1992.) ferences are important to recognize relative to performance potential. This chapter also dis- cusses some of the biomechanical differences and weigh less (less mass), are shorter, and have implications of specialized sports equipment. shorter legs and a wider pelvis compared with men. This leads to a lower COM, which may be desirable in some activities (i.e. judo take- Anthropometry/structure down) and a hindrance in others (high jump). Anthropometry consists of body measure- Other general characteristics of women include ments, including height, weight/mass, segment less muscular development and greater flexi- lengths, segment masses and moments of inertia bility compared with their male counterparts (resistance to change in motion). In studying (Hutchinson & Ireland, 1995). human body measurements it is apparent that Specific anatomical differences that seem to be there is a high degree of variability within a apparent in females include greater genu certain population and between different popu- valgum, increased femoral anteversion, greater lations and genders. The difference in standing external tibial torsion and a greater Q-angle. height between genders and different popula- Genu valgum is defined as the angulation of the tions is given in Fig. 6.1 as an example of the level tibia away from the midline of the body (Fig. 6.2). of structural variability. Therefore, some caution This change in angulation may be important must be exercised when describing the body when investigating kinematics and forces at the dimensions of a group of athletes and their asso- knee joint. In the genu valgum condition, the ciated skill levels since some athletes may lie medial aspect of the knee undergoes greater outside the average for the group but still may be tensile forces compared with the greater com- highly skilled performers. pressive forces on the lateral side (Norkin & Taking into account that there may be a great Levangie, 1992). The normal angulation of the deal of structural variability, women tend to femoral neck is approximately 15° and any biomechanics 95

Fig. 6.2 (a) Genu valgum and (b) genu varum. In genu valgum, there is a compressive force on the lateral side and a tensile force on the medial side. In genu varum there is a medial compressive force and a lateral tensile force at the knee joint. (a) (b)

anterior deviation from this constitutes femoral not necessarily excluded from knee problems anteversion (Hoppenfeld, 1976). An increase in (Norkin & Levangie, 1992). femoral anteversion causes greater internal rota- As can be gleaned from this brief anthropo- tion, which may be seen as a toe-in type of gait. metric review, the primary structural differences As with genu valgum, the change in angulation between the genders are most evident in the may have an effect on kinematics and forces lower extremity. Due to the predominance of occurring at the hip joint. This also has an effect upright bipedal actions in sport, these structural on the base of support in bipedal sporting differences can lead to major differences in per- activities. formance outcomes between males and females. The Q-angle is defined by two lines, one from In addition, injury potentials differ due to unique the anterior superior iliac spine to the midpoint force applications and tissue tolerances. of the patella and one from the midpoint of the patella to the tibial tubercle (Fig. 6.3). The Q- Kinematics angle is important since it is the angle through which the net force of the quadriceps acts during Kinematics is used to describe motion and leg extension. A Q-angle of >20° when measured includes position, velocity and acceleration in in the standing position is thought to be abnor- both linear (translation) and angular (movement mal and increases the lateral forces on the patella. about a fixed axis) components. Kinematic analy- As the knee flexes the Q-angle decreases as the ses can be as simple as timing a person running tibia internally rotates. Although large Q-angle over a marked distance or as complex as using values may predispose a person to knee prob- high-speed video or film and taking very sensi- lems, individuals with normal alignment are tive measures from the visual records. More 96 training the female athlete

Q-angle

a

r

a

Fig. 6.4 Absolute angle of the thigh and leg (a) and relative angle of the knee (r).

most important factors when analysing perfor- mance. A very common and clear example is that Fig. 6.3 Measurement of the Q-angle. The angle is of the long jump and foot placement on the take- defined by two lines, one extending from the anterior off board. Since maximum distance is the desired superior iliac spine to the midpoint of the patella and a goal and the jump is measured from the end of vertical line from the midpoint of the patella to the the board, it is intuitive that the athlete’s foot be tibial tuberosity. as close to the end of the board as possible. This maximizes the horizontal distance travelled independent of the distance the COM travels information can be gained from the example of while airborne. timing a person across a given distance by divid- ing the overall distance into smaller and smaller Angular position increments. Utilizing film or video, the distance increments are minute and therefore more infor- Angular position may be described in either mation about the performance can be obtained. absolute or relative terms. An absolute angle In either case spatial and timing information is (Fig. 6.4) defines a segment’s orientation in gained in order to describe and ultimately under- space, while the relative angle refers to the stand the motion of the system. included angle between two segments. It is important to note that the relative angle refers only to the segment orientations to each other Position and gives no information as to how the segment Position is where the object of interest lies in is orientated in space. Another method of space at any point in time. The position of the describing angular position more commonly athlete with respect to their final goal is one of the used in clinical professions is that of ‘degrees biomechanics 97

Resultant Vertical velocity velocity 120º Horizontal velocity

60º

Fig. 6.5 Two different angle measurements: relative knee angle (120°) and ‘degrees flexion’ (60°).

flexion’ or ‘degrees extension’. For example, if an athlete had a knee angle at full extension of 180° and then actively flexed the knee by moving the Fig. 6.6 Projectile motion of the javelin, the resultant velocity vector can be broken down into the component leg 60°, the resulting knee angle could be vectors (horizontal and vertical). described as 60° flexion or a knee angle (relative) of 120° (Fig. 6.5). Angular position of joints is important to ascertain whether or not the athlete is in a poten- relative to the performer. The vertical–horizontal tially injurious situation. One sport activity in resolution of vectors is used because of the verti- which knee angle plays a vital role in injury pre- cal orientation of the force of gravity. When an vention is landing. Many athletic events incorpo- athlete releases a javelin for example, it has a rate landing from some type of airborne phase, resultant velocity vector. However, that velocity i.e. basketball, gymnastics and volleyball. It has can be broken down into components that may been found that by decreasing the knee angle give more meaningful information to the athlete upon impact a ‘softer’ landing is obtained or coach when trying to achieve the longest (Devita & Skelly, 1992; Dufek et al., 1995). By throw (Fig. 6.6). landing in a softer position it is thought that the injury potential is decreased. Angular velocity

Angular velocity is defined as the time rate of Velocity change in angular position or simply the change Velocity is defined as the time rate of change in in angle over a change in time. When investigat- position. Velocity is considered a vector quantity, ing performance and injury, the joints are usually meaning that it has a magnitude and acts in a a primary focal point because of the rotational particular direction. In many instances a velocity nature of motion about the joints; position data vector is broken down into vertical and horizon- alone may not give as much information as one tal components, which yield more information needs. It may be important to understand how 98 training the female athlete

quickly the angle is changing and, in combina- tion with knowledge of tissue properties, Projection whether the joint structures may be at risk for velocity damage. From the coach’s perspective it may also be beneficial to understand the angular Projection velocity of joints acting in a sequence. For angle example, determining the velocity and position of the shoulder, elbow and wrist during a shot- put activity may show that the athlete is chang- ing one joint position too quickly compared with the other joints in the system, therefore minimiz- ing total force production potential. Projection height Acceleration

Acceleration is defined as the change in velocity over a change in time, and like position and velocity it has both linear and angular compo- nents. Since acceleration is related to velocity, it too is a vector quantity having both magnitude and direction. In sports, frequently a quick change in acceleration is a possible mechanism Fig. 6.7 Factors to consider in projectile motion: projec- for injury. A good example is the lower extremity tion velocity, projection angle and projection height. at the end of the swing phase during running just prior to touchdown. The hamstrings must act to slow the leg down and change the direction that (height) or horizontal distance needs to be the leg is moving. If the acceleration of the leg is maximized. too great relative to muscular strength, a ham- Projection angle, projection velocity and pro- string strain is possible. jection height are the three major factors that determine the subsequent path of the projectile once it is airborne (Fig. 6.7) (the fourth factor, Projectile motion aerodynamics, is ignored in this discussion). The Projectile motion occurs whenever a system is projection angle determines the shape of the pro- thrust into the air. The system can be some type jectile path and is defined by the angle that the of athletic equipment or the body itself. Some projection velocity vector makes with the hori- examples of where projectile motion occurs are zontal and ranges from 0 to 90°. If the athlete basketball, discus, diving, high jump, javelin, wants to maximize height, the projection angle long jump, shot put, softball and volleyball. In should be fairly steep (90°); a smaller angle projectile motion once the system is airborne the would be desired if horizontal distance is to be only forces acting on it are gravity and air resist- maximized. In the high jump, maximum vertical ance. For the most part, air resistance can be height is desired and the angle of projection neglected because the effects are generally ranges from 40 to 48° (Dapena, 1980); in the long minimal and it simplifies the analysis. Therefore, jump, where horizontal distance is desired, in this situation the horizontal velocity is con- values range from 18 to 27° (Hay, 1986). stant and the acceleration due to gravity is also Projection velocity is the resulting velocity at constant. When analysing projectile motion it is the moment of release or take-off. The projection important to determine whether the vertical velocity will influence the height and the hori- biomechanics 99

zontal distance of the projectile’s path. If the pro- defined as the ratio of FA to RA. If MA (FA/RA) jection angle is 45°, the vertical and horizontal is >1, then force application is maximized with components of the velocity vector will be equal. the lever. If MA is <1, range and velocity of As the angle increases from 45°, the vertical com- motion are maximized with the lever. Finally, if ponent increases; similarly with angles <45° the MA=1, then the lever system offers neither horizontal velocity increases. Therefore, if the advantage. Figure 6.8 summarizes common lever object is to gain maximum horizontal distance examples as well as those found in the body. the angle of projection should be <45°, which is the case for the long jump. First-class lever Projection height is the vertical difference between the height at take-off and at landing. If A first-class lever has the fulcrum positioned the initial and final heights are equal, the shape of between the RA and the FA. The most common the parabola is symmetrical, the time of ascent example is a see-saw. In this type of system, and descent are equal and the horizontal dis- depending on the position of the fulcrum, either tance travelled during the ascent and descent are force or range of motion can be maximized. An equal. When the initial position is higher than the example of a first-class lever in the body is per- final position, the parabola is not symmetrical forming a French press or overhead triceps and the time to the apex is less than the time from extension. The elbow is the fulcrum and the the apex to the final position. It is important to insertion site of the triceps is the point of force. realize that all three factors are related and that The resistance is the mass of the arm acting at the all must be considered in order to optimize the COM of the segment. projectile’s path. An example of differences in projection height is the long jump. The COM of Second-class lever the athlete is higher at take-off than at landing and therefore the athlete will travel a greater Asecond-class lever maximizes force because the horizontal distance in the second half of the jump FA is always longer than the RA by definition (i.e. on the way down). (resistance lies between the force and the fulcrum). A common example is the wheelbar- row, where the fulcrum is at the wheel, the RA Lever systems extends from the wheel to the centre of the load All lever systems are comprised of a pivot point in the wheelbarrow and the FA extends from the or fulcrum, a resistance that is being manipu- wheel to the handle of the wheelbarrow where lated (object or body segment) and a force (inter- the person exerts a force. It is easy to understand nal, external or inertial) that is the ‘source’ of the how force is maximized because a person can lift motion. The distance from the fulcrum to the a much heavier load in a wheelbarrow than by resistance is termed the resistance arm (RA) and carrying. Very few examples of second-class the distance of the force from the fulcrum is levers exist in the body, although the jaw can be termed the force arm (FA). There are three types thought of as such a lever when biting down on or classes defined by the orientation of the three an object. Also, if a muscle is working eccentri- parts. Lever systems can be identified within the cally many times it is acting as a second-class body, by looking at the musculoskeletal system, lever. and also outside the body, by observing the body interacting with external objects. The functional Third-class lever role of a lever system is to maximize either force production or range of motion. In this regard, it is A third-class lever maximizes range of motion important to view the lever system and deter- because the RA is longer than the FA, yielding an mine its mechanical advantage (MA), which is MA <1 (force lies between the fulcrum and the 100 training the female athlete

Definition Common example Example in body

FA RA R 1 10 F R F FIRST Direction A Axis of motion CLASS R (10) FA RA RA FA F (100)

R (100)

R F F Direction of motion SECOND CLASS FA RA FA RA 1 RA A Axis R FA 10 F (10)

A F (100)

RA F R FA THIRD F CLASS R RA FA 1 FA Axis Direction RA 10 of motion R (10)

Fig. 6.8 Examples of different lever systems. A, axis; F, force; FA, distance from fulcrum to F arrow; R, resistance force; RA, distance from fulcrum to R arrow. resistance). A common example is that of a Application of lever systems shovel, where the hand at the top acts as the fulcrum, the RA extends from the fulcrum to the Application and manipulation of levers are load at the end of the shovel and the FA extends important concepts to consider when trying to from the fulcrum to the other hand. The third- achieve a successful athletic performance. class lever is the most common lever system Anatomical lever systems (such as the biceps found in the body and can be illustrated by a during execution of elbow flexion) are fixed by biceps curl. The elbow again acts as the fulcrum, definition, but can be functionally modified the FA is from the elbow to the insertion site of through training. For example, body mass can be the biceps and the RA is from the elbow to the altered and maximum force production can be COM of the arm. enhanced. In addition, the line of pull of the biomechanics 101

muscle changes dynamically, influencing the magnitude of force generated and subsequent movement velocity. Of particular concern for the female athlete are the structural differences between males and females. These differences (e.g. shorter legs) influence the MA of the lever system and can affect performance outcome. (a) (b) (c) However, strength differences produce more obvious deviations with respect to lever applica- tions between men and women. The MA of the lever system and strength differences are impor- tant factors to consider when designing and selecting equipment for the female athlete.

(d) (e) Centre of gravity/centre of mass Fig. 6.9 Different types of athletic stances that define The centre of gravity (COG) is the point about the base of support: (a) a square stance; (b) an angled which all the point masses of the body are bal- stance; (c) a one foot stance; (d) a three point stance; and anced and through which the weight vector acts; (e) a four point stance. COM refers only to the even distribution of the masses. Since gravity is always acting on objects on the earth, COM and COG are frequently used athlete to the ‘set’ position, the athlete shifts the interchangeably. The COM can be thought of as a COG to the edge of the base of support by elevat- theoretical point that moves in response to the ing the hips in the direction of desired motion movements of the surrounding segments; if seg- so that it is easier to accelerate out of the start. ments are orientated in a particular manner the Conversely, a volleyball player set to receive a COM can actually lie outside the boundary of the serve is in a very stable position because the COG body. is low, the base of support is wide, and the COG COG is closely related to stability, which is the is positioned forward towards the oncoming resistance to linear and angular acceleration of force. the system (Hall, 1991). Stability in sports events Stability and instability are desirable in athletic needs to be minimized, maximized or some events; however, being stable at the wrong time combination of both depending on the desired can place the athlete in a potentially injurious outcome. Stability can be gained by lowering the situation. One of the most common injuries is the COG in the vertical direction, by increasing the unhappy triad, which involves the medial area of the base of support of the system, by collateral ligament, anterior cruciate ligament increasing the system’s mass, by increasing the and medial meniscus. The injury occurs when friction between the contacting surfaces and by the foot is fixed and the femur is forced (usually positioning the COG at the edge of the base of by an external force) to rotate medially. This is a support towards an incoming force. Figure 6.9 common injury in skiing but occurs in other illustrates different base-of-support configura- activities as well. In this example, the foot is in a tions that are found in athletic events. stable position by being fixed on a surface; if the When performing an event, athletes are foot were not fixed or if it was unstable the injury manipulating their stability from being stable to might be avoided. Therefore, as a coach or athlete unstable and usually back again. During either a it is important to know when it is beneficial to standing or crouch track start, the ‘on your mark’ have maximum stability and when instability position can be stable. As the starter instructs the may be better. 102 training the female athlete

A vivid example of controlling the movement (F=ma). Finally, Newton’s third law states that of the COG, along with the role of stability and for every action there is an equal and opposite instability, is the balance beam apparatus in gym- reaction (action–reaction). nastics. The gymnast must create instability in Generally forces can be divided into two order to perform the movement patterns, yet categories: contact and non-contact (Hamill & must keep the COG positioned directly over the Knutzen, 1995). As suggested by the name, a beam. If the COG shifts too far to either side of contact force occurs between objects that touch the beam, the gymnast has to correct for the shift each other, while a non-contact force occurs by moving a segment of the body to bring the between objects over a distance. The non-contact COG back over the beam; in the worst case the force always present on the earth is gravity. This gymnast will fall from the beam. force requires that whatever goes up must come Determining the path of the COG during a down because of gravity’s pull towards the movement can be insightful when analysing centre of the earth. The most common contact sporting events. For example, evaluating the forces that must be considered are ground reac- path of the COG of a high jumper will truly iden- tion force, friction, joint reaction forces, muscle tify the ‘highest jumper’. It is entirely possible forces, fluid resistance primarily from air or that the high jumper’s COG can pass through or water, and inertial forces. even under the bar, yet the jump can be success- ful. This is achieved by manipulating various Ground reaction force body segments in an appropriately timed fashion in order to influence the whole-body COG, The ground reaction force (GRF) is the opposing which is constrained to projectile motion once force as an object contacts the ground. However, the jumper becomes airborne. reaction forces occur between all surfaces and objects in contact. In biomechanics laboratories, Kinetics GRF is often measured using a device called a force platform. The force platform can measure Kinetics, either linear or angular, are the forces forces in the vertical, anteroposterior and medio- that act upon a system, where the force is a push lateral directions. Vertical GRFs have been or pull between two or more objects that causes analysed to illustrate the role of impact forces motion. Force, like velocity and acceleration, is and the effects on the body during the support also a vector quantity, having magnitude and phase of walking, running and landing. Vertical direction. Forces have a point of application, GRF is most often studied because of its large which is the point where the force is applied to magnitude compared with the other two GRF the object, and a line of action, which is the line or components (anteroposterior and mediolateral). direction in which the force acts. Newton’s laws A characteristic vertical GRF vs. time curve for are a useful starting point when trying to under- walking is shown in Fig. 6.10. The curve is stand the interaction between kinetics and kine- bimodal with two peak forces usually ranging matics or the forces and the motion that they from 1.0 to 1.5 body weights. The GRF is most cause. Newton’s first law of inertia states that an often reported as number of body weights so that object will remain at rest or in motion unless comparisons between individuals with different acted on by some type of force (steady state). masses can be made. The first peak corresponds Inertia is defined as an object’s resistance to to the body lowering after full foot contact with change its state and is related to mass. If an object the ground. The second peak represents the has a large mass then its inertia is greater and it is phase where the foot is pushing against the more difficult to move. Newton’s second law of ground to prepare for the next step. The antero- acceleration dictates that the force is equal to the posterior GRF for walking has a magnitude mass of the object multiplied by its acceleration much less than that of the vertical component biomechanics 103

1200 200

1000 100 800

600 0

400

Vertical force (N) ( ) –100

200 Anteroposterior force (N) ( )

Fig. 6.10 Vertical (---) and –200 0.2 0.4 0.8 anteroposterior (—) GRF curves 0 0.6 for walking. Time (s)

2500 400

300 2000 200

1500 100 0

1000 –100

Vertical force (N) ( ) –200

500 Anteroposterior force (N) ( ) –300

Fig. 6.11 Vertical (---) and anteroposterior (—) GRF curves 0 0.05 0.10.15 0.2 0.25 for running. Time (s)

(Fig. 6.10). Generally, there is a negative portion rapidly after initial contact is considered the of the curve that corresponds to a braking phase impact peak and may be related to running followed by a positive portion related to propul- injuries (James et al., 1978; Nigg, 1986). The sion for the next step. The minimum of the verti- second peak, similar to walking, corresponds to cal GRF corresponds to the zero point on the the person preparing for push-off. The antero- anteroposterior curve. As the body is lowered posterior forces in running are similar to those after the initial peak in vertical GRF, the knee found during walking but are greater in magni- joint flexes to decrease the force and the COG of tude. It should be noted that a midfoot striker or the body is decelerated. As the person prepares toe runner generally does not have an impact for push-off, the COG must be accelerated; there- peak present on the vertical GRF curve. fore, the force increases and changes direction. The mediolateral GRF has been found to show Much attention has been given to the impact a great deal of variability between individuals force that occurs during heel–toe running. A and has not received much attention (Hamill et typical vertical GRF curve for a heel–toe runner al., 1983). The variation in mediolateral forces is shown in Fig. 6.11. The first peak that occurs may be attributed to foot placement on the force 104 training the female athlete

2500 tional force acts parallel to the contacting sur- faces between two objects and is equal to the 2000 product of the normal or reaction force and the coefficient of friction. The coefficient of friction 1500 depends upon the materials found in the inter- acting surfaces. Static friction occurs when an 1000 object undergoes a push or pull from another force yet no movement occurs. At some point the Vertical force (N) 500 push or pull becomes great enough that limiting friction is overcome and motion occurs; dynamic friction is then present until the object comes 0 0.02 0.04 0.06 0.08 0.1 back to rest. Time (ms) Friction is necessary in order for locomotion to occur. If the coefficient of friction is very low it is Fig. 6.12 Vertical GRF curve for landing. difficult to walk, such as when attempting to walk on ice with smooth-soled shoes. In some sporting events, such as ice skating and downhill platform, variations in foot mechanics between skiing, the coefficient of friction must be mini- people, or footwear use and accommodating mized in order to gain greater speeds and ease of characteristics relative to foot morphology. movement. In other activities, such as soccer and Another possible reason why mediolateral forces softball, athletes wear shoes with cleats to have been neglected is that the magnitude of the increase traction and the coefficient of friction. forces is very small, approximately 0.01 body As with most other types of forces, the coefficient weights during walking and 0.1 body weights of friction needs to be optimized for the par- for running. ticular activity. A slip or fall may occur if the Landing is a common activity found in many coefficient of friction is too low; conversely, an sports. A typical vertical GRF curve for landing is injury could occur if the coefficient of friction is illustrated in Fig. 6.12. Again the vertical compo- too high, such as the unhappy triad discussed nent has been of primary interest due to the previously. potentially high magnitudes. The first peak cor- responds to forefoot contact, while the second Joint reaction forces peak is related to heel contact (opposite to that of heel–toe running). As discussed before, if a Joint reaction forces are the net internal forces person lands with greater knee flexion the acting across the joint at a particular instant in second peak can be attenuated and therefore a time. It is important to determine joint reaction softer landing occurs. However, some work has forces when trying to ascertain if the joint is shown that previous landing experience or undergoing forces that may cause injury to the landing on different materials may affect vertical joint or surrounding tissues. Joint reaction forces GRF (Dufek et al., 1991; McNitt-Gray et al., 1994). are calculated from kinematic and kinetic data This may be because individuals perceive a and are not generally measured directly. The softer landing due to the landing surface mater- joint reaction force in any single plane consists of ial and therefore perform in a different fashion. a compressive force acting to pull the two adjoin- ing body segments together and a shear force perpendicular to the compressive force. The Friction shear force component is most often studied, Another contact force is the frictional force, since joint and bone structures are least tolerant which can be either static or dynamic. The fric- to forces acting in this direction. biomechanics 105

moves through an area where two fluids meet Muscle forces (i.e. air and water). Athletes such as swimmers, Muscles create a pull on the insertion site in order cyclists, skiers and sprinters tend to wear form- to move the body segment through a particular fitting clothing that helps streamline them and range of motion. Since a muscle can only create a minimize the effects of drag. pull on the insertion site, muscles must always The lift force acts perpendicular to the drag work in pairs. The agonist muscle creates the pull force and occurs only if the object is not symmet- and the antagonist muscle resists the agonist in rical in shape or is spinning. Lift occurs because order to maintain a smooth and controlled move- the air or water on one side of the object moves ment. The net muscle force can be broken down faster than the medium on the other side, creat- into rotational and stabilizing components in ing a pressure differential. Lift is expressed math- each plane. The stabilizing component acts ematically as Bernoulli’s principle (pressure= towards the joint centre. As the angle of muscle 1/velocity). A common example is the wing of an pull relative to the insertion site becomes greater, aeroplane, where the air on top of the wing the rotational component is greater than the sta- moves faster than the air underneath, creating a bilizing component, up to a maximum of 90°, at high-pressure area below the wing. Since the lift which point the rotational component is maxi- force acts from a high-pressure area to a low- mized and the stabilizing component equals pressure area, the wings of the plane are sub- zero. As with joint forces, muscle forces in vivo jected to the lift force. Similarly swimmers use are rarely measured, although it can be done by the lift principle by orienting their hands in dif- placing a force transducer at the myotendinous ferent positions relative to the water. This may junction. Generally, muscle force is estimated by help the swimmer stay ‘on top’ of the water and using a mathematical model developed using enhance overall speed. Lift force or the Magnus different assumptions about the system, such as effect also influences the curved path of a spin- insertion point location and angle of pull. ning object, such as a tennis ball that has topspin. The Magnus effect is also related to a pressure differential and explains why a ‘curve ball’ Fluid resistance curves. Human movement is affected by air resistance when moving on land and water resistance when Inertial forces swimming. The density and viscosity of air and water are the two properties that have the As with kinematics, kinetics also has angular greatest effect on the body moving through the analogues. However, forces acting about a par- medium. Fluid resistance, which is the transfer of ticular axis cause rotation and the result is energy from the body to the medium, consists of termed a torque or moment of force. The torque two components, drag and lift. is equal to the product of the applied force and The drag force always acts directly opposite to the perpendicular distance from the line of action the velocity vector of the system and is the to the point of rotation. This perpendicular dis- product of the coefficient of drag, the frontal area tance is generally termed the moment arm. All of the object, the fluid viscosity and the relative of Newton’s laws have angular analogues and velocity of the object to the fluid. There are three may be defined as follows. The first law states types of drag force: surface, form and wave. that angular momentum is conserved or that Surface drag is related to the surface of the object an object maintains its current angular motion (texture and shape) interacting with the fluid, unless acted on by some external torque. The while form drag creates a pressure differential second law can be stated in angular terms such from the front of the object to the rear. Wave drag that torque is equal to the product of the moment is a reaction force to ‘waves’ generated as a body of inertia and angular acceleration of the object (T 106 training the female athlete

=Ia). The moment of inertia is the object’s resis- these values provide information about the net tance to change in angular motion. It is similar to forces occurring at the joint. It is important to inertia in that it is dependent on mass, but the realize that joint moments represent the net moment of inertia also depends on the way the effects of what is happening at the joint. For mass is distributed. Recall that the COG is example, the joint moment includes muscle dependent on the mass distribution of the seg- forces, soft tissue forces, contact forces and any ments, so that the COG can be defined as the other external force. However, determining a point about which the sum of all the torques is general value of force occurring at the joint and equal to zero. Finally, the third law states that for comparing this with failure values measured on any torque exerted on one object, an equal and cadavers may be of some use when establishing opposite torque is applied to the first object. the safety level of an activity. Torques and momentum (mass¥velocity, linear or angular) are principles extensively Equipment interaction applied in sports. A diver or gymnast creates angular momentum prior to being airborne by As female participation in sports increases, exerting a torque on the ground. Since angular manufacturers are developing special equipment momentum is conserved (Newton’s first law), designed specifically for the female athlete. Most manipulations of the limbs and therefore dis- of these design differences are based on the tribution of masses result in the ability to accom- anthropometric variation found between males plish complex aerial manoeuvres without having and females. For example, a woman’s basketball any other forces acting except gravity. Torques or is smaller in diameter due to the generally moments occurring at the joints during activities smaller hand size of the female. Women’s tennis are also calculated to determine if athletes may racquets tend to be shorter because of the be at risk for joint injury. strength differences seen between males and Impulse is defined as the product of a force females in the upper extremity. When choosing acting over a time interval and can be thought sports or strength equipment it is important to of as the quantity of force needed in order to consider the anthropometrics of the individuals change the motion of the object. If the force is using the equipment. However, the laws of applied over time, the momentum of the object physics do not discriminate between genders is changed and this defines the impulse– and a good understanding of how the body acts momentum relationship (Ft=mass¥velocity). in the physical world is of utmost importance. An object’s momentum can be changed by a large force acting over a short period of time or a Conclusion smaller force acting over a longer period of time. For example, if a person wanted to jump higher Primary kinematic and kinetic relationships they would try to generate greater impulse have been discussed relative to sport and/or per- against the ground, which would increase the formance. It is important to recognize that kine- momentum and increase the jump height. Inves- matic measures are the outcomes or effects of tigating the above equation one can see that if the forces (kinetics) applied to the system. Therefore, mass changes, in order to maintain the same if a coach is viewing an effect (i.e. a change in impulse value the resulting velocity must also position or velocity), the resulting change is a change. More specifically, since women tend to consequence of an applied force. In order to have less mass than men, they must increase change a performance outcome, the coach must their velocity in order to generate the same focus on the cause of motion (force) and how, impulse as a man of larger mass. when and where it is applied. In any situation, Joint moments (torques) are calculated from we are governed by Newton’s three laws of kinetic, kinematic and anthropometric data and motion in an environment subjected to the forces biomechanics 107

of gravity and friction. The athlete who best Hamill, J. & Knutzen, K.M. (1995) Biomechanical Basis of utilizes her mechanical advantages by manipu- Human Movement. Williams and Wilkins, Baltimore. Hamill, J., Bates, B.T. & Knutzen, K.M. (1983) Varia- lating the COM and lever systems while under- tions in ground reaction force parameters at dif- standing how Newton’s laws are affecting her is ferent running speeds. Human Movement Science 2, often the best performer in any given event. 47–56. Hay, J.G. (1986) The biomechanics of the long jump. Exercise and Sports Sciences Reviews 14, 401–446. References Hoppenfeld, S. (1976) Physical Examination of the Spine and Extremities. Appleton and Lange, Norwalk, Con- Dapena, J. (1980) Mechanics of translation in the necticut. Fosbury flop. Medicine and Science in Sports and Exer- Hutchinson, M.R. & Ireland, M.L. (1995) Knee injuries cise 12, 37–44. in female athletes. Sports Medicine 19, 288–302. Devita, P. & Skelly, W.A. (1992) Effect of landing stiff- James, S.L., Bates, B.T. & Osternig, L.R. (1978) Injuries ness on joint kinetics and energetics in the lower to runners. American Journal of Sports Medicine 6, extremity. Medicine and Science in Sports and Exercise 40–50. 24, 108–115. McNitt-Gray, J.L., Yokoi, T. & Millward, C. (1994) Dufek, J.S., Bates, B.T., Davis, H.P. & Malone, L.A. Landing strategies used by gymnasts on different (1991) Dynamic performance assessment of selected surfaces. Journal of Applied Biomechanics 10, 237–252. sport shoes on impact forces. Medicine and Science in Nigg, B.M. (1986) Biomechanics of Running Shoes. Sports and Exercise 23, 1062–1067. Human Kinetics Publishers, Champaign, Illinois. Dufek, J.S., Bates, B.T., Stergiou, N. & James, C.R. (1995) Norkin, C.C. & Levangie, P.K. (1992) Joint Structure and Interactive effect between group and single-subject Function: A Comprehensive Analysis. F.A. Davis, response patterns. Human Movement Science 14, Philadelphia. 301–323. Pulat, B.M. (1992) Fundamentals of Industrial Ergonomics. Hall, S.J. (1991) Basic Biomechanics. Mosby Year Book, St Prentice Hall, Englewood Cliffs, New Jersey. Louis. Chapter 7

Psychological Aspects of Training

JOAN L. DUDA

Introduction personality characteristics of female athletes and discussions of the psychological consequences Past work on the psychological factors affecting of, and socialization into, the role of athlete female athletes has been limited. For the most (Oglesby, 1978; Boutilier & SanGiovanni, 1983). part, the female athlete and/or this dimension of Other areas that are covered include gender sports involvement has been ignored, or what stereotyping in the media portrayal of female has been addressed has been restricted in terms athletes; implications of gender role socialization of her total athletic experience. Although the through sport; the frequency of participation of physiological aspects of training and perfor- females in the roles of athletes, coaches or sport mance among female athletes has received some administrators; and the embodiment of gender attention (Wells, 1991; Pearl, 1993), less concen- in regard to how women experience their bodies, trated efforts have targeted psychological sport and physical activity (see, for example, factors. For example, in The Athletic Female (Pearl, Oglesby & Hill, 1993; Birrell & Cole, 1994). More- 1993), only one of the 21 chapters deals with psy- over, chapters on the psychological aspects of chological aspects. In Women and Sport: Interdisci- female athletes almost always contain a descrip- plinary Perspectives (Costa & Guthrie, 1994) tion of how female athletes characterize them- several chapters focus on sociological and selves in terms of attributes deemed masculine, feminist treatments of the topic, although the feminine or androgynous; purported value con- majority are concerned with physiological/ flicts between female athletes and a male-created physical issues, and only two of the 22 chapters and male-dominated sport system; and gender centre on the psychology of the female athlete. differences in achievement characteristics. In With regard to sports psychology texts specifi- short, the latter work suggests that she is less cally, the attention given to the sporting female is competitive and outcome-orientated (Gill & Dze- also confined. Occasionally there is a separate waltowski, 1988). In general, this literature chapter or section on gender and the female makes a point of distinguishing between sex dif- athlete (Gill, 1986; Horn, 1992; Singer et al., ferences in sport participation and performance 1993; Cox, 1994; Weinberg & Gould, 1995). (i.e. the biological differences between males and Incredulously, there are even cases where the females) and gender differences (i.e. the social presentation of information on the psychological and psychological attributes and behaviours facets of sport for females is combined with a dis- typically observed in males and females within cussion of coaching youth sport athletes (Anshel, the physical domain) (Gill, 1993). 1997). Although greater coverage is warranted, I am In current textbooks dealing with women in not suggesting that what has been written on the sport, the topics typically addressed include the physiology and psychology of women in sport is 108 psychological aspects of training 109

not pertinent to understanding their involve- anxiety; (ii) to be able to deploy their concentra- ment or lack of involvement in sports. How- tion more efficiently before and during competi- ever, the existent contributions convey little tion; (iii) to experience stronger and more stable relevant information concerning the psychologi- self-confidence; (iv) to rely more on internally cal dimensions of sport training for girls and focused and kinaesthetic imagery than on third- women. In this chapter, I tackle this particular person visual forms of mental preparation; and topic by summarizing four contemporary areas (v) to invest more motivation and personal of investigation: (i) research on female athletes’ meaning in doing well in their sport. In total, use of psychological skills in their training and these findings indicated that female and male preparation for competition; (ii) studies of the élite athletes had more proficient psychological efficacy of mental skills training in female ath- skills than the other athletes. However, it should letes; (iii) work on the psychological factors be noted that, as a group, 14–30% of the male and leading to overtraining in female athletes; and female élite competitors reported experiencing (iv) research concerning the optimal psychologi- performance-related anxiety problems and cal environments for training female competi- 25–31% of these outstanding athletes indicated tors. The chapter is biased towards highly that they had concentration and self-confidence trained female athletes. problems. These latter results suggest that even the highest-level athletes experience psychologi- cal difficulties during sport performances and Use of mental skills thus need further to improve their mental skills. Maximal athletic training and sport performance Mahoney et al. (1987) observed gender differ- requires the synchronization and optimization of ences among the non-élite athletes only. In par- both the physical and psychological systems. The ticular, non-élite female athletes reported lower development of competencies such as vivid and self-confidence than their male counterparts. controlled imagery, sound goal-setting, stress They also used more self-talk and indicated that management, attentional focusing and positive they experienced more problems with stress. The self-talk are presumed to foster mind–body absence of gender-related distinctions among the unison and enhance the execution of athletic élite athletes in the study by Mahoney et al. skills. agrees with past research indicating that gender The first major study to examine mental skills differences in self-confidence dissipate or disap- and the employment of psychological techniques pear completely when the task at hand is deemed among athletes was conducted by Mahoney et al. gender appropriate, feedback is contingent and (1987). The athletes in this investigation included clear, and the individuals in question have females and males who varied in competitive equivalent skill and experience with the activity level. Specifically, the sample included élite (Gill, 1993). Their results are also consonant with (placed fourth or above in the national champi- studies indicating that the confidence of females onships, the Olympics or world championships; can be enhanced via physical training (Holloway n=50), pre-élite (junior national athletes or indi- et al., 1988). viduals invited to special camps by national gov- The observed gender difference in anxiety erning bodies from 11 different sports; n=33) and levels among the non-élite athletes in the study non-élite (members of university athletic teams by Mahoney et al. has also emerged in other from 21 different sports; n=185) competitors. investigations. For example, Jones and Cale When Mahoney and his colleagues compared (1989) administered the multidimensional Com- the élite female and male athletes with petitive State Anxiety Inventory-2 to a sample of intercollegiate-level athletes, they found the male and female university athletes 2 weeks, 1 former group: (i) to be more balanced and moder- week, 2 days, 1 day, 2 hours and 30min before the ate in their experience of worry and performance start of a competition. Results indicated that the 110 training the female athlete

female athletes increased their level of cognitive ences were reported in terms of the associations anxiety (or degree of worry) as the competition between expectations and the perception that neared while the males exhibited no such one’s stress level was beneficial. change; 30min before the competitive event, Another study of mental skills usage among the females were significantly more cognitively élite performers involved 633 of 1200 Olympic anxious than the males. Although the male ath- hopefuls who were participating in the 1988 US letes increased their degree of somatic anxiety Track and Field Olympic Trials (Ungerleider & starting on the day of competition, females Golding, 1992). The sample comprised 52% began to report greater somatic symptoms (e.g. women and 48% men but the results were not increased heart rate, muscular tension) earlier in analysed separately by gender. The major find- the period before competition. Finally, Jones and ings of the study revolved around the use of Cale also found that the male athletes’ degree of imagery: 85% of the athletes reported that they self-confidence changed little before the contest; practised imagery, with one-third of these indi- in contrast, the female athletes’ self-confidence viduals using imagery at least three to six times decreased on the day of competition. per week; 99% of the imagery users employed Jones et al. (1991) attempted to replicate the visualization before competing but only one- findings of Jones and Cale (1989) among 13 male third employed this strategy during competition. college-level field hockey, 15 female rugby and Results also indicated that, in general, those ath- 13 female netball athletes from the UK. They letes who became Olympians used imagery more reported parallel results for cognitive anxiety. In than those who did not. Moreover, injured ath- the later investigation, however, both males and letes who used imagery to foster the rehabilita- females exhibited greater somatic anxiety on the tion process were more likely to make the team day of the competition. Further, both exhibited than injured athletes who were not imagers. decreases in self-confidence, although this decre- Hall et al. (1990) examined imagery use among ment was more pronounced among the female 381 male and female participants from six sports. athletes. Finally, Jones et al. (1991) found different This sample varied from recreational level to élite antecedents of precompetitive anxiety as a func- international and/or national competitors. Con- tion of gender. For females, the perceived threat sistent with the results of Ungerleider and of not obtaining one’s personal goals and per- Golding (1992), Hall et al. found that the élite ath- ceived readiness for the forthcoming competi- letes (female and male) reported greater use of tion were the major predictors of precompetitive imagery in general. It was also found that a high stress. For the males, ratings of the competition use of imagery was associated with all-time best and expectations concerning a successful out- performance in the case of these female and male come contributed to their state anxiety levels. athletes. When predicting the level of sport perfor- Past work has also pointed to the relevance of mance of females (as well as males), we should attentional skills with respect to maximizing note that it is not only the level of competitive sport performance. In a qualitative study of 16 state anxiety that must be considered but also former US national champion figure skaters how athletes interpret their anxiety responses. A (nine females and seven males), Jackson (1992) study by Jones and Hanton (1996) indicated that examined the characteristics of an optimal if an athlete expects to achieve her/his goal in the skating experience (or flow state) and the major forthcoming contest, she or he is more likely to contributors to this state. As conceptualized by interpret the degree of cognitive anxiety and Csikszentmihalyi (1975), flow results when there somatic anxiety as facilitative in terms of perfor- is enjoyment and a balance between perceived mance. The subjects in this investigation were abilities and demands. When in flow, the athlete competitive swimmers (46 females and 45 males) feels like she is totally involved in the activity at aged between 14 and 28 years. No gender differ- hand, i.e. there is a merging of action and aware- psychological aspects of training 111

ness (Csikszentmihalyi, 1975). Based on exten- solving coping strategies. In fact, both female sive interview data, Jackson (1992) found that and male athletes tended to engage in effective perceived clarity in, and control of, one’s atten- coping. tional focus were major attributes of an optimal In general, past work suggests that élite female skating experience. Similarly, a factor deemed athletes possess stronger mental skills than significant to the athlete attaining the flow state lower-ranking female athletes. At the highest was the ability to maintain one’s concentration or levels of competition, female athletes are much appropriate attentional focus. In a follow-up more similar to their male cohorts with regard to investigation involving 28 (14 female, 14 male) the employment of mental skills. Research indi- élite Australian athletes from seven sports, cates that gender differences are more likely to be Jackson (1995) found that the capacity to focus evident at lower competitive levels. The differ- was important to the facilitation, prevention and ences that emerge are typically related to varia- disruption of the flow experience. tions in self-confidence and the reported degree Another critical facet of mental skill develop- of competitive stress experienced. Given that ment concerns athletes’ responses to the less anxiety is likely to result when athletes perceive desirable moments in training or a competitive that their abilities do not match the demands event. In other words, how does the athlete typi- being placed on them, it appears that gender- cally react or cope when performance is not related distinctions in confidence may also result going well? In a sample that included 12 junior in the observed differences in anxiety levels female tennis players, Van Raalte et al. (1994) between male and female athletes. found that negative self-talk was associated with losing matches and those players who indicated Effectiveness of that they believed in the value of positive self- mental skills training talk won more points than their counterparts who did not perceive much utility in this Since sport psychology studies indicate that the performance-enhancement technique. possession of strong mental skills is linked to With regard to athletes’ explanations for higher competitive level and athletic achieve- performance-related problems, Hausenblas and ment, it is important to ascertain whether such Carron (1996) studied 144 élite female and 101 skills can be learned or enhanced among female élite male athletes from a variety of sports. They athletes. With the aim of exploring the docu- found that female athletes were more likely than mented effectiveness of mental skills interven- male athletes to indicate that performance tions, Greenspan and Feltz (1989) examined disruptions were due to sport problems (e.g. results across 19 published studies. They found cancelled practice), their physical state and evidence to suggest that educational-based problems with family and friends. relaxation interventions and cognitive restruc- Crocker and Graham (1995) conducted an turing techniques with individual athletes investigation focused specifically on athletes’ produce positive results. Unfortunately in terms coping responses. The subjects were 169 women of the focus of this chapter, only seven of the and 208 men (mean age 20.5±2.5 years) who studies examined were exclusively based on were involved in a variety of sports. Their com- female athletes. Since this review, female com- petitive level ranged from regional to national petitors have been subjects in a number of inves- competitive experience. Female athletes indi- tigations on the effects of mental skills training. cated that they sought out emotional social Examples of such work are reviewed below. support and increased their efforts when con- Burton (1989) conducted a season-long goal- fronted with stress related to thwarted goals. setting training programme with 13 female (and Contrary to what was expected, no evidence 17 male) collegiate Division I swimmers. The emerged that males used greater problem- emphasis of this programme was to encourage 112 training the female athlete

the swimmers to set personal performance deduced from a lowering of the athlete’s anxiety standards rather than outcome goals. In contrast before the game, improvement in performance with a control group, trained female athletes (as reflected in game statistics) and the coach’s reported more accurate performance expecta- overall rating of the athlete. tions, exhibited lower cognitive anxiety and wit- Daw and Burton (1994) conducted a multi- nessed greater performance improvement. The faceted mental skills training programme for six self-confidence of the experimental group was male and six female collegiate tennis players also higher than the control group but this differ- over the course of a year. The athletes were ence was not statistically significant. taught goal-setting, imagery and arousal regula- In a study involving four female collegiate tion with the intention of developing an indi- basketball players, Kendall et al. (1990) examined vidualized programme. Results based on the effectiveness of a 5-day programme during case-study analyses, a within-team comparison which the athletes received training in the areas of highly committed and poorly committed of imagery, relaxation and self-talk. A single- players, and a comparison with a control group subject multiple-baseline design was employed of tennis players indicated that the programme and the behaviour of interest was the defensive was effective. skill of cutting an offensive player’s move to the A season-long, multifaceted programme with baseline/hoop. Based on observational data, 14 members of a Division I collegiate women’s questionnaire assessments and personal logs gymnastics team was evaluated by Cogan and completed by the women, a positive effect for the Petrie (1995). The intervention focused on team- intervention was demonstrated. building and anxiety-management techniques. Elko and Ostrow (1991) determined the impact In contrast with a control group, the intervention of a rational–emotive programme on the state group exhibited higher social cohesion and anxiety and performance of six collegiate Divi- lower cognitive and somatic anxiety. sion I gymnasts who were identified as anxiety Kerr and Goss (1996) examined the effect of a prone. The focus of this programme was to have comprehensive, 16-session stress management the athletes become more attuned to the role of programme on eight female and 16 male élite trigger thoughts and irrational beliefs in the gymnasts. The study took place over an 8-month stress process. The gymnasts were also taught period and the dependent variables of interest how to substitute such stress-enhancing irra- included stress levels and perceptions of being tional statements with positively reinforcing injured. With respect to the latter variable, the self-statements. Following the cognitive inter- experimental group (females and males) spent vention, five of the six gymnasts decreased their less time injured than the control group but this cognitive anxiety. However, no effect was difference was not statistically significant. From observed on the gymnasts’ somatic anxiety, mid-season to peak season, however, the gym- performance and reported content of thoughts nasts trained in stress management reported sig- while they were experiencing competitive- nificantly less negative athletic stress. related stressors. Lerner et al. (1996) conducted a study of 12 Savoy (1993) examined the effect of a mental female athletes who were members of a colle- training programme on a female intercollegiate giate basketball team. Utilizing a multiple- Division I basketball player across a season. This baseline, single-subject ABA design, subjects athlete was requested to participate in the pro- were assigned to one of three conditions: (i) goal gramme due to her purported problem handling setting, (ii) imagery or (iii) goal-setting and distractions and difficulty in becoming moti- imagery. Three athletes in the goal-setting condi- vated for practices. The techniques employed tion and one participant in the imagery/goal- included imagery, centring, focusing and arousal setting condition increased their free-throw regulation. The efficacy of the programme was shooting success. However, three athletes who psychological aspects of training 113

were in the imagery-alone condition decreased being placed on the athlete and her ability to their mean free-throw performance. Shambrook meet those demands. Silva defines staleness as and Bull (1996) in their investigation of the an initial failure of the body’s adaptive mecha- impact of imagery training on the basketball free- nisms to cope with the psychophysiological throw shooting of four female players also stress created by training stimuli. When athletes reported mixed results. are subjected to chronic training stress and are in In their research on seven female and six male a continuous state of staleness, they become club-level golfers from Australia, Thomas and overtrained. Overtraining leads to ‘detectable Fogarty (1997) revealed a beneficial effect of a 2- psychophysiological malfunctions and is charac- month imagery and self-talk training on the ath- terized by easily observable changes in the letes’ imagery skills and psychological responses athlete’s mental orientation and physical per- to competition. Improvements in golf perfor- formance’ (Silva, 1990). Thus, when an athlete mance were also observed. is stale or overtrained, a training plateau or In sum, investigations concerning the efficacy detraining effect is likely to ensue. If such a situa- of mental skill training suggest that programmes tion continues over time, burnout and with- geared towards the development of mental skills drawal from the sport are presumed to be likely are beneficial for female competitors. After learn- consequences. According to Silva, the latter ing techniques such as self-talk, goal-setting and experiences are what characterize the negative stress management, female athletes who partici- training stress syndrome. pate in a variety of sports have been found to Silva’s (1990) study of the prevalence and exhibit less anxiety and better performance. significance of the negative training stress syn- Results concerning the effectiveness of imagery drome involved 25 female and 43 male inter- training on the execution of sport skills have collegiate athletes from a variety of sports. been more inconsistent. Almost 73% of the athletes indicated that they had experienced staleness during their collegiate careers but a little more than half found this Psychological factors experience to be tolerable; 66% of the athletes and overtraining indicated that they experienced overtraining Overtraining and potential burnout are critical while participating in college sports. Further, areas of concern regarding the development of almost half of the athletes reported that they had contemporary female athletes. As pointed out by experienced burnout and over 80% suggested Weinberg (1990), ‘training in most sports now that burnout was the worse response to training requires year round workouts with off season stress. becoming shorter and shorter. In fact, in sports Murphy et al. (1990) examined the psychologi- such as tennis, gymnastics, and swimming, there cal and performance-related impact of increased is really no “off season” as competitions occur training loads among seven female and eight throughout the year.’ male judo athletes who lived at the US Olympic Silva (1990) has distinguished between posi- Training Center in Colorado Springs. Assess- tive and negative training stress. In terms of the ments were made on the athletes over a 10-week former, he refers to the desirable adaptations to period and were divided into three phases: a training (such as increased strength, skill devel- baseline phase (weeks 1–4), an increased condi- opment, confidence) as a function of the over- tioning training volume phase (weeks 5–8) and loads placed on the athlete. The responses to an increased sport-specific training volume negative training stress are presumed to vary phase (weeks 9–10). By week 8, the athletes along a continuum from staleness to overtraining reported their greatest perceived effort related to to burnout. Such responses generally occur when training and higher fatigue levels compared with an imbalance is evident between the demands baseline. By week 10, athletes were angrier than 114 training the female athlete

at the onset of training and exhibited greater deficits (e.g. decreased performance). This burn- general anxiety, higher somatic anxiety and out process is presumed to be circular, continu- lower self-confidence. Further, there was a ous and reciprocal. Based on the findings of their decrease in anaerobic endurance and strength by initial study, Gould et al. (1996a) concluded that the conclusion of training. These findings are ‘stress-induced burnout appears to be explicitly compatible with the earlier, large-scale work of intertwined with motivation and participant Morgan et al. (1987). They reported greater mood motivation concerns, and burnouts must be disturbances such as greater anger, depression studied in a longitudinal process-orientated and fatigue associated with training stimulus fashion to understand the interaction between increases among a sample of 400 male and female these variables’. competitive swimmers over a 10-year period. In the second investigation, 10 junior élite Recently, Gould et al. (1996a,b) have focused tennis players who experienced burnout (six specifically on the characteristics of young élite females, four males) engaged in an in-depth athletes who burn out. Two studies were con- interview concerning the characteristics of, and ducted. The first entailed a quantitative analysis reasons for, burnout (Gould et al., 1996b). With of the psychological and environmental factors regard to the former, study participants indi- that distinguished between a national sample of cated that burnout was accompanied by a lack of junior tennis players (26 females, 36 males) who motivation, low energy, negative affect, a sense experienced burnout, in contrast to a comparable of isolation and concentration problems. The group of young tennis players. The second inves- physical symptoms experienced by these ath- tigation involved a qualitative analysis of a sub- letes were varied and not found to be a signifi- sample of the burned-out tennis players from the cant facet of burnout. The major themes that first study. The results of the initial study indi- emerged concerning the perceived contributors cated that burned-out tennis players felt they to burnout included a dissatisfaction with one’s had less influence on their training, competed in social life, negative parental influences, unful- too many tournaments and were higher in moti- filled and/or inappropriate expectations and a vation. This group of athletes also felt that their lack of enjoyment of tennis. parents were highly critical and held high expec- In summary, the training of female athletes can tations for the tennis performance. They had lead to negative rather than positive effects, i.e. lower personal standards but exhibited a greater when the physical and psychological training fear about making mistakes. Finally, in terms of demands placed on female athletes chronically coping strategies, the burned-out athletes were surpass their capacity to meet such demands, less likely to employ planning and positive re- there are both physical and psychological costs interpretation when experiencing stress com- to pay. She can become physiologically over- pared with their healthy cohorts. trained, emotionally and motivationally burned In contrast to Silva’s (1990) suggestion that out, and may quit her athletic activity as a result. burnout is a result of long-term exposure to Based on the literature, the determinants of this excessive physical training, Gould et al. (1996a) negative training stress syndrome (Silva, 1990) argued that their results were compatible with appear to be similar for female and male sport Smith’s (1986) cognitive–affective model of participants. burnout in sport. This framework suggests that burnout is a three-stage process: (i) the athletes Adaptive psychological perceive that the demands placed on them, both training environments physical and psychological, are overwhelming; (ii) they respond to this appraisal with physio- The fourth and final line of research reviewed in logical manifestations of stress; and (iii) they this chapter deals with a theoretically based body exhibit motivational problems and behavioural of work on the correlates of the motivational psychological aspects of training 115

climate surrounding athletes. Drawing from goal (iv) preferences for and perceptions of the leader- perspective theories of achievement motivation ship behaviours exhibited by the coach. The sub- (Nicholls, 1989; Ames, 1992), it is assumed that jects in this study were 219 tennis players (73 these climates are created by the athletes’ signifi- females, mean age 15.6±2.1 years) from clubs cant others and tied to those goals emphasized in Spain. Over 30% of the athletes were at an in the athletic environment, namely task or ego intermediate level, while more than 60% were goals. In the former, the focus is on personal advanced or professional level tennis players. improvement, task mastery and the exhibition of Tennis players who perceived that their coaches high effort. Perceptions of one’s ability are self- created a more task-involving environment were referenced when an athlete is task-involved. more satisfied with their year’s results and level When ego goals are evoked, concern is with of play and reported greater improvement in the the demonstration of superior ability and out- psychological and tactical dimensions of their performing others. In this case, perceiving tennis. They also perceived that their coach oneself to be able stems from favourable social provided more training, instruction and social comparisons. support. Satisfaction with the training provided Recent studies of high-level athletes (including by the coach and the players’ indication that their female athletes in the competitors sampled) have present coach was similar to the coach they looked at the achievement-related variables would prefer, were negatively related to percep- associated with strongly task or ego climates tions of an ego-involving climate and positively reinforced by coaches. For example, Pensgaard associated with perceptions of a task-involving and Roberts (1996) conducted an investigation of atmosphere. The observed associations did not the relationship between Norwegian athletes’ vary as a function of the gender of the athlete. perceptions of the motivational climate operat- Extending this study to a team sport, the results ing on their teams and their reported sources of reported by Balaguer et al. (1996, in press) were stress. The athletes in this study were partici- replicated in national-level female handball pants in the 1994 Winter Olympics. The results players from Spain (Balaguer et al., 1997). indicated that a perceived ego-involving atmos- Another direction in this area of inquiry phere was associated with a stronger emphasis focuses on whether the motivational climate on cognitive factors (e.g. a lack of perceived created by significant others predicts whether control) and the coach as contributors to sport is ‘health conducive or health compromis- competition-related stress. ing’ for athletes (Duda, 1996). Pertinent to this Other researchers have examined the links issue, the media and popular press have recently between the situationally emphasized goal struc- raised concerns about the pressures placed on tures created by coaches and athletes’ appraisals athletes, especially female athletes involved in concerning their coaches’ leadership style and individual, subjectively scored sports in which personal performance and skill development. the élite competitor is often quite young (Ryan, For example, Balaguer et al. (1996, in press) exam- 1995) (Fig. 7.1). In a series of studies involving ined the perceptions of competitive club tennis élite female gymnasts, Duda and her colleagues players of the motivational climate created by the (Duda & Benardot, 1997; Duda & Kim, 1997; coach in relation to: (i) preference for their Duda, in press) have examined the associations present coach and ratings of his or her signifi- between perceptions of the motivational climate cance in their tennis training; (ii) satisfaction operating in the gyms where the gymnasts train with their current competitive results, level of and psychological and energy balance precur- play and the overall instruction they received sors to the development of eating disorders and from the coach; (iii) perceptions of their improve- other health and performance-related problems; ment in the technical, tactical, physical and psy- 70 members of the 1994 USA Gymnastics Talent chological components of their tennis game; and Opportunity Program National Team (mean age 116 training the female athlete

Fig. 7.1 The success of the United States 1996 gymnastics team, which won the Gold Medal in the Atlanta Olympics, raised questions about the pressure on young athletes to perform in spite of injury. (© Allsport.)

10.3 years) participated in the initial investiga- results indicated that a perceived ego-involving tion (Duda & Benardot, 1997). The sample of gym environment corresponded to lower self- junior élite female gymnasts who perceived the esteem and greater dissatisfaction with one’s training environment created by the coach(es) to body. When these young gymnasts felt that their be task-involving exhibited higher self-esteem, a coaches emphasized ego goals and their parent- more positive body image and enjoyed their induced motivational climate was ego- sport more. Perceptions of a task-involving gym involving, they tended to be more perfectionist. environment corresponded negatively to the fre- Finally, we found that the latter variable medi- quency and magnitude of energy deficits during ated the relationship between the two motiva- a typical 24-hour training day. Among the older tional atmospheres surrounding junior élite girls in this sample (age 11 years), perceptions of gymnasts and their attitudes and behaviours an ego-involving climate were positively corre- concerning food. lated with the degree of competitive stress expe- The results of the work of Duda and her col- rienced. Duda and Benardot (1997) replicated leagues is consonant with ethnographic studies these findings with a subsequent sample of 15 of female gymnasts. Krane et al. (1997) conducted members of the US international women’s artis- a qualitative case study of a former élite gymnast tic team (mean age 15.4 years) and 23 girls of involving three unstructured interviews. similar age who were on the national artistic Through the information gathered, Krane et al. team (Duda, in press). found that coaches and parents seemed to create Duda and Kim (1997) extended the studies of an ego-involving atmosphere which appeared to Duda and Benardot in three ways. First, the ath- contribute to the development of the gymnast’s letes’ perceptions of the degree to which their strong ego orientation (e.g. she was very con- parents create a task- vs. ego-involving climate cerned with demonstrating her superior com- were determined. Second, we measured another petence as a gymnast and was extrinsically important psychological precursor of the devel- motivated). Apparently due to this social envi- opment of eating disorders, namely perfec- ronment and her resulting focus on ego-involved tionism. Third, we assessed disordered eating goals, the gymnast’s athletic experience was behaviours and preoccupations with food marked by overtraining, competing while among more recent members of the Talent injured and engaging in disordered eating Opportunity Program National Team. The behaviours. psychological aspects of training 117

In summary, the current research on contextu- ship of goal orientations and the perceived motiva- ally emphasized goal perspectives supports the tional climate to coaches’ leadership style. In R. Lidor & M. Bar-Eli (eds) Innovations in Sport Psychology: desirability of task-involving training environ- Linking Theory and Practice. International Society of ments for athletic girls and women. The evidence Sport Psychology, Part 1, pp. 94–96. suggests that such a training climate is conducive Balaguer, I., Duda, J.L. & Crespo, M. (in press) Motiva- to skill development, optimal performance and, tional climate and goal orientations as predictors of most critically, the overall psychological and perceptions of improvement, satisfaction and coach ratings among tennis players. Scandinavian Journal of physical welfare of female athletes. Medicine and Science in Sport, in press. Birrell, S. & Cole, C.L. (eds) (1994) Women, Sport, and Conclusion Culture. Human Kinetics Publishers, Champaign, Illinois. The research reviewed indicates that the most Boutilier, M.A. & SanGiovanni, L. (1983) The Sporting Woman. Human Kinetics Publishers, Champaign, adaptive and effective training of female athletes Illinois. must consider the psychological components Burton, D. (1989) Winning isn’t everything: examining and consequences of such training. Élite female the impact of performance goals on collegiate swim- athletes have been found to possess strong mers’ cognitions and performance. Sport Psychologist mental skills as well as outstanding physical 3, 105–132. Cogan, K. & Petrie, K. (1995) Sport consultation: an skills and physiological capacities. Most relevant evaluation of a season-long intervention with female to sound sport practice, the psychological skills collegiate gymnasts. Sport Psychologist 9, 282–296. in question, such as maintaining one’s confi- Costa, D.M. & Guthrie, S.R. (eds) (1994) Women and dence and attentional focus, reducing unwanted Sport: Interdisciplinary Perspectives. Human Kinetics stress, goal-setting and use of imagery, are train- Publishers, Champaign, Illinois. Cox, R.H. (1994) Sport Psychology: Concepts and Applica- able. The training of serious female athletes tions. Brown & Benchmark, Madison, Wisconsin. becomes excessive when both the physical and Crocker, P.R.E. & Graham, T.R. (1995) Coping by psychological requirements are too great. The competitive athletes with performance stress: gender implications of overtraining for the athletic differences and relationships with affect. Sport Psy- female affect the body and the mind and, eventu- chologist 9, 325–338. Csikszentmihalyi, M. (1975) Beyond Boredom and ally, her continued involvement in the athletic Anxiety. Jossey-Bass, San Francisco. domain. Conceptually driven investigations are Daw, J. & Burton, D. (1994) Evaluation of a comprehen- now providing insight into, and guidance con- sive psychological skills training program for colle- cerning the nature of, the training environments giate tennis players. Sport Psychologist 8, 37–57. most beneficial to the performance and participa- Duda, J.L. (1996) Fostering motivation in sport and physical education for children and adolescents: the tion of female athletes in sport. case for greater task involvement. Quest 48, 290–302. Duda, J.L. (in press) The implications of the motiva- References tional climate for motivation, health, and the devel- opment of eating disorders in gymnasts. Revista de Ames, C. (1992) Classroom: Goals, structures, and Psicologia Social Aplicada, in press. student motivation. Journal of Educational Psychology Duda, J.L. & Benardot, D. (1997) The motivational 84, 261–271. climate and psychological and energy balance pre- Anshel, M.H. (1997) Sport Psychology: From Theory to cursors to the development of eating disorders in Practice, 3rd edn. Gorsuch Scarisbrick Publishers, female gymnasts. Submitted for publication. Scottsdale, Arizona. Duda, J.L. & Kim, M. (1997) Parental and gym motiva- Balaguer, I., Crespo, M. & Duda, J.L. (1996) Disposi- tional climates and the development of eating disor- tional goal perspectives and perceptions of the moti- ders among young elite gymnasts. Journal of Sport vational climate as predictors of coach ratings, and Exercise Psychology 19 (Suppl.), S48. satisfaction and perceived improvement among Elko, P.K. & Ostrow, A.C. (1991) Effects of a competitive club tennis players. Journal of Applied rational–emotive education program on heightened Sport Psychology 8 (Suppl.), S139. anxiety levels of female collegiate gymnasts. Sport Balaguer, I., Duda, J.L. & Mayo, C. (1997) The relation- Psychologist 5, 235–255. 118 training the female athlete

Gill, D.L. (1986) Psychological Dynamics of Sport. Human Krane, V., Greenleaf, C.A. & Snow, J. (1997) Reaching for Kinetics Publishers, Champaign, Illinois. gold and the price of glory: a motivational case study Gill, D.L. (1993) Psychological, sociological, and cul- of an elite gymnast. Sport Psychologist 11, 53–71. tural issues concerning the female athlete. In A.J. Lerner, B.S., Ostrow, A.C., Yura, M.T. & Eztel, E.F. (1996) Pearl (ed.) The Athletic Female, pp. 112–131. Human The effects of goal-setting and imagery training pro- Kinetics Publishers, Champaign, Illinois. grams on the free-throw performance of female Gill, D.L. & Dzewaltowski, D.A. (1988) Competitive collegiate basketball players. Sport Psychologist 10, orientations among intercollegiate athletes: is 382–387. winning the only thing? Sport Psychologist 2, 212–221. Mahoney, M.J., Gabriel, T.J. & Perkins, T.S. (1987) Psy- Gould, D., Udry, E., Tuffey, S. & Loehr, J. (1996a) chological skills and exceptional athletic perfor- Burnout in competitive junior tennis players: I. A mance. Sport Psychologist 1, 181–199. quantitative psychological assessment. Sport Psychol- Morgan, W.P., Brown, D.R., Raglin, J.S., O’Connor, P.J. ogist 10, 322–340. & Ellickson, K.A. (1987) Psychological monitoring of Gould, D., Tuffey, S., Udry, E. & Loehr, J. (1996b) overtraining and staleness. British Journal of Sports Burnout in competitive junior tennis players: II. Medicine 21, 107–114. Qualitative analysis. Sport Psychologist 10, 341–366. Murphy, S.M., Fleck, S.J., Dudley, G. & Calllister, R. Greenspan, M.J. & Feltz, D.L. (1989) Psychological (1990) Psychological and performance concomitants interventions with athletes in competitive situations: of increased volume training in elite athletes. Journal a review. Sport Psychologist 3, 219–236. of Applied Sport Psychology 2, 34–50. Hall, C.R., Rodgers, R.M. & Barr, K.A. (1990) The use of Nicholls, J.G. (1989) The Competitive Ethos and Democra- imagery by athletes in selected sports. Sport Psycholo- tic Education. Harvard University Press, Cambridge, gist 4, 1–10. Massachusetts. Hausenblas, H.A. & Carron, A.V. (1996) Group cohe- Oglesby, C. (1978) Women and Sport: From Myth to sion and self-handicapping in female and male ath- Reality. Lea & Febiger, Philadelphia. letes. Journal of Sport and Exercise Psychology 18, Oglesby, C. & Hill, K.L. (1993) Gender and sport. In R. 132–143. Singer, M. Murphey & L.K. Tennant (eds) Handbook of Holloway, J.B., Beuter, A. & Duda, J.L. (1988) Self- Research on Sport Psychology, pp. 392–413. Macmillan, efficacy and training for strength in adolescent girls. New York. Journal of Applied Social Psychology 18, 699–719. Pearl, A.J. (ed.) (1993) The Athletic Female. Human Horn, T.S. (ed.) (1992) Advances in Sport Psychology. Kinetics Publishers, Champaign, Illinois. Human Kinetics Publishers, Champaign, Illinois. Pensgaard, A.M. & Roberts, G.C. (1996) Winter Jackson, S. (1992) Athletes in flow: a qualitative investi- Olympic athletes’ perception of the motivational gation of flow states in elite figure skaters. Journal of climate and sources of stress. Journal of Applied Sport Applied Sport Psychology 4, 161–180. Psychology 8 (Suppl.), S153. Jackson, S. (1995) Factors influencing the occurrence of Ryan, J. (1995) Little Girls in Pretty Boxes: The Making and the flow state in elite athletes. Journal of Applied Sport Breaking of Elite Gymnasts and Figure Skaters. Double- Psychology 7, 138–166. day, New York. Jones, G. & Cale, A. (1989) Precompetition temporal Savoy, C. (1993) A yearly mental training program for patterning of anxiety and self-confidence in males a college basketball player. Sport Psychologist 7, and females. Journal of Sport Behavior 12, 183–195. 173–190. Jones, G. & Hanton, S. (1996) Interpretation of com- Shambrook, C.J. & Bull, S.J. (1996) The use of a single- petitive anxiety symptoms and goal attainment case research design to investigate the efficacy of expectancies. Journal of Sport and Exercise Psychology imagery training. Journal of Applied Sport Psychology 18, 144–157. 8, 27–43. Jones, G., Swain, A. & Cale, A. (1991) Gender differ- Silva, J.M. III (1990) An analysis of the training stress ences in precompetition temporal patterning and syndrome in competitive athletics. Journal of Applied antecedents of anxiety and self-confidence. Journal of Sport Psychology 2, 5–20. Sport and Exercise Psychology 13, 1–15. Singer, R., Murphey, M. & Tennant, L.K. (eds) (1993) Kendall, G., Hrycaiko, D., Martin, G.L. & Kendall, T. Handbook of Research on Sport Psychology. Macmillan, (1990) The effects of an imagery rehearsal, relaxation, New York. and self-talk package on basketball game perfor- Smith, R. (1986) Toward a cognitive–affective model mance. Journal of Sport and Exercise Psychology 12, of athletic burnout. Journal of Sport Psychology 8, 157–166. 36–50. Kerr, G. & Goss, J. (1996) The effects of a stress manage- Thomas, P.R. & Fogarty, G.J. (1997) Psychological skills ment program on injuries and stress levels. Journal of training in golf: the role of individual differences in Applied Sport Psychology 8, 109–117. cognitive preferences. Sport Psychologist 11, 86–106. psychological aspects of training 119

Ungerleider, S. & Golding, J.M. (1992) Beyond Strength: Weinberg, R.S. & Gould, D. (1995) Foundations of Sport Psychological Profiles of Olympic Athletes. Brown, and Exercise Psychology. Human Kinetics Publishers, Dubuque, Iowa. Champaign, Illinois. Van Raalte, J.L., Brewer, B.W., Rivera, P.M. & Petitpas, Wells, C.L. (1991) Women, Sport, and Performance: A A. (1994) The relationship between observable self- Physiological Perspective, 2nd edn. Human Kinetics talk and competitive junior tennis players’ match Publishers, Champaign, Illinois. performances. Journal of Sport and Exercise Psychology 16, 400–415. Chapter 8

Nutrition

ANN C. GRANDJEAN, JAIME S. RUUD AND KRISTIN J. REIMERS

Introduction have been explored and are reviewed here briefly. The past 25 years have seen a dramatic increase in the number of studies examining the physio- energy efficiency logical, psychological and sociological factors that influence female sports performance. The If the female athlete does indeed become energy information acquired from these studies has efficient, this could be occurring via changes in brought to the forefront many of the nutrition one or more of the components that constitute and health-related issues affecting female total energy expenditure, i.e. resting energy athletes today. This chapter reviews the most expenditure (REE), the thermic effect of food common nutrition-related problems of female (TEF) or physical activity. Certainly one explana- athletes, with emphasis on identification and tion for a lower than expected energy expendi- potential interventions. ture could be a decrease in REE in response to energy restriction (Henson et al., 1987; Leibel et Inadequate energy intake al., 1995). Because REE generally constitutes the largest proportion (60–70%) of total energy Low energy intake is of concern because of the expenditure, perturbations in this component increased risk for illness and injury that can could partially explain lower energy require- result. Studies have repeatedly shown discrepan- ments. However, in four contemporary studies cies between reported energy intake and REE has not been shown to be lower in athletes estimated energy expenditure among female compared with controls (Schulz et al., 1992; athletes. (Deuster et al., 1986; Nieman et al., 1989; Horton et al., 1994; Beidleman et al., 1995; Dahlström et al., 1990; Wilmore et al., 1992; Fogelholm et al., 1995). In contrast, a study by Edwards et al., 1993; Beidleman et al., 1995; Thompson et al. (1995) does indicate a lower Tanaka et al., 1995). This phenomenon can be daily sedentary energy expenditure in a group of explained by at least four different hypotheses: male endurance athletes. (i) these female athletes have become ‘energy The cost of TEF is relatively small, accounting efficient’, expending fewer kilojoules than esti- for about 7–10% of total energy needs. Some data mated by indirect methods; (ii) the athletes are have shown that female athletes have a lower under-reporting food intake; (iii) inexact stan- TEF than non-athletes, indicating that they may dards and equations may be the cause, or at least be more energy efficient (LaBlanc et al., 1984). partial cause, of error; and (iv) some female ath- However, other studies have found no differ- letes have energy requirements that are truly ences (Myerson et al., 1991; Wilmore et al., 1992; lower than non-athletic peers. These hypotheses Beidleman et al., 1995). Of all the components of 120 nutrition 121

total energy expenditure, physical activity is the metric), unfamiliarity with the foods consumed most variable among individuals. It is affected by and entry of generic vs. exact recipes. Precision age, gender, height, weight, body composition, often requires obtaining recipes from restaurants type of activity, physical conditioning, clothing, and to secure food labels in order to verify ingre- playing surface, environment in which the activ- dients. Database limitations (i.e. limited varieties ity takes place, genetics, and frequency, intensity of foods) increase error. With every food substi- and duration of the event or training session. tution made, the potential for error exists even Among well-trained female athletes, energy though it may be small; for example entering expended during physical activity can be as high regular milled white rice instead of long-grain as 36–38% of total energy expenditure (Schulz et brown rice contributes to error, as does entering al., 1992; Horton et al., 1994). While it is assumed pink grapefruit instead of white. Deliberate mis- that athletes in training have higher energy reporting (e.g. skimmed milk instead of semi- expenditure during physical activity compared skimmed) must also be considered. with non-athletes, this variability may be If small inaccuracies occur throughout the diminished if non-training physical activity is process of estimating energy expenditure and considered. recording and analysing diet records, it is easy to see the potential cumulative effect. For example, under-reporting if REE and TEF are each overestimated by 2%, activity over a 24-hour period is overestimated For years, scientists have questioned the accu- by 2%, recorded food intake is underestimated racy and reliability of food records. In 1942, by 2%, and data entry and analysis underesti- Huenemann and Turner compared two different mate actual intake by 2%, a 10% disparity methods of obtaining food intake data. Subjects between energy intake and energy expenditure were interviewed at length regarding food intake would result when, in reality, small errors in each (diet history). Following the interview, the sub- component account for the disparity. jects recorded food intake for a period of 10–14 days (diet record). Results showed large discrep- inexactness of standards ancies between the two methods. According to the authors, subjects had difficulty estimating the The standards, equations and formulas by which amounts of food they ate. For instance, subjects energy requirements/expenditures are esti- who thought they drank 1litre of milk a day actu- mated use arbitrary ‘ideal’ heights and weights, ally consumed 0.5 litre. Such errors, which can be body weight, averages, derived values and pop- significant, have continued to elicit doubts ulation data. Even REE is commonly estimated regarding the interpretation of dietary intake by using any of several empirically derived data (Guthrie, 1984; Dwyer et al., 1987; Yuhas et equations (Food and Nutrition Board, National al., 1989; Bandini et al., 1990; Dwyer, 1994; Young Research Council, 1989). Therefore, preciseness & Nestle, 1995; Beaton et al., 1997). cannot be expected in many of these calculations. While under-reporting is often the conclusion reached by investigators, other factors must be individuals with low energy needs considered. One such factor is inadequate instruction on how to record dietary information; Based on the limited data available, one cannot proper instruction may require up to 1 hour per identify energy efficiency, under-reporting or subject to ensure an acceptable degree of accu- inexact standards as the conclusive causes of the racy. Another factor is error during computer reported low energy intakes in female athletes. entry. Human error during this process results Generally, the accuracy of data becomes an acad- from careless coding, miscalculations of amounts emic discussion, and the perceived problem of (e.g. converting household measurements to low nutrient intake may not be valid. None the 122 training the female athlete

less, there undoubtedly are female athletes who Indications have low energy intakes. For discussion pur- poses, this group can be divided into those who Subjective observations indicative of low energy are in energy balance but whose intake is lower intake include the following. than a selected standard and those who are in • Expressed or displayed concerns about body negative energy balance. weight or body composition, even when appro- priate for sport. • Decrease in performance, such as decreased Energy intake below a standard endurance, decreased power or simply Athletes participating in sports that require low decreased enthusiasm. body weight for performance, such as figure • Amenorrhoea or oligomenorrhoea: menstrual skating, gymnastics, dance, etc., often achieve irregularity caused by negative energy balance this body composition by maintaining a low may be difficult to distinguish from normal energy intake. An energy intake below an esti- oligomenorrhoea observed in adolescents before mated or recommended level in the absence of the menstrual cycle is established. However, weight loss does not automatically equate to a irregular menses combined with the other char- nutritional problem. Other criteria must be acteristics listed here can be indicative of an present. While low energy intake may be accom- energy shortfall. panied by reduced intake of some nutrients, • Weight loss may be so gradual that it is very these can often be corrected without an adjust- difficult to discern, especially for the coach or ment in energy intake. However, if indications of trainer who observes the athlete daily. energy deficiency are present, even in the • Frequent illness: many factors influence fre- absence of weight loss, increased energy intake quency of illness, e.g. heavy training, regardless may be warranted. of energy intake, can negatively affect immunity. • Avoidance of dietary fat: see below for an in-depth discussion of this phenomenon. Negative energy balance ‘Dieting’ to decrease or maintain low body fat is Management often cited by athletes as a reason for low energy intake. While restriction of energy is indicated for Because energy restriction can be a symptom of some, because they will experience enhanced anorexia nervosa and other eating disorders, performance, the necessity of restricting energy ruling out its presence is indicated as an initial intake for others is not as clear. If asked about step. Discussion with the athlete should elicit their purpose in restricting energy intake, quite whether she is fearful of weight gain, has a dis- often these athletes are unable to provide a torted body image, or is misinformed about the response. Indeed, in some cases, energy restric- effect of body weight and body composition on tion or dieting simply appears to be ‘fashionable’. performance. If an eating disorder is suspected, Although many hypotheses and/or scenarios evaluation by a mental health professional and a exist, one theme prevails: female athletes com- physician is indicated. If an eating disorder is monly try to achieve a lower energy intake than ruled out, the next step is to assess whether the that indicated to support training. Although cer- food restriction is deliberate in order to achieve tainly not as detrimental to performance as a weight loss or whether the restricted food intake clinical eating disorder, long-term low energy is secondary to other situations, such as problem- intake may impede the athlete from reaching her atic relationships, lack of time, lack of money, full potential and, moreover, lead to negative stress or gastrointestinal pathology. consequences, such as inadequate carbohydrate, Discussing problems with the athlete and protein, vitamin and mineral intake, increased asking her to record her dietary intake may be risk of injury and increased risk of illness. effective in increasing dietary intake. It is undeni- nutrition 123

able that in many cases the athlete achieves a choices and has been associated with a signifi- small but noticeable increase in body weight/fat cant reduction in high-density lipoprotein (HDL) if energy intake is augmented. This can be an cholesterol levels in women (Denke, 1996). obstacle for the athlete who genuinely believes Furthermore, it appears that in endurance ath- that a lower weight is necessary for good perfor- letes with stable weight and body composition, mance. In this case, focusing on performance risk factors for coronary heart disease are not should be the goal. If performance improves adversely affected by increasing dietary fat calo- with the increased energy intake and this offsets ries from 30% to 42% (Leddy et al., 1996). In a the change in body composition, the athlete study of 375 élite athletes, A.C. Grandjean should experience less anxiety. None the less, for (unpublished data) reported that female athletes other athletes the mental hurdle of gaining (n=110) averaged 33% of total energy from fat weight will not be overcome. In this case, dietary with a range of 12–56%. When comparing data supplementation is a partial solution to an inade- from other countries, mean fat intakes of female quate diet. It is important not to alienate the athletes from the USA are less than those from athlete who is resistant to change, as her readi- China (42–49%) (Chen et al., 1989) but compa- ness to cooperate may alter at a later time. rable to those from The Netherlands (30–35%) (van Erp-Baart et al., 1989). Just as drastically reducing dietary fat can Excessive restriction of dietary fat cause problems, reducing body fat may also The importance placed on thinness and the negatively affect an athlete’s health and per- health messages that eating a high-fat diet leads formance. Body fat performs many critical to chronic health problems (obesity, cancer, dia- functions: it serves as internal padding and sur- betes) have resulted in a trend observed in many rounds vital organs and protects them from people, including female athletes: fat phobia or shock and injury. The layer of fat beneath the skin fear of fat. Weight-conscious athletes often go to also insulates and protects against the cold. extremes to avoid fat. They exclude foods such as Many female athletes strive to achieve and main- meat and dairy products and opt for reduced-fat tain body weight and body fat at levels much and fat-free products like rice cakes, pretzels, lower than that considered normal or genetically vegetables and salad with no dressing. Their determined. The most usual motivating factor is diets are repetitive, lack variety and are often the desire to be thin. The challenge to the health nutritionally inadequate. The fat-free trend professional working with such athletes is to that many athletes perceive as healthy and help them achieve a body composition that performance-enhancing is in fact neither. promotes optimal health and performance. Athletes who consume too little fat can suffer a variety of problems, including low energy levels, Indications menstrual problems and nutrient deficiencies. Extremely low dietary fat intakes are frequently • Negative attitudes to food: disparaging com- associated with low intakes of vitamins and min- ments may be made about fried foods, gravies or erals, such as vitamin B12, folate, vitamin B6, meats with visible fat. However, more telling are calcium, iron and zinc. the comments that a food with 1g of fat is much There is no dietary requirement for fat other superior to one with 3g of fat. than to provide essential fatty acids for phospho- • Decrements in performance: when fat avoid- lipids and cell membranes. The World Health ance results in a low energy intake, decre- Organization recommends that the total energy ments in performance are likely, as discussed from fat is not less than 15% (World Health previously. Organization Study Group, 1990). A prudent • Hunger: because dietary fat strongly influ- level of fat in the diet is 30% of total energy. Low ences satiety, the athlete who has a restricted dietary fat intake (15–20%) greatly limits dietary dietary fat intake may experience ‘always being 124 training the female athlete

hungry’. Our experience with these athletes is be instigated. The nutrients most likely to be that in many cases they are ingesting a relatively inadequate include iron and calcium. high-energy diet from high-carbohydrate sources yet not feeling full after eating. When fat Iron deficiency intake is increased, these athletes often reduce their energy intake but feel more satisfied after The amount of iron absorbed from the diet is eating. determined by multiple factors, with bioavail- • Obvious avoidance of fat in the diet: while ability being a primary one. Research on the omission of entire food groups or specific foods, bioavailability of iron allows one to predict, with such as meat, milk, cheese or other dairy prod- a degree of confidence, the amount of non-haem ucts, may be couched in reasons such as vegetari- iron that will be absorbed from different diets anism, dislike of the food or perception of the (Monsen et al., 1978; International Nutritional food (‘it’s not healthy’), the true underlying moti- Anemia Consultative Group, 1981) and to clas- vation for avoiding some of these foods is, in sify diets as low, medium or high bioavailability. some cases, simply an effort to avoid fat. The amount of available iron that is absorbed by the mucosal cell is inversely related to the iron content of the body. Thus, the total amount of Management iron in the diet, the bioavailability of that iron The existence of a very low fat diet by itself is not and the factors that affect iron requirements and indicative of dietary risks or impaired perfor- losses in women (e.g. menses, pregnancy, lacta- mance. Indeed some fastidious athletes achieve tion) collectively affect the quantities of iron that balanced varied diets on a low fat intake. On the must be present in the diet if iron balance is to be other hand, some athletes develop a monotonous maintained. unvaried diet that leads to inadequate protein, With median menstrual iron losses of 0.4–0.5 vitamin and mineral intake. Assessing the mg daily and basal iron losses of 0.8mg daily, athlete’s dietary intake via computerized diet half the female population would remain in iron analysis, checklists, yearly screenings or obser- balance if 1.3mg of iron could be absorbed daily; vation are useful measures for determining 95% of women would remain in iron balance if whether dietary change is indicated. 2.8mg of iron could be absorbed. For women to When dietary inadequacies have been identi- absorb 2.8mg of iron when consuming a low- fied and the culprit appears to be excessive bioavailable diet would require 56mg of iron in avoidance of fat, it is important to discuss with the diet daily (International Nutritional Anemia the athlete the social, emotional, cultural and Consultative Group, 1981). These calculations taste issues leading to fat avoidance in order to consider only the bioavailability of diet and elicit faulty perceptions. When misinformation become inaccurate in the light of other factors or inaccuracies about the role and function of that interfere with the absorption of iron. dietary fat are identified, the first step should be Compounding factors include pathological to provide accurate information and dispel bleeding and the malabsorption that occurs with misinformation. In some cases the athlete will gastrointestinal pathology. Depending on the appear relieved that it is appropriate to increase substance consumed, pica may lead to iron defi- dietary fat intake. In other cases, perhaps where ciency. Medicinal antacids can also interfere with the athlete has ‘grown up’ in an environment iron absorption. where fat is thought of as negative, change will It is easy to see why the prevalence of iron defi- be slow or non-existent. Like the situation of low ciency is significant in women. The fact that meat energy intake, if the athlete is resistant to change, and vitamin C-rich foods (known enhancers of dietary supplementation of those vitamins and iron absorption) are not available to vast seg- minerals documented to be inadequate should ments of the earth’s population is obviously a nutrition 125

contributing factor. In developed countries, the endurance athletes in heavy training and vege- problem of decreased energy intake is relevant. tarian athletes. With an increasingly sedentary lifestyle, the Resistance to taking pills, intolerance of ele- quantity of food eaten per day has declined sig- mental iron and/or the fact that iron supple- nificantly and thus iron intake has also declined. ments are not available, necessitate aggressive For female athletes, iron deficiency has long dietary strategies in some anaemic female ath- been an issue with regard to general health and letes. Information gathered during assessment performance (see Chapter 21). Studies assessing can be used to estimate dietary iron absorption the diets of female athletes show that iron intake and indicate appropriate dietary changes. is frequently less than the amount recommended In the athlete electing for dietary intervention, by different countries (Manore et al., 1989; awareness of good sources of dietary iron is Reggiani et al., 1989; Pate et al., 1990; Faber & essential. Iron bioavailability depends on several Spinnler, 1991; Lukaski et al., 1996). Most scien- factors, including the form of iron (haem vs. non- tists investigating the iron status of athletes are haem), the presence of enhancers (e.g. animal primarily interested in sports performance, tissue, vitamin C) and inhibitors (e.g. poly- although recent data on cognitive performance phenols in tea, phytates, bran), and the athlete’s should also be recognized. Studies indicate that iron status. Including meat, poultry and fish in non-anaemic, low iron levels can impair memory the diet and foods containing vitamin C will and verbal learning capacity in female adoles- increase iron absorption. In diets where little or cents (Bruner et al., 1996). no meat is consumed, intake can be increased by including more iron-rich foods such as dried fruits, cooked beans, dark-green leafy vegeta- Indications bles, whole grains and, if available, iron-fortified • Distinguishing haematological indices (see foods (Table 8.1). The use of iron cookware can Chapter 21). significantly increase iron intake. • Fatigue. Athletes who are iron deficient should receive • Decreased performance. dietary counselling and, when indicated, supple- • Impairment of temperature regulation. mental iron as described in Chapter 21. However, • Growth retardation. routine use of iron supplements by all athletes is • Scholastic underachievement. not warranted and in some cases is contraindi- • Impaired ability to concentrate. cated (see next section). • Impaired cognitive functioning. • Thin, brittle fingernails and toenails. Precautions • Pallor. When screening athletes for anaemia, it is im- perative that health professionals be aware of Management haemolytic anaemias/haemolytic disorders. Of Awareness, early detection and adequate knowl- the haemolytic disorders, sickle cell anaemia and edge are important steps in preventing iron thalassaemia (major and minor) are more likely deficiency. Ideally, female athletes should be to be encountered when working with athletes. screened once a year to detect the early stages of The red cell destruction that occurs with the iron deficiency (International Center for Sports haemolytic disorders increases free iron. Use of Nutrition and the United States Olympic iron supplements compounds the problem by Committee, 1990). However, this is impractical further increasing free iron and can result in iron for many. Therefore, emphasis should be placed overload. Chronic iron overload is characterized on high-risk groups, such as chronic dieters, by greater than normal focal or generalized women with heavy and long menstrual cycles, deposition of iron within body tissues Table 8.1 (a) Dietary haem sources of iron* Table 8.1 (b) Dietary non-haem sources of iron*

Food (85 g, cooked, Total iron Available Food Portion size Total iron Available lean only) (mg) iron (mg) (mg) iron (mg)

Beef Cereal Liver, pan fried 5.34 0.60 Raisin bran (enrich), 28 g 4.5 0.23 Chuck, arm pot 3.22 0.48 dry roast, braised Corn flakes (enrich), 28 g 1.8 0.09 Tenderloin, roasted 3.05 0.46 dry Sirloin, broiled 2.85 0.42 Shredded wheat, dry 28 g 1.20 0.06 Roundtip, roasted 2.50 0.38 Oatmeal, cooked 117 g 0.80 0.04 Top round, broiled 2.45 0.37 Whole wheat hot 121 g 0.75 0.04 Top loin, broiled 2.10 0.31 cereal Ground, lean, broiled 1.79 0.27 Breads and rice Eye round, roasted 1.65 0.25 Bagel 1 1.8 0.09 Pork Bran muffin, home 1 1.4 0.07 Shoulder, blade, 1.36 0.15 recipe Boston, roasted Whole wheat bread 1 slice 1.0 0.05 Tenderloin, roasted 1.31 0.15 White rice (enrich), 80 g 0.9 0.05 Ham, boneless, 1.19 0.14 cooked 5–11% fat White bread (enrich) 1 slice 0.7 0.04 Loin chop broiled 0.78 0.09 Brown rice, cooked 98 g 0.5 0.03 Loin, roasted 2.07 0.31 Fruit Leg, shank half, 1.75 0.26 Apricots, dried 7 halves 1.16 0.06 roasted Prunes, dried 3 medium 0.84 0.04 Lamb Raisins 20 g 0.38 0.02 Loin, roasted 0.93 0.14 Banana 1 medium 0.35 0.02 Cutlet, pan fried 0.74 0.11 Apple 1 medium 0.25 0.01 Orange 1 medium 0.13 0.01 Chicken Liver, simmered 7.20 0.81 Vegetables Leg, roasted 1.11 0.17 Potato, baked with 1 medium 2.75 0.14 Breast, roasted 0.88 0.13 skin Peas, cooked 80 g 1.26 0.06 Turkey Spinach, raw 15 g 0.76 0.04 Leg, roasted 2.26 0.34 Broccoli, raw 44 g 0.39 0.02 Breast, roasted 0.99 0.14 Carrots 1 medium 0.36 0.02 1 Fish Lettuce, iceberg /8 head 0.34 0.02 Tuna, light meat, 2.72 0.31 Corn, cooked 82 g 0.25 0.01 canned Pulses Tuna, white meat, 0.51 0.06 Kidney beans, boiled 89 g 2.58 0.13 canned Kidney beans, 128 g 1.57 0.08 Halibut, dry heat 0.91 0.10 canned Salmon, sockeye, dry 0.47 0.06 Chickpeas, boiled 82 g 2.37 0.12 heat Chickpeas, canned 120 g 1.62 0.08 Flounder/sole, dry 0.23 0.03 Baked beans, 127 g 0.37 0.02 heat canned, plain Seafood Dairy Oysters, 6 medium, 5.63 0.63 Milk, low fat 244 g 0.12 0.01 raw Yogurt, plain low fat 245 g 0.18 0.01 Shrimp, moist heat 2.63 0.30 Cheese, cheddar 28 g 0.19 0.01 Crab, Alaskan king, 0.65 0.07 moist heat Miscellaneous Tofu 99 g 2.3 0.12 Egg 1 whole 1.0 0.05 Egg 1 yolk 0.95 0.05 Egg 1 white trace – Peanut butter 32 g 0.6 0.03 Cane, blackstrap 20 g 5.05 0.25

*Source: Iron in Human Nutrition. National Live Stock and Meat Board, Chicago, IL, 1990. nutrition 127

(haemosiderosis), which can result in tissue vegans (Weaver & Plawecki, 1994). Calcium from injury (haemochromatosis) and, when left soybeans and green leafy vegetables such as untreated, more severe sequelae. broccoli contain less calcium per serving than milk but are absorbed as well (Weaver & Plawecki, 1994). Lime-processed tortillas, dried Inadequate calcium intake fruits, almonds, softened bones of fish and pul- Optimal calcium intake during childhood and verized eggshells added to gruels are also signifi- adolescence is important for the attainment of cant sources of calcium for many cultures. peak bone mass and for the prevention of osteo- It is important that young female athletes porosis (Matkovic et al., 1990). Although ade- know that dietary and lifestyle factors affect bone quate calcium intake is important for all women, health. Although most women are aware of the it is of extra concern in amenorrhoeic females importance of calcium and think they consume who are at increased risk of low bone mineral enough, dietary reports from female athletes density because of decreased oestrogen levels often reveal less than optimal intakes (Table 8.2). (Emans et al., 1990). The role of calcium in the Information provided to athletes on calcium prevention and treatment of osteoporosis is should describe a wide variety of sources, since covered in Chapter 27. This section briefly pre- milk and milk products are often omitted from sents dietary intake data of female athletes and the diet in an attempt to reduce fat and/or discusses dietary intervention strategies for energy intake, or for personal, religious or women with confirmed inadequate intakes. philosophical reasons. The recommended intake for calcium varies among countries, with influencing factors being Indications the composition of the native diet, public health concerns and physiological adaptations. The Low consumption in otherwise healthy women World Health Organization recommended is indicated by dietary intake analysis, food fre- intake for calcium is 400–500mg for adults quency questionnaire or screening instrument (World Health Organization Study Group, 1990). for calcium intake. No biochemical tests to The recommended intake in Colombia, Hungary, measure status exist. For example, calcium levels India, Mexico, Philippines, Singapore, Thailand in the blood are independent of intake and will and the UK is 500mg; in Australia, Brazil, be defended during long periods of very low Canada, the former Czechoslovakia, France, intake by bone resorption. Germany, Ireland, Portugal, South Africa and Uruguay it is 800mg; in Italy it is 1000mg; and in Management the USA the current dietary reference intake value is 1300mg daily for females aged 9–18 and While there are many reasons for inadequate 1000mg daily for females aged 19–51 years (Food intake in the presence of adequate supply, three and Nutrition Board, 1997). common ones are: (i) the misperception that Milk and milk products are the richest sources intake is adequate (e.g. overestimation of con- of calcium. In the USA they provide more than sumption); (ii) lack of awareness of calcium half the calcium in a typical diet (Fleming & requirements (e.g. 1200mg is equal to almost Heimbach, 1994). Other calcium-rich foods con- 1000ml of fluid milk, 130g of hard cheese or sumed in the USA include dark-green leafy veg- 640–4200g of leafy green vegetables); and (iii) etables, canned fish with small bones, and foods avoidance of dairy products because of negative fortified with calcium (e.g. juices, bread). attitudes toward fat and energy. Appropriate Calcium-set tofu (tofu processed with a calcium education/intervention will be dictated by the salt) and calcium-fortified soy milk are impor- contributing factor(s). tant sources of calcium in the diets of many Dietary assessment can determine, to a relative 128 training the female athlete

Table 8.2 Summary of calcium intake of female athletes

No. of Calcium‡ Reference subjects Age* Sport Energy†‡ in kJ (kcal) (mg)

Cohen et al. (1985) 12 24.4 ± 3.8 Dance 6993 ± 1881 (1673 ± 450) 821 ± 311 Deuster et al. (1986) 51 29.1 ± 0.8 Running 10019 ± 435 (2397 ± 104) 1227 ± 95 Nowak et al. (1988) 10 19.4 ± 0.97 Basketball 7231 ± 2395 (1730 ± 573) 903 ± 612 Vallieres et al. (1989) 6 22.3 ± 0.5 Swimming 10333 ± 2997 (2472 ± 717) 970 ± 369 Barr (1989) 10 16 ± 1.6 Swimming 8627 ± 1990 (2064 ± 476) 1354 ± 521 Benardot et al. (1989) 22 11–14§ Gymnastics 7131 ± 1760 (1706 ± 421) 867 ± 403 Heyward et al. (1989) 12 28.7 ± 7.2 Bodybuilding 6813 ± 2299 (1630 ± 550) 704 ± 389 Keith et al. (1989) 8 22.0 ± 5.0 Cycling 7445 ± 2993 (1781 ± 716) 719 ± 369 Reggiani et al. (1989) 26 12.3 ± 1.7 Gymnastics 6487 ± 2128 (1552 ± 509) 539 ± 291 Tilgner and 19 19 Swimming 10421 ± 2270 (2493 ± 543) 1046 ± 404 Schiller (1989) 8 19 Hockey 8176 ± 1568 (1956 ± 375) 762 ± 281 Kleiner et al. (1990) 8 28 ± 4 Bodybuilding 9447 ± 11119 (2260 ± 2660) 293 ± 231 Benson et al. (1990) 12 12.5 ± 1.1 Gymnastics 6454 ± 1664 (1544 ± 398) 966 ± 339 18 12.8 ± 0.9 Swimming 7909 ± 1864 (1892 ± 446) 764 ± 408 Pate et al. (1990) 103 30.6 ± 7.4 Running 6701 ± 201 (1603 ± 48) 630 ± 23 Worme et al. (1990) 21 32 ± 2 Triathlon 9050 ± 476 (2165 ± 114) 1259 ± 105 Barr (1991) 14 19.8 ± 1.2 Swimming 9597 ± 1990 (2296 ± 476) 808 ± 343 Faber and 10 22.3 ± 2.9 Field hockey 9285 ± 2013 (2215 ± 479) 739 ± 642 Spinnler (1991) Berning et al. (1991) 21 15.0 ± 2.0 Swimming 14930 ± 614 (3572 ± 147) 1234 ± 96 Bergen-Cico 44 13.9 ± 1.1 Cross-country 10400 ± 1262 (2488 ± 302) 972 ± 372 and Short (1992) running Snead et al. (1992) 19 31.9 ± 1.3 Running 8251 ± 607 (1972 ± 145) 948 ± 54 Webster and 32 14.1 ± 1.6 Gymnastics – 1005 ± 534 Barr (1995) 25 14.3 ± 1.6 Speed – 1527 ± 750 skating Kirchner et al. (1995) 26 19.7 ± 0.2 Gymnastics 5773 ± 456 (1381 ± 109) 683 ± 58

*Age reported as mean unless otherwise indicated; ± SD given if provided by authors. †Kilocalories converted to kilojoules (1kcal = 4.18kJ). ‡Mean ± SD (range). §Only range reported.

degree of accuracy, the current level of calcium food treated with liquid lactose preparations are intake. Dietary modification and/or supplemen- other approaches for managing lactose intoler- tation should then be calculated to obtain the ance. Those totally intolerant or who experience goal level for the athlete while avoiding levels in increased intolerance during times of stress (e.g. excess of 2500mg (Hathcock, 1997). international travel, major competitions) will Some athletes avoid milk and milk products need to include other sources of calcium (Table due to actual or perceived lactose intolerance. 8.3) and/or use calcium supplements. Many with lactose intolerance can tolerate foods with low lactose, such as yoghurt and hard Conclusion cheeses such as Swiss, Colby and Cheddar; some can tolerate small amounts of milk. Ingestion of This chapter has been limited to brief discussions 240ml of milk twice daily resulted in no change of four significant dietary problems commonly in symptoms in lactose-intolerant individuals in found individually or in combination in female one double-blind crossover study (Suarez et al., athletes. This is not to imply that nutritional 1997). Lactose tablets consumed before meals or problems are limited to these four. As with all nutrition 129

Table 8.3 Sources of calcium. (Adapted from Weaver & Plawecki, 1994 with permission)

Estimated absorbable Portion Calcium calcium per Food size (g) content (mg) serving (mg)

Almonds, dry 28 80 17.0 roasted Beans, pinto 86 44.7 7.6 Beans, red 172 40.5 6.9 Beans, white 110 113 19.2 Broccoli 71 35 18.4 Brussel sprouts 78 19 12.1 Cabbage, Chinese 85 79 42.5 Cabbage, green 75 25 16.2 Cauliflower 62 17 11.7 Citrus punch with 240 300 150 calcium citrate maleate Fruit punch with 240 300 156 calcium citrate maleate Kale 65 47 27.6 Kohlrabi 82 20 13.4 Milk 240 300 96.3 Mustard greens 72 64 37.0 Radish 50 14 10.4 Rutabaga 85 36 22.1 Sesame seeds, 28 37 7.7 no hulls Soy milk 120 5 1.6 Spinach 90 122 6.2 Tofu, calcium set 126 258 80.0 Turnip greens 72 99 51.1 Watercress 17 20 13.4

athletes, adequate hydration, appropriate train- and nonobese adolescents. American Journal of ing diet, adequate carbohydrate consumption, Clinical Nutrition 52, 421–425. Barr, S.I. (1989) Energy and nutrient intakes of elite individualized precompetition meal and manag- adolescent swimmers. Journal of the Canadian Dietetic ing nutrition when travelling, to name a few, are Association 50, 20–24. also nutritional concerns of the female athlete. Barr, S.I. (1991) Relationship of eating attitudes to Although we have identified common character- anthropometric variables and dietary intakes of istics among females, there is a risk in generaliz- female collegiate swimmers. Journal of the American Dietetic Association 91, 976–977. ing this population. Each female athlete presents Beaton, G.H., Burema, J. & Ritenbaugh, C. (1997) Errors unique nutritional challenges based on her sport, in the interpretation of dietary assessments. training, environment, genetic predisposition American Journal of Clinical Nutrition 65, 1100S–1107S. and learned dietary behaviours. Beidleman, B.A., Puhl, J.L. & De Souza, M.J. (1995) Energy balance in female distance runners. American Journal of Clinical Nutrition 61, 303–311. References Benardot, D., Schwarz, M. & Heller, D.W. (1989) Nutrient intake in young, highly competitive gym- Bandini, L.G., Schoeller, D.A., Cyr, H.N. & Dietz, W.H. nasts. Journal of the American Dietetic Association 89, (1990) Validity of reported energy intake in obese 401–403. 130 training the female athlete

Benson, J.E., Allemann, Y., Theintz, G.E. & Howald, H. intake in field athletes (discus-, hammer-, javelin- (1990) Eating problems and calorie intakes in Swiss throwers and shotputters). International Journal of adolescent athletes. International Journal of Sports Sports Medicine 12, 324–327. Medicine 11, 249–252. Fleming, K.H. & Heimbach, J.T. (1994) Consumption of Bergen-Cico, D.K. & Short, S.H. (1992) Dietary intakes, calcium in the U.S.: food sources and intake levels. energy expenditures, and anthropometric character- Journal of Nutrition 124, 1426S–1430S. istics of adolescent female cross-country runners. Fogelholm, G.M., Kukkonen-Harjula, T.K., Taipale, Journal of the American Dietetic Association 92, 611–612. S.A., Sievänen, H.T., Oja, P. & Vuori, I.M. (1995) Berning, J.R., Troup, J.P., VanHandel, P.J., Daniels, J. & Resting metabolic rate and energy intake in female Daniels, N. (1991) The nutritional habits of young gymnasts, figure-skaters and soccer players. adolescent swimmers. International Journal of Sports International Journal of Sports Medicine 16, 551–556. Medicine 1, 240–248. Food and Nutrition Board (1997) Dietary Reference Bruner, A.B., Joffee, A., Duggan, A.K., Casella, J.F. & Intakes for Calcium, Phosphorus, Magnesium, Vitamin Brandt, J. (1996) Randomised study of cognitive D, and Fluoride. National Academy Press, effects of iron supplementation in non-anaemic Washington DC. iron-deficient adolescent girls. Lancet 348, 992–996. Food and Nutrition Board, National Research Council Chen, J.D., Wang, J.F., Li, K.J. et al. (1989) Nutritional (1989) Recommended Dietary Allowance, 10th edn, p. problems and measures in elite and amateur 179. National Academy Press, Washington, DC. athletes. American Journal of Clinical Nutrition 49, Guthrie, A.H. (1984) Selection and quantification of 1084–1089. typical food portions by young adults. Journal of the Cohen, J.L., Potosnak, L., Frank, O. & Baker, H.A. American Dietetic Association 84, 1440–1444. (1985) Nutritional and hematologic assessment of Hathcock, J.N. (1997) Vitamin and Mineral Safety. elite ballet dancers. Physician and Sportsmedicine 13, Council for Responsible Nutrition, Washington DC. 43–54. Henson, L.C., Poole, D.C., Donahoe, C.P. & Heber, D. Council for Responsible Nutrition (1996) Vitamin and (1987) Effects of exercise training on resting energy Mineral Safety. Washington, DC. expenditure during caloric restriction. American Dahlström, M., Jansson, E., Nordevang, E. & Kaijser, L. Journal of Clinical Nutrition 46, 893–899. (1990) Discrepancy between estimated energy Heyward, V.H., Sandoval, W.M. & Colville, B.C. (1989) intake and requirement in female dancers. Clinical Anthropometric, body composition and nutritional Physiology 10, 11–25. profiles of bodybuilders during training. Journal of Denke, M.A. (1996) Lipids, estrogen status, and coro- Applied Sport Science Research 3, 22–29. nary heart disease risk in women. Medicine and Horton, T.J., Drougas, H.J., Sharp, T.A., Martinez, L.R., Science in Sports and Exercise 28, 13–14. Reed, G.W. & Hill, J.O. (1994) Energy balance in Deuster, P.A., Kyle, S.B., Moser, P.B., Vigersky, R.A., endurance-trained female cyclists and untrained Singh, A. & Schoomaker, E.B. (1986) Nutritional controls. Journal of Applied Physiology 76, 1937–1945. survey of highly trained women runners. American Huenemann, R.L. & Turner, D. (1942) Methods of Journal of Clinical Nutrition 44, 954–962. dietary investigation. Journal of the American Dietetic Dwyer, J.T. (1994) Dietary assessment. In M.E. Shils, Association 18, 562–568. J.A. Olson & M. Shike (eds) Modern Nutrition in International Center for Sports Nutrition and the Health and Disease, 8th edn, pp. 842–860. Lea & United States Olympic Committee (1990) Iron and Febiger, Philadelphia. Physical Performance. ICSN, Omaha. Dwyer, J.T., Krall, E.A. & Coleman, K.A. (1987) The International Nutritional Anemia Consultative problem of memory in nutritional epidemiology Group (1981) Iron Deficiency in Women. Nutrition research. Journal of the American Dietetic Association Foundation, Washington DC. 87, 1509–1512. Keith, R.E., O’Keeffe, K.A., Alt, L.A. & Young, K.L. Edwards, J.E., Lindeman, A.K., Mikesky, A.E. & Stager, (1989) Dietary status of trained female cyclists. J.M. (1993) Energy balance in highly trained female Journal of the American Dietetic Association 89, 1620– endurance runners. Medicine and Science in Sports and 1623. Exercise 25, 1398–1404. Kirchner, E.M., Lewis, R.D. & O’Connor, P.J. (1995) Emans, S.J., Grace, E., Hoffer, F.A., Gundberg, C., Bone mineral density and dietary intake of female Ravnikar, V. & Woods, E.R. (1990) Estrogen defi- college gymnasts. Medicine and Socience in Sports ciency in adolescents and young adults: impact Exercise 27, 543–549. on bone mineral content and effects of estrogen Kleiner, S.M., Bazzarre, T.L. & Litchford, M.D. (1990) replacement therapy. Obstetrics and Gynecology 76, Metabolic profiles, diet, and health practices of 585–592. championship male and female bodybuilders. Faber, M. & Spinnler, A.J. (1991) Mineral and vitamin Journal of the American Dietetic Association 90, 962–967. nutrition 131

LaBlanc, J., Diamond, P., Cote, J. & Labrie, A. (1984) density in women runners. American Journal of Hormonal factors in reduced postprandial heat pro- Clinical Nutrition 56, 705–711. duction of exercise-trained subjects. Journal of Applied Suarez, F.L., Savaiano, D., Arbisi, P. & Levitt, M.D. Physiology 56, 772–776. (1997) Tolerance to the daily ingestion of two cups of Leddy, J., Horvath, P., Rowland, J. & Pendergast, D. milk by individuals claiming lactose intolerance. (1996) Effect of a high or a low fat diet on cardiovas- American Journal of Clinical Nutrition 65, 1502–1506. cular risk factors in male and female runners. Tanaka, J.A., Tanaka, H. & Landis, W. (1995) An assess- Medicine and Science in Sports and Exercise 29, 17–25. ment of carbohydrate intake in collegiate distance Leibel, R.L., Rosenbaum, M. & Hirsch, J. (1995) runners. International Journal of Sports Nutrition 5, Changes in energy expenditure resulting from 206–214. altered body weight. New England Journal of Medicine Thompson, J.L., Manore, M.M., Skinner, J.S., Ravussin, 332, 621–628. E. & Spraul, M. (1995) Daily energy expenditure in Lukaski, H.C., Siders, W.A., Hoverson, B.S. & male endurance athletes with differing energy Gallagher, S.K. (1996) Iron, copper, magnesium and intakes. Medicine and Science in Sports and Exercise 27, zinc status as predictors of swimming performance. 347–354. International Journal of Sports Medicine 17, 535–540. Tilgner, S.A. & Schiller, M.R. (1989) Dietary intakes of Manore, M.M., Besenfelder, P.D., Carroll, S.S. & female college athletes: the need for nutrition educa- Hooker, S.P. (1989) Nutrient intakes and iron status tion. Journal of the American Dietetic Association 89, in female long-distance runners during training. 967–969. Journal of the American Dietetic Association 89, 257–259. van Erp-Baart, A.M.J., Saris, W.H.M., Binkhorst, R.A., Matkovic, V., Fontana, D., Tominac, C., Goel, P., Vos, J.A. & Elvers, J.W.H. (1989) Nationwide survey Chestnut III, C.H. (1990) Factors that influence peak on nutritional habits in elite athletes. Part I. Energy, bone mass formation: a study of calcium balance and carbohydrate, protein, and fat intake. International the inheritance of bone mass in adolescent females. Journal of Sports Medicine 10, S3–S10. American Journal of Clinical Nutrition 52, 878–888. Vallieres, F., Tremblay, A. & St-Jean, L. (1989) Study of Monsen, E.R., Hallberg, L., Layrisse, M. et al. (1978) the energy balance and the nutritional status of Estimation of available dietary iron. American Journal highly trained female swimmers. Nutrition Research of Clinical Nutrition 31, 134–141. 9, 699–708. Myerson, M., Gutin, B., Warren, M.P. et al. (1991) Weaver, C.M. & Plawecki, K.L. (1994) Dietary calcium: Resting metabolic rate and energy balance in amen- adequacy of a vegetarian diet. American Journal of orrheic and eumenorrheic runners. Medicine and Clinical Nutrition 59, 1238S–1241S. Science in Sports and Exercise 23, 15–22. Webster, B.I. & Barr, S.I. (1995) Calcium intakes of ado- Nieman, D.C., Butler, J.V., Pollett, L.M., Dietrich, S.J. & lescent female gymnasts and speed skaters: lack Lutz, R.D. (1989) Nutrient intake of marathon of association with dieting behavior. International runners. Journal of the American Dietetic Association 89, Journal of Sport Nutrition 5, 2–12. 1273–1278. Wilmore, J.H., Wambsgans, K.C., Brenner, M. et al. Nowak, R.K., Knudsen, K.S. & Schultz, L.O. (1988) (1992) Is there energy conservation in amenorrheic Body composition and nutrient intakes of college compared with eumenorrheic distance runners? men and women basketball players. Journal of the Journal of Applied Physiology 72, 15–22. American Dietetic Association 88, 575–578. World Health Organization Study Group (1990) Diet, Pate, R.R., Sargent, R.G., Baldwin, C. & Burgess, M.L. Nutrition, and the Prevention of Chronic Diseases. WHO (1990) Dietary intake of women runners. Inter- Technical Report Series 797. WHO, Geneva. national Journal of Sports Medicine 11, 461–466. Worme, J.D., Doubt, T.J., Singh, A., Ryan, C.J., Moses, Reggiani, E., Arras, G.B., Trabacca, S., Senarega, D. & F.M. & Deuster, P.A. (1990) Dietary patterns, gas- Chiodini, G. (1989) Nutrition status and body com- trointestinal complaints, and nutrition knowledge of position of adolescent female gymnasts. Journal of recreational triathletes. American Journal of Clinical Sports Medicine and Physical Fitness 29, 285–288. Nutrition 51, 690–697. Schulz, L.O., Alger, S., Harper, I., Wilmore, J.H. & Young, L.R. & Nestle, M. (1995) Portion sizes in dietary Ravussin, E. (1992) Energy expenditure of elite assessment: issues and policy implications. Nutrition female runners measured by respiratory chamber Reviews 53, 149–158. and doubly labeled water. Journal of Applied Yuhas, J.A., Bolland, J.E. & Bolland, T.W. (1989) The Physiology 72, 23–28. impact of training, food type, gender, and container Snead, D.B., Stubbs, C.C., Weltman, J.Y. et al. (1992) size on the estimation of food portion sizes. Journal of Dietary patterns, eating behaviors, and bone mineral the American Dietetic Association 89, 1473–1477.

PART 4

THE MASTERS ATHLETE

Chapter 9

Cardiorespiratory Function in Masters Athletes

CHRISTINE L. WELLS

Introduction have had for challenging and intense athletic competition. Sports performance varies with age. Inevitably, In this chapter, a masters woman athlete is at some point following young adulthood, it defined as a woman over 30 years of age who begins a slow decline. To accommodate all com- enters competitive events for masters athletes at petitors, many sports currently conduct both a high level of competence. The chapter describes ‘open’ competition, in which competitors of any cardiorespiratory determinants of performance age may compete, and ‘masters’ competition, in these women relative to the physiological events designed for athletes who exceed the age processes of ageing. requisite for success in open competition. The minimum age for masters competition varies Why study the female from sport to sport, but usually reflects the age masters athlete? range at which world records are typically estab- lished. In swimming, for example, world records The highly competent masters woman athlete are typically held by very youthful competitors represents an extremely small proportion of her and the minimum age for masters competition is age cohort. She represents ‘the extreme end of a 19 years. In track and field events, world record distribution that ranges from physical disability holders are frequently in their twenties, and the and dysfunction at one end to elite athletic minimum age for masters competition is 40 for accomplishments at the other’ (Spirduso, 1995). men and 35 for women. At the very least, these athletes possess physical People engage in masters competition for and physiological capabilities of value to the sci- numerous reasons. For some, it is a purely re- entific understanding of ageing. Their accom- creational activity in which fun and social con- plishments and abilities ‘raise the ceiling’ for tacts are the primary goal. For others, it is to everyone at a time when there is a transforma- maintain levels of fitness attained in youth or to tion in our thinking about the physical limita- improve their fitness level in order to benefit tions of older adults. And this is particularly true their health. For an élite few, masters events offer relative to athletic performance by masters the same intensity of competition as open events, women. Whereas outstanding physical achieve- and the primary goal of these athletes is to ment was previously unusual in women (or at achieve athletic excellence (Fig. 9.1). Before the least not recognized due to lack of opportunity 1970s, few women trained vigorously. Due to the and social acceptance), there has been little social relatively recent ‘acceptance’ of highly com- or intellectual conceptualization of the physical petitive sports for women, masters competition competence and ability of women as a whole, may offer the first opportunity many women and of middle-aged or elderly women in particu- 135 136 the masters athlete

Fig. 9.1 Age-group winners at a duathlon (run–bike) and triathlon (swim–bike–run) event with Olympic distances (1500-m swim, 40-km bike ride and 10-km run).

· lar. The outstanding athletic accomplishments of 1 maximum oxygen uptake (VO ); · 2max masters women athletes serve to remind us all 2 maximum cardiac output (Qmax); that physical ability can be maintained, at 3 peripheral blood flow and arteriovenous remarkable levels, for a very long period of one’s oxygen (a-vO2) difference; lifespan and that physical disability is not 4 skeletal muscle oxidative capacity; inevitable. Thus, the study of masters women 5 oxygen-carrying capacity and blood volume; athletes shatters ‘the barriers of expectations’ we 6 pulmonary function; currently have for the aged (Spirduso, 1995). 7 lactate threshold; 8 heat tolerance. Cardiorespiratory determinants There are very few published studies on masters of performance women athletes. The results published appear to vary considerably with the performance capacity Numerous variables have been identified as of the subjects studied (very few élite perform- important determinants of physical perfor- ers), as well as with the intensity and duration (in mance. Essentially, athletic performance is years) of training in these subjects. Because of limited by the ability of metabolic processes to this, much of my commentary is based on my provide a continuous supply of adenosine general interpretation of the literature obtained triphosphate (ATP) to the contractile mecha- from both moderately active and highly trained nisms of active muscle. This requires ‘fuelling’ by men and women. I will specifically highlight, metabolic processes and removal of metabolic where available, research published on women, end-products to prevent or delay fatigue. These especially masters women athletes. It is my hope processes function in a highly integrated manner that exercise scientists will soon act to fill in the that is impossible to describe fully here. A central gaps. feature is an efficient oxygen transport system, characterized by a well-developed heart and vas- Maximum oxygen uptake cular system coupled with a healthy lung and · adequate blood volume. The performance of VO2max is widely accepted as the best single masters women athletes in relation to the ageing measure of cardiorespiratory fitness and is process is discussed in terms of the following often referred to as maximal aerobic power. variables: This is due to the strong positive relationships cardiorespiratory function 137

· · between VO2max and variables such as total 30. Élite women athletes often have VO2max · –1 –1 work output and endurance capacity. VO2max values exceeding 60 ml·kg ·min . The highest represents the upper limit of ‘aerobic’ perfor- value reported for a woman was 77ml·kg–1·min–1 mance. Humans can run at speeds that require in a cross-country skier. Table 9.1 presents com- · · 79–98% VO during 10-km races and 68–88% parative VO values for adult women reported · 2max 2max VO2max during much longer races (Farrell et al., by age and physical activity. 1979). The women described in Table 9.1 are very · In untrained women, peak values for VO2max diverse in physical activity. The sedentary typically occur before age 20, but in trained ath- women had no regular physical activity. The · letes VO2max continues to increase until age 25 or active women had much higher physical activity

. o -1 -1 Table 9.1 Comparative V 2max values (ml·kg ·min ) for adult women reported by age and physical activity. (Adapted from Wells et al., 1992)

Age (years)

Activity level 35 40 45 50 55 60 65 70

Sedentary women Profant et al. (1972) 28.3 25.7 24.5 18.7 Drinkwater et al. (1975) 31.7 29.5 23.7 Upton et al. (1984) 31.4 Fleg & Lakatta (1988) 28.3 25.7 24.5 Stevenson et al. (1994) 26.5

Active women Profant et al. (1972) 31.8 29.0 25.8 27.1 Drinkwater et al. (1975) 41.4 39.2 34.5 Plowman et al. (1979) 33.9 30.4 27.9

Masters athletes Wilmore & Brown 58.8 (1974) (aged > 31 years) Vaccaro et al. (1981a) 37.6 (swimmers) Vaccaro et al. (1981b) 43.4 (distance runners) Upton et al. (1984) 48.5 (10-km runners) Upton et al. (1984) 55.5 (marathon runners) Vaccaro et al. (1984) 30.3 27.5 26.0 21.9 (non-highly trained swimmers) Vaccaro et al. (1984) 42.1 38.3 35.9 32.1 (highly trained swimmers) Wells et al. (1992) 54.1 47.4 43.6 41.2 39.5 (distance runners) Stevenson et al. (1994) 48.6 (distance runners) 138 the masters athlete

energy expenditure, but activity was somewhat years and their average time for a marathon (42 irregular in nature and did not follow a specific km) was 3hours 47min. The 49 runners in the pattern. These women did not ‘train’ for athletic study by Wells et al. (1992) ranged in age from 35 competition; they were merely physically active to 70 years and had been training for 8.4 years. in a variety of recreational pursuits, such as Many supplemented their training by swimming hiking, backpacking, tennis and golf. The (n=8) or cycling (n=18). They currently were masters athletes, on the other hand, possessed running about 42km·week–1 and competed at a not only highly active lifestyles but regularly high level in regional and local events. The 13 ‘trained’ for competition and competed in subjects in the study by Stevenson et al. (1994) masters events. Descriptions of the physical had an average age of 54.8 years, had been activity of the masters women athletes are training for 18±2 years (range 10–40 years!) and described below. were currently running 50km·week–1 including The subjects in Wilmore and Brown’s (1974) one or two speed/interval sessions, all at study were eight very lean women over the age moderate altitude (Colorado, USA). They were of 31 years who were national and international- consistent age-group winners in national-level calibre distance runners training at high weekly competitions. mileage (not specified by the authors). The two Performance begins to decline soon after the 70-year-old swimmers in the study by Vaccaro most frequent age at which open competition et al. (1981a) were members of the 1980 All- records are set. Athletic performance is a func- American Masters Swimming Team. One, age 71, tion of many factors, and may never be totally began training at age 65; the other, age 70, began explained because there are simply too many training at age 67. Both held national age-group confounding variables that remain uncontrolled, · records at the time they were tested and were perhaps even unidentified. However, VO2max is a much leaner than typical women their age. The major determinant of performance in sports with 10 national-calibre distance runners in the study a substantial aerobic component, e.g. middle- by Vaccaro et al. (1981b) had an average age and long-distance running, swimming, cycling, of 43.8 years and ran between 58 and 106 skating, cross-country skiing, rowing, etc. km·week–1. The 84 swimmers studied by Vaccaro The literature clearly indicates that, after · et al. (1984) were divided into ‘highly trained’ reaching a peak value, VO2max declines with and ‘non-highly trained’ groups. The highly advancing age, although the rate of decline and trained swimmers swam a minimum of three when that decline commences remains con- times per week for at least 1hour per session, troversial. In general, cross-sectional studies · covering a minimum of 1638m (range 1638–2275 suggest that VO2max declines at the rate of about m). The non-highly trained swimmers swam a 9% per decade beginning at about age 30 in minimum of twice per week for at least untrained men and women (Heath et al., 1981; 30min per session, covering a minimum of 455m Pollock et al., 1992). The rate of decline in data · (range 455–637m). The VO2max of the highly derived from longitudinal studies in men seems trained swimmers exceeded the non-highly to be greater than that determined from cross- trained swimmers by 30%. The nine middle-aged sectional studies. This is probably because 10-km runners in the study by Upton et al. (1984) subjects who volunteer for cross-sectional inves- had an average age of 33.1 years and ran an tigations tend to be more physically fit and average of 40km·week–1. They had trained for disease-free than those who do not volunteer, about 3.5 years, and their best times for 10km and thus the subject sample is biased. However, averaged 52min 25s. The 42 middle-aged in the most comprehensive review of this topic to marathon runners in the study by Upton et al. date, Buskirk and Hodgson (1987) proclaim that (1984) had been running for 5.6 years and aver- longitudinal studies present a ‘picture of incon- aged 74.2km·week–1. Their mean age was 38.2 sistency’, with regression slopes of the decline in cardiorespiratory function 139

· –1 –1 · VO2max with age ranging from 1.04ml·kg ·min that VO2max is limited by central factors that per year to 0.04ml·kg–1·min–1 per year in men. determine oxygen delivery to active cells. These Two longitudinal studies have been completed in factors include cardiac output (a product of heart women. Astrand et al. (1973) reported a decline of rate and stroke volume), the haemoglobin con- 0.44ml·kg–1·min–1 per year in Swedish physical centration of the blood (a major determinant of education teachers aged 22–43 years and oxygen-carrying capacity) and the ability of the Plowman et al. (1979) reported a decline of 0.32 lung to oxygenate the blood returned from ml·kg–1·min–1 per year in nine ‘active’ women peripheral tissues (active muscles and other aged 30–49 years. The only cross-sectional study organs). A number of changes have been docu- that has examined this question in masters mented in these variables with increasing age women athletes reported a regression slope of beyond 30 years. 0.47ml·kg–1·min–1 per year in women aged 35–70 years (Wells et al., 1992). There have been no · Maximum cardiac output longitudinal studies of the decline in VO 2max · in masters women athletes. It is likely that the reduction in Qmax occurs Of major interest is whether or not the decline largely because of a decline in maximum heart · in VO2max occurs irrespective of the amount of rate with age. It appears that highly trained ath- training that an individual undertakes. Some letes experience a similar decline in maximal data (Kasch & Wallace, 1976; Heath et al., 1981; heart rate as sedentary people (maximum heart Pollock et al., 1987, 1992) suggest that if physical rate=220–age), although this has not been training and body composition are kept constant, shown in all studies. The decrease in maximum deterioration due to ageing is substantially heart rate is mostly mediated by a decrement in delayed or lessened for a period of about 10–20 sympathetic nervous system reactivity (Pollock years. However, the data are not consistent on et al., 1992). With ageing, the heart and vas- this issue, and thus the question of whether a culature become less sensitive to b-adrenergic high level of physical training may delay or stimulation and thus the heart cannot achieve · prevent some of the age-related decline in VO2max the maximum heart rate values achieved dur- remains unclear. ing youth (Spirduso, 1995). Maximum stroke Undoubtedly, the suggestion that the physio- volume decreases with age at a lesser rate than logical ageing process affects all systems, organs does maximum heart rate (Saltin, 1986). The and functions equally is an oversimplification at Frank–Starling mechanism, in which initial best and misleading at worst. It is far more likely stretching of a muscle fibre yields a more forceful that different rates of decline prevail (whether contraction, apparently compensates for the best described as linear or curvilinear) due to age-related decline in maximum heart rate by variations in genetic endowment, physical train- causing the ejection of a larger volume of blood ing, body weight gain or loss, ‘wear and tear’ during systole following increased ventricular stress, and disease. Thus, a whole ‘family of filling during the heart’s relaxation phase (end- curves’ (Buskirk & Hodgson, 1987) may be nec- diastolic volume) during diastole (Spirduso, · essary to describe variance in VO2max and other 1995). This means that healthy, fit older athletes cardiorespiratory variables relative to age, physi- can maintain a high cardiac output even in the cal activity level, gender and ethnicity. What is face of a lesser increase in heart rate. Aerobic quite clear is that masters athletes, both men and training is well known to increase end-diastolic women in their sixties and seventies and irre- heart volume and stroke volume even in older · · spective of their rate of decline, have VO2max subjects. Differences in VO2max between seden- values equivalent to healthy, untrained men and tary middle-aged men and trained middle-aged women 20 or more years younger. men were due almost entirely to a larger stroke Joyner (1993) provides a compelling argument volume in the trained subjects (Saltin, 1986). 140 the masters athlete

There is no reason to believe this would be differ- but, eventually, training intensity declines with ent in women. age. This would indicate that the lesser training intensity of the masters athlete would eventually result in reduced oxidative capacity in skeletal Peripheral blood flow and arteriovenous muscle. These variables need further study, espe- oxygen difference cially in women. The ageing cardiovascular system is less able to redirect blood flow from inactive tissues Oxygen-carrying capacity and blood volume (muscles, viscera, skin) to active tissues. This appears to occur largely because of a decreased Oxygen-carrying capacity of arterial blood is number of b-receptors in smooth muscle of largely determined by haemoglobin concentra- arterial walls and results in an imbalance tion. Daily exercise stimulates a more rapid rate between a- and b-adrenoreceptor function so of red blood cell development, and the number that the peripheral vasculature leans toward of red blood cells may be higher in older athletes vasoconstriction. Coupled with the increased than in their age-matched sedentary counter- stiffness of the vascular tree with age (Saltin, parts. However, in the absence of iron deficiency, 1986), this increases peripheral resistance, the effects of increasing age on oxygen-carrying decreases limb blood flow during exercise and capacity are probably insignificant. increases blood pressure. During strenuous exer- Endurance training is well known to enhance cise, a decreased a-vO2 difference results. Saltin’s plasma volume. The net effect is that well- (1986) studies of young and middle-aged orien- conditioned athletes usually have high blood teers led him to conclude that the observed 30% volume. Nevertheless, pulmonary diffusing · difference in VO was almost equally related capacity for oxygen gradually declines in the · 2max to lower Qmax and systemic a-vO2 difference in elderly and there is a decrease in efficiency of the older athletes. alveolar–arterial gas exchange (Spirduso, 1995). Oxygen pulse is a function of stroke volume This would result in decreased arterial oxygen and a-vO2 difference. The reduction in oxygen saturation in older masters athletes. pulse (a measure of cardiorespiratory efficiency) during maximal work in ageing athletes is due Pulmonary function to the decline in maximal stroke volume and a reduction in systemic oxygen extraction (a-vO2 With increasing age, many minor changes occur difference), with the latter contributing the most in the lung that additively contribute to a reduc- (Saltin, 1986). tion in the volume of air that can be breathed per · minute (Ve). These changes include degenera- tion of the elastin and collagen fibres that Skeletal muscle oxidative capacity support alveoli, leading to an increase in the size

Factors associated with a-vO2 difference include of alveoli, loss of elastic recoil and, eventually, skeletal muscle blood flow and skeletal muscle breakdown of alveolar walls (Jones, 1986). There oxidative capacity. Cartee (1994) summarized is a gradual loss of small capillaries in the lung research on old animals and humans and con- and an increase in resistance to flow through cluded that the evidence supported attenuated these vessels with age. These changes alter the blood flow during contractile activity with distribution of blood through the lung and thus increasing age. He also concluded that the level the ventilation–perfusion ratios. This most likely of physical training largely determined skeletal leads to higher pressures in the right ventricle muscle oxidative capacity as revealed by enzy- and a higher systolic mean pulmonary artery matic profiles of muscle biopsies. A few masters pressure at rest and exercise in older compared athletes train as intensively as younger athletes with younger subjects. cardiorespiratory function 141

There are also age-associated changes in the removal may also decline with age due to reduc- chest cage, including changes in the joints of the tions in intramuscular blood flow. The slower ribs where they attach to the vertebral column, clearing of lactic acid may explain age-related changes in the cartilage joining the ribs to the decreases in endurance. sternum and a gradual loss of strength and meta- The net effect of these age-related changes is bolic capacity of the muscles of respiration that the onset of blood lactic acid usually occurs (Jones, 1986). All of this contributes to a stiffening at a lower power output in older adults because · of the chest wall, an increase in the residual their VO2max has declined and thus older persons volume of the lung (air that cannot be expired) perform a given exercise task at a higher percent- · and a shift to the left in the pressure–volume age of VO2max. Allen et al. (1985) have reported characteristics of the lung. The main effect is an that the lactate threshold may occur at a higher · increase in the mechanical work of breathing that percentage of VO2max in older endurance athletes. is largely expressed in an increased conscious- Long-term training of the anaerobic system ness of respiratory effort or sense of effort in may serve to maintain this metabolic system breathing during exercise. It is not known what with advancing age. Reaburn and Mackinnon the effect of an increased cost of breathing has on (1990) found no age-related deterioration in exercise economy—the relationship between a lactic acid accumulation in male masters athletes given exercise intensity and oxygen consump- after a sprint swimming race. The 46–56-year- tion (Joyner, 1993). old swimmers, competitors in the 1988 World Training increases respiratory muscle strength Masters Swimming Championships, did not at any age and thus high levels of physical activ- differ from 25–35-year-old swimmers in produc- ity may maintain the efficiency of the lungs at ing or removing lactic acid. This needs to be con- a high level for many years. Nevertheless, the firmed in women masters athletes who are well older athlete will experience a greater degree of trained at sprint running and swimming. breathlessness or sense of respiratory effort than a similarly well-trained younger athlete. The Heat tolerance increased breathlessness during exercise is real. · Because VO is lower, older athletes are exer- Heat tolerance is largely a function of cardiores- 2max · · cising at a higher fractional utilization of VO2max piratory fitness. If VO2max declines, then tolerance than younger athletes at a given power output to exercise performed in the heat also declines. and lactate accumulation may be higher. The Thus, heat tolerance or intolerance is largely · resulting elevation in blood acidity results in a associated with the decline in VO2max with age. strong respiratory drive that, with accumulating Many studies have shown a decrement in heat years, may not be met adequately. The sensation tolerance with ageing and thus old age is often of breathlessness results. associated with heat intolerance. Nevertheless, it remains unclear if this simply reflects a decline in cardiorespiratory fitness or is a real impairment Lactate threshold of thermoregulatory function. The point at which the rate of lactic acid produc- Women are known to sweat less than men and tion significantly exceeds lactic acid removal is several studies have shown that older women called the blood lactate threshold. With ageing, sweat less than younger women (Shoenfeld et al., lactic acid production typically declines due to a 1978; Drinkwater & Horvath, 1979). Because loss of muscle mass, specifically a disproportion- sweating is the primary effector mechanism for ate decrease in the size and number of glycolytic dissipating heat during thermal stress, these fast-twitch muscle fibres. This is usually accom- results may be important in relation to age dif- panied by a gradual loss of strength (0.6–0.9% ferences in endurance performance in warm per year; Green, 1986). The rate of lactic acid climates. 142 the masters athlete

Decline in physical training with age terone on the cardiorespiratory system are not particularly well understood. Strenuous training Nearly every investigator of age-related decre- in young women often results in menstrual dys- ments in performance or physiological function function characterized by a shortened luteal comments on the decline in habitual physical phase, anovulation or oligomenorrhoea, all con- activity that inevitably seems to accompany ditions distinguished by lowered levels of cyclic ageing. It is clear that physiological functions oestrogen and/or progesterone. In recent years, · · · such as VO2max, Qmax, VEmax and maximum heart research has focused on understanding these rate decline eventually irrespective of the issues and on the often consequent lowering of amount of training that a masters athlete does, bone mineral density. Concurrent investigations although it is not yet clear whether this should also be directed to the study of cardiores- inescapable decline is delayed or slowed by piratory function in relation to changing hor- maintaining a high level of training. It appears monal environments in highly trained women. that masters athletes eventually reduce their Until very recently, most masters women ath- training intensity, even when they attempt not to letes began serious training for competition rela- do so. When queried, many comment that they tively late in life. A recurring scenario in women currently train at a much slower pace/intensity that I have worked with is that they began exer- than they did 10 or 20 years ago or that they have cising on a regular basis when a husband was altered their training so that they do more long, diagnosed with heart disease. They began a slow, distance training and less interval or walking programme to encourage their hus- ‘power’ training than in their younger years. bands and later took up jogging and then Many incorporate ‘cross-training’ into their daily running or swimming. Upon discovering com- routine in order to maintain their desired level of petition, their ‘masters’ career began. These cardiorespiratory fitness while at the same time women are studied in the exercise physiology easing stress and strain on the musculoskeletal laboratory after a few years of competitive train- structures used in their primary sport. Many ing preceded by many years of a basically seden- complain of various aches and pains, which they tary lifestyle. attribute to osteoarthritis from either earlier Today, many girls have competitive sport sports injuries or simply growing older. experiences early in life. Some continue their It is difficult to distinguish between the effects competitive training throughout their lives, often of ageing and deconditioning when studying switching to a different sport. Few of these lifelong changes in physiological function and women have yet been studied in the exercise performance. Although the factors responsible physiology laboratory. What is most needed is a for age-related decline are interrelated and very longitudinal study of these well-trained women complex, decline is inevitable. Nevertheless, it is as they experience menstruation, childbirth, the clear that prolonged intense training throughout menopause, hormone replacement therapy and life allows masters athletes to surpass the perfor- growing old. Such a study has never been mance capabilities of a majority of the younger attempted and would be difficult to complete for population. a wide variety of reasons. Nevertheless, lifetime cardiorespiratory function in women should be Recommendations for future research studied as a function of sports training and changing hormonal environment. As mentioned above, nearly all research avail- able on age-related changes in cardiorespiratory function has been conducted on men. What References makes women biologically unique from men, of Allen, W.K., Seals, D.R., Hurley, B.F., Ehsani, A.A. course, are the endocrine hormones of reproduc- & Hagberg, J.M. (1985) Lactate threshold and tion. The effects of cyclic oestrogen and proges- distance-running performance in young and older cardiorespiratory function 143

endurance athletes. Journal of Applied Physiology 58, R.J. Shephard & P.-O. Åstrand (eds) Endurance in 1281–1284. Sport, pp. 390–406. Blackwell Scientific Publications, Astrand, I., Åstrand, P.-O., Hallback, I. & Kilbom, A. Oxford. (1973) Reduction in maximal oxygen intake with age. Profant, G.R., Early, R.G., Nilson, K.L., Fusumi, F., Journal of Applied Physiology 35, 649–654. Hofer, V. & Bruce, R.A. (1972) Responses to maximal Buskirk, E.R. & Hodgson, J.L. (1987) Age and aerobic exercise in healthy middle-aged women. Journal of power: the rate of change in men and women. Applied Physiology 33, 595–599. Federation Proceedings 46, 1824–1829. Reaburn, P.R.J. & Mackinnon, L.T. (1990) Blood lactate Cartee, G.D. (1994) Aging skeletal muscle: response to responses in older swimmers during active and exercise. Exercise and Sport Sciences Reviews 22, passive recovery following maximal sprint swim- 91–120. ming. European Journal of Applied Physiology 61, Drinkwater, B.L. & Horvath, S.M. (1979) Heat tolerance 246–250. and aging. Medicine and Science in Sports 11, 49–55. Saltin, B. (1986) The aging endurance athlete. In Drinkwater, B.L., Horvath, S.M. & Wells, C.L. (1975) J.R. Sutton & R.M. Brock (eds) Sports Medicine for Aerobic power of females, ages 10–68. Journal of the Mature Athlete, pp. 59–80. Benchmark Press, Gerontology 30, 385–394. Indianapolis. Farrell, P.A., Wilmore, J.H., Coyle, E.F., Billing, J.E. & Shoenfeld, Y., Udassin, R., Shapiro, Y., Ohri, A. & Sohar, Costill, D.L. (1979) Plasma lactate accumulation and E. (1978) Age and sex difference in response to short distance running performance. Medicine and Science exposure to extreme dry heat. Journal of Applied in Sports 11, 338–344. Physiology 44, 1–4. Fleg, J.L. & Lakatta, E.G. (1988) Role of muscle loss in Spirduso, W.W. (1995) Physical Dimensions of Aging. · the age-associated reduction in VO2max. Journal of Human Kinetics Publishers, Champaign, Illinois. Applied Physiology 65, 1147–1151. Stevenson, E.T., Davy, K.P. & Seals, D.R. (1994) Green, H.J. (1986) Characteristics of aging human Maximal aerobic capacity and total blood volume in skeletal muscle. In J.R. Sutton & R.M. Brock (eds) highly trained middle-aged and older female Sports Medicine for the Mature Athlete, pp. 17–26. endurance athletes. Journal of Applied Physiology 77, Benchmark Press, Indianapolis. 1691–1696. Heath, G.W., Hagberg, J.M., Ehsani, A.A. & Holloszy, Upton, S.J., Hagan, R.D., Lease, B., Rosentswieg, J., J.O. (1981) A physiological comparison of young and Gettman, L.R. & Duncan, J.J. (1984) Comparative older endurance athletes. Journal of Applied physiological profiles among young and middle- Physiology 51, 634–640. aged female distance runners. Medicine and Science in Jones, N.L. (1986) The lung of the masters athlete. Sports and Exercise 16, 67–71. In J.R. Sutton & R.M. Brock (eds) Sports Medicine for Vaccaro, P., Dummer, G.M. & Clarke, D.H. (1981a) the Mature Athlete, pp. 319–328. Benchmark Press, Physiological characteristics of female masters Indianapolis. swimmers. Physician and Sportsmedicine 9(12), 75–78. Joyner, M.J. (1993) Physiological limiting factors and Vaccaro, P., Morris, A.F. & Clarke, D.H. (1981b) distance running: influence of gender and age on Physiological characteristics of masters female dis- record performances. Exercise and Sport Sciences tance runners. Physician and Sportsmedicine 9(7), Reviews 21, 103–133. 105–108. Kasch, F. & Wallace, J. (1976) Physiological variables Vaccaro, P., Ostrove, S.M., Vendervelden, L., Goldfarb, during 10 years of endurance exercise. Medicine and A.H. & Clarke, D.H. (1984) Body composition and Science in Sports 8, 5–8. physiological responses of masters female swim- Plowman, S.A., Drinkwater, B.L. & Horvath, S.M. mers 20–79 years of age. Research Quarterly for (1979) Age and aerobic power in women: a longitudi- Exercise and Sport 55, 278–284. nal study. Journal of Gerontology 34, 512–520. Wells, C.L., Boorman, M.A. & Riggs, D.M. (1992) Effect Pollock, M.L., Foster, C., Knapp, D., Rod, J.L. & of age and menopausal status on cardiorespiratory Schmidt, D.H. (1987) Effect of age and training on fitness in masters women runners. Medicine and aerobic capacity and body composition of master Science in Sports and Exercise 24, 1147–1154. athletes. Journal of Applied Physiology 62, 725–731. Wilmore, J.H. & Brown, C.H. (1974) Physiological pro- Pollock, M.L., Lowenthal, D.T., Graves, J.E. & Carroll, files of women distance runners. Medicine and Science J.F. (1992) The elderly and endurance training. In in Sports 6, 178–181. Chapter 10

Muscle Function in Masters Athletes

M. ELAINE CRESS

Introduction as a member of a national or international sports team (Drinkwater, 1984). The qualifying age for Since the 1970s, individual sport has been more masters status varies from sport to sport. For accessible to the general population and as a the purposes of this chapter, a masters athlete is result the number of women regularly participat- a woman competitor aged 35 years or older. ing in sport has increased dramatically. This phe- ‘Active’ refers to a woman who engages in a nomenon has been called ‘mass sport’ (Okonek, structured exercise regimen of at least 30min 1996). In 1972 the USA enacted legislation to three times per week. ‘Sedentary’ refers to a require equal opportunities for participation in woman who does not maintain a structured exer- sports for males and females in federally funded cise programme at the level of an active woman. public schools and colleges (Women’s Sports Unless otherwise stated, the data in this chapter Foundation, 1997). Not only in the USA but inter- were gathered specifically on women and nationally, competitive skilled women athletes address age effects related to women. In particu- are participating in sport in greater numbers lar, this chapter focuses on women masters ath- (Dyer, 1989). Legal protection against discrimi- letes and the muscle characteristics altered by nation in sport was provided for women in age, training, disuse and type of sport. Due to the Canada in 1982 (Hoffman, 1989) and in Australia lack of research data on women masters athletes, in 1984 (Dyer, 1989). As these women bring a data on sedentary and active women are used for greater level of skill and understanding of com- comparison. The reader is referred to publica- petition to masters sporting events, performance tions that compare and contrast muscle charac- records are set at a rapid rate, with large increases teristics of men and women (Wells & Plowman, in performance with each new record (Stefani, 1983; Wilmore, 1984; Buskirk & Hodgson, 1987; 1989). During the period 1990–2000, the first Wells, 1991). women who played competitive sports in school are qualifying for masters athlete status. The Body composition material in this chapter addresses muscle mor- phology, function and performance in relation to Body composition comprises body fat and fat- age specifically for women masters athletes. free mass, which includes skin, bone, internal An athlete is defined as a woman who organs and muscle mass (Going et al., 1995). The trains regularly and participates in sport in balance of body fat to lean muscle mass shifts either a competitive or non-competitive event with age as the loss of lean mass is exacerbated (Drinkwater, 1984). Unless otherwise desig- by increased fat deposition. A cross-sectional nated, in this chapter ‘athlete’ refers specifically comparison of sedentary women indicates that to women. An élite athlete is a woman who ranks percentage body fat is higher in 50–60-year-old 144 muscle function 145

100 90 80 70 60 50 40 Fig. 10.1 Body composition: lean mass () and body fat ( ). A comparison of 30 Body composition (%) body composition in several categories, 20 including active young, sedentary sixth- decade and masters athletes from 10 several sports (endurance, short 0 distance and non-weight-bearing). Active Sedentary Master Master Master (Adapted from Kavanagh & Shephard, young 50–60 endurance short non-weight- 1990.) year olds distance bearing

women (42.1%) compared with women in their tion and ageing, masters athletes appear to have twenties (27.1%) and seventies (36.7%). The two principal advantages over the general popu- absolute quantity of body fat of masters athletes lation of older adults: (i) a lower rate of decline in is similar to that of young active women and lean muscle mass, and (ii) no significant increase lower than that of sedentary 50–60-year-old in body fat with age. women (Fig. 10.1). Cross-sectional data indicate that the percentage of body fat for masters ath- Basic characteristics of muscle letes is relatively constant at about28% between structure, function and capillarization the ages of 35 and 75 (Kavanagh & Shephard, 1990) (Fig. 10.1). In masters athletes the percent- The basic characteristics of muscle structure and age body fat varies by sport (Fig. 10.1). Athletes function are described in detail in The Olympic participating in weight-bearing endurance Book of Sports Medicine (Komi, 1988). The most sports (e.g. long-distance track) have a lower important aspects of muscle structure, function percentage body fat (23.5%) than those partici- and metabolism are provided here to facilitate pating in short-distance track (28.8%), racket the understanding of how ageing may affect sports (29.5%) or non-weight-bearing sports muscle in athletes and non-athletes. Skeletal such as swimming or canoeing (26.9–28.6%) muscle is composed of individual muscle cells (Kavanagh & Shephard, 1990). (fibres) arranged in bundles. Connective tissue, For the same age span, masters athletes have made up largely of collagen, surrounds each a lower rate of decline (7.5%) in lean muscle mass muscle and converges at the ends to form the than the general population (25–30%) (Grimby & tendon of origin and of insertion. Light Saltin, 1983; Kavanagh & Shephard, 1990). Due microscopy is used to illuminate the striated to the small decline in muscle mass, masters (striped) appearance of muscle, which is due to athletes have a slightly higher proportion of the actin and myosin filaments, the primary con- body fat compared with young athletes (Proctor tractile elements of muscle. Electron microscopy & Joyner, 1997). Thus masters athletes have a is used to illuminate the ultrastructure of muscle: slower increase in body fat and preserve lean the dark, anisotropic (A) bands are due to the mass to a greater extent than the general popula- overlap of the thick (myosin) and thin (actin) tion. In summary, with respect to body composi- myofilaments; the isotropic (I) bands are less 146 the masters athlete

dense and therefore appear light. The I-band is glycolytic muscle fibres contribute to strength divided by a Z-band, which forms the founda- and speed; since these fibres diminish with age, tion for the molecular mechanism of muscle speed and strength also decline. Women over the shortening. The Z-band shows some qualitative age of 60 have an accelerated decline in muscle changes with age. However, the impact of these mass, due in part to loss of fibre number (Sato et changes on muscle function is not well under- al., 1984; Flynn et al., 1989). Loss in fibre number stood (Orlander et al., 1978; Wang et al., 1993). is attributed to the denervation of fast muscle Muscle fibre types are categorized according fibres and subsequent reinnervation by axonal to their physiological, ultrastructural and meta- nerve sprouting of slow motor neurones bolic characteristics (Komi, 1988). Type I (slow- (Faulkner et al., 1995). In addition to the loss of oxidative) muscle fibres have a slow contractile fibre number, comparisons of muscle groups in velocity, low actomyosin adenosine triphos- the vastus lateralis indicate a similar selective phatase (ATPase) activity and a high mitochon- diminution in area with ageing (Lexell, 1995). drial density that parallels the oxidative enzymes Slow-twitch fibre cross-sectional area remains of the Krebs cycle and the electron transport constant (3500–4300mm2), whereas absolute fast- chain. Type IIa (fast-oxidative) muscle fibres glycolytic fibre area is reduced (from 3900 to have a relatively fast contractile velocity, inter- 1500mm2). Figure 10.2 illustrates that a larger mediate ATPase activity and mitochondrial proportion of high-oxidative fibres (slow-twitch density and metabolic characteristics similar to and fast-oxidative) occupy the muscle cross- those of type I fibres. Type IIb (fast-glycolytic) sectional area of women in their sixties and muscle fibres have a fast contractile velocity, high seventies (Saltin et al., 1977; Essen-Gustavsson & ATPase activity, low mitochondrial density and Borges, 1986; Cress et al., 1991). Loss of myofibril- oxidative metabolic characteristics, and high gly- lar protein has been identified as one mechanism colytic metabolic capacity. In young individuals, for muscle atrophy in sedentary older women type I fibres are about 20% smaller than type II (Cress et al., 1991, 1996). The shift towards slow- fibres and have 15–20% greater blood supply oxidative muscle fibres and the implications for (Rogers & Evans, 1993). performance are addressed later in the chapter. Different muscle groups (upper body, lower body) are characterized by a different profile of Sarcopenia fibre distribution. The upper body (biceps Sarcopenia has been defined as the reduction in brachii) has a greater proportion of fast-twitch lean muscle mass often associated with ageing fibres, whereas the weight-bearing muscles of (Evans, 1995). For a full account of the changes the lower body (vastus lateralis) have a greater in muscle structure and function with age the proportion of slow-twitch fibres (Grimby, 1995). reader is referred to several comprehensive Unlike the lower body, no age-associated reduc- review articles (Grimby & Saltin, 1983; Vander- tion in fast-twitch fibre cross-sectional area is voort et al., 1983; Rogers & Evans, 1993). Ageing found in biceps brachii of the general population skeletal muscle undergoes a dramatic loss in (Grimby, 1995). This may be because women mass, approximately 33%, between the ages of never have a large fast-twitch fibre cross- 25 and 75 (Grimby & Saltin, 1983). The decline sectional area and therefore there is little to lose. in muscle mass occurs primarily via two An alternative explanation is that the upper body mechanisms: (i) decrease in size of individual is called upon for short bursts of strength and muscle fibres (atrophy) (Grimby & Saltin, 1983); power for such things as carrying groceries, and (ii) attrition (Lexell, 1995). Because fast- children, briefcases, books or laundry; stimuli glycolytic fibres (types IIa and IIb) are more labile may remain relatively constant across the adult than slow-oxidative fibres, there is a selective lifespan, accounting for the sustained cross- decline in the former (Lexell, 1995). Fast- sectional area of fast-twitch fibres. To understand muscle function 147

100 90

80 70

60 50 Fig. 10.2 Muscle composition: slow 40 twitch (), fast oxidative ( ) and fast 30 glycolytic ( ). The percentage contribution of fibre cross-sectional area Muscle composition (%) 20 (mm2) to total cross-sectional area (mm2) 10 in sedentary and active women by age is shown. (Adapted from Saltin et al., 1977; 0 Essen-Gustavsson & Borges, 1986; Cress 16 40 50 60 70 et al., 1991.) Age (years)

more fully the effects of age, disuse and activ- and women and male élite athletes have lower ity on upper-body muscle fibre morphology rates of health-care utilization (Kujala et al., 1996; will require a longitudinal research study that Buchner et al., 1997). includes muscle biopsy data. Sarcopenia has several metabolic and func- Capillarization tional consequences. People with hip fractures have a lower muscle and bone mass (Aniansson Energy balance is maintained in part by the tight et al., 1984). Lower muscle mass is associated regulation between mitochondrial oxidative with a lower resting metabolic rate (Rogers capacity and oxygen delivery via capillarization & Evans, 1993). Muscle mass is needed for (Conley, 1994). The absolute number of capillar- minimizing the development, and maximizing ies is decreased with age, resulting in a decrease control, of type 2 (adult-onset) diabetes, hyper- in blood flow to the working muscle (Coggan tension and cardiovascular disease (Roger & et al., 1992a). However, due to the reduction of Evans, 1993). Adequate muscle mass is essential fibre size, the overall ratio of capillaries tofibres for physical activity, used as a means to maintain is not altered (Coggan et al., 1992a). The ability of an appropriate level of body fat. Older women the muscle to replace the immediate energy with low muscle mass are at risk of institutional- stores (ATP) and remove muscle metabolites ization in later life (Guralnik et al., 1994). generated by muscle contraction decreases with Regular physical activity may prolong inde- age (Chick et al., 1991). Capillarization and oxida- pendence, maintain quality of life and delay the tive enzymatic activity is generally well main- onset of disability to a time just before death, a tained in the lower body of older adults; phenomenon known as compression of morbidity however, it can still be increased with endurance (Fries, 1996). Scientific evidence has clearly training, by as much as 20% (Coggan et al., 1992a; demonstrated the ability to reverse the loss in Grimby, 1995). Insufficient data are available to lean muscle mass with age. Male athletes, partic- report on the effect of resistive training on muscle ularly those that train for power lifting, have blood flow in women. Muscle blood flow is one a higher muscle mass (Klitgaard et al., 1990). determinant of muscle enzymatic activity. In the Active adults have lower morbidity and lower absence of an adequate supply of oxygen, muscle risk of death from all causes (US Department of is dependent upon glycolytic pathways of Health and Human Services, 1996). Active men energy production (Schaufelberger et al., 1997). 148 the masters athlete

fully activated the force generated per square Glycolysis centimetre of muscle (specific force) is lower in Working muscle derives its energy from a old compared with young women (Phillips et al., balance between the glycolytic and aerobic path- 1992). Besides a lower specific force, lower ways. The sympathetic system, important in strength in older women could be due to partial stimulating glycolysis, is diminished in tandem recruitment of all motor neurones, lower motiva- with reduced fast skeletal muscle fibres (Fagius tion to give a full effort or joint problems. et al., 1996). Muscle enzymatic activity differs Isokinetic assessment of muscle strength can between muscle groups, particularly lower and be attained at varying limb velocities. Velocities upper body. Lactate production is blunted of 30–60°·s–1 are considered slow while velocities during submaximal activity in older compared above 300°·s–1 are considered fast (Davies, 1984). with younger women (Chick et al., 1991). Male Research studies suggest that the force–velocity masters athletes with the same performance time relationship in muscle is altered with ageing. for 10km as young male athletes have a 46% Muscle of older women has a lower neural capac- lower activity of lactate dehydrogenase (enzyme ity for generating as much force at faster speeds of the glycolytic pathway) than their young (Harries & Bassey, 1990). Increased time to peak counterparts (Coggan et al., 1990). Compre- tension and increased time to relaxation has been hensive and definitive studies on lactate produc- attributed to the reduced contribution of fast- tion and utilization in masters and young twitch fibres to muscle performance. The age- women athletes could help us understand the related decline in power (force/time) is steeper effect of sport and training on the balance than the decline in force because of the loss in between the primary pathways of energy pro- velocity. Because of the inverse relationship duction. Yet from the evidence at hand it appears between body fat and lean mass, power relative that the diminished ability to produce lactate to body mass (power/body weight) is even more may be due to a combination of decreased fast- markedly reduced with age (Bassey & Short, glycolytic fibres and reduced sympathetic 1990; Young & Skeleton, 1994). Older weaker stimulation. individuals are also slower to develop force and Cureton et al. (1988) has suggested that therefore are not operating at the optimum posi- muscle-fibre attrition may be intrinsic whereas tion on the power–velocity curve (Bassey & atrophy is behaviourally based. The data are Short, 1990). Older mice have a 20% decline in clear that at older ages the muscle profile accom- specific force and a 30% decline in power com- modates endurance activity, with a proportional pared with that of young mice (Faulkner et al., shift toward slow-oxidative fibres and oxidative 1995). Decreased leg power is closely associated enzymatic composition. Although there are (r=0.83–0.93) with declines in performance on fewer data on athletes, these suggest that this mobility tasks (Bassey & Short, 1990; Bassey et al., pattern is consistent in both active and sedentary 1992). The lower capacity to generate force women (Cureton et al., 1988). and power is not explained by differences in dry-weight mass, extracellular components or intrinsic force-generating capacity of the muscle Muscle strength and muscle quality cross-bridges, excessive connective tissue or Muscle force development (strength) is directly interstitial fat falsely elevating the area measure- related to muscle mass. Muscle quality is the ment (Young et al., 1984; Faulkner et al., 1995). ability of muscle to generate force per unit of By exclusion this suggests that the fault muscle mass (Saltin & Gollnick, 1983). Does the is with the neural stimulation or motivational quality of muscle change with age? Is there a dis- aspect of performance. However, even highly crepancy between loss of strength (intrinsic motivated athletes exhibit performance deficits muscle failure) and loss of muscle mass? When over time, suggesting that the decline in strength muscle function 149

is more than just a reflection of less rigorous sor/flexor imbalance that may predispose a training or effort. Contraction-induced micro- woman to injury or early functional decline (see damage has been hypothesized as one explana- the section Injuries in this chapter). tion for the failure of well-trained muscle to generate the expected specific force (Faulkner Muscle endurance and innervation et al., 1995). Although most studies indicate that resistive As described above, the decline in strength with training increases fat-free weight, not all studies ageing is accompanied by the selective loss of are in agreement (Cureton et al., 1988). Pro- fast muscle fibres, which is more pronounced for gressive resistive training increases strength fast-glycolytic than fast-oxidative fibres. The to a greater extent than muscle hypertrophy ability to sustain power during short bouts of (Cureton et al., 1988). Increased muscle myofib- repeated muscle contractions, such as that rillar protein in older women is the underlying required for short-distance sprinting events, basis for increased muscle strength, which in appears to decay with age (Gerard et al., 1986; turn is related to muscle performance (Cress et Stones & Kozma, 1986). The preservation of al., 1996). Sufficient studies are not available to endurance performance characteristics has been address the influence of hormone replacement linked to the greater relative contribution of the therapy, menopause, sport or cross-training on slow-twitch fibre population to sustained perfor- muscle strength and quality. mance (Harries & Bassey, 1990; Laforest et al., For optimal performance and to minimize 1990). Long-distance running or rowing relies on injury, a balance of strength between the agonist the maintenance of an energy balance, which is and antagonist muscles is suggested (Wathen, largely dependent upon the capacity of the 1994). In the thigh, it is recommended that the muscle to metabolize immediate energy stores ratio of the strength of the quadriceps to that of (phosphocreatine) and the muscle’s capacity for the hamstring is 3:2, although this is not without recovery via aerobic metabolism. The phospho- controversy (Wathen, 1994). Women tend to creatine/ATPase buffer system offers a simple show a more marked loss in concentric strength feedback mechanism between energy supply than eccentric strength with increasing age and demand. The maximum power output (Hurley, 1995). Ageing is associated with a dis- that can be sustained in endurance activity in old proportionate loss in strength of the knee flexors mice is 69% of that which can be sustained in compared with that of the knee extensors, result- adult mice (Faulkner et al., 1990). Age-associated ing in an imbalance in agonist and antagonist physiological changes seem to affect velocity to muscles (Cress et al., 1991; Stanley & Taylor, a greater extent at short distances than longer 1993). In sitting down and descending stairs, the distances (Riegel, 1981). Comparing the endur- primary action of the quadriceps is eccentric ance performance of masters and young athletes, movement. In running or stair climbing, the the gap between the two ages is greater for sprint primary action of the hamstrings is concentric and short distances (£1500m) that require power movement (Joseph & Watson, 1967). Previously than for endurance events (≥15km) (Riegel, sedentary older women who train with 1981). endurance and stair climbing exhibit a greater Twitch and tetanic tension of the soleus and gain in strength of the knee flexors compared plantaris muscles decrease significantly with age with that of the knee extensors. The imbalance (Klitgaard et al., 1989). In athletes, the slope of between the quadriceps and hamstrings may be the decline in muscular endurance of the knee is a combination of intrinsic age-related changes more pronounced than that of plantar flexion within the muscle and added decline from infre- when using body weight in a partial squat to quent use of the muscle in daily function. This generate resistance (Nakao et al., 1989). Sustained imbalance in turn may result in a knee exten- performance that involves large muscle contrac- 150 the masters athlete

tions are similar in older and younger women. predisposition or to training is not fully under- However, function in small muscle groups, such stood. Preservation of muscle mass may occur as that required for sit-ups and push-ups, deteri- via inhibition of the loss of muscle fibres, mainte- orates by as much as 60% (Shephard,1986). nance of individual muscle fibre area, or both Although trained women have greater absolute (Kavanagh & Shephard, 1990). With proper tech- strength and muscle endurance, the rate of nique, resistive training results in increases in fatigue is similar for the two groups (Huczel & fibre size whether or not one moves from seden- Clark,1993). tary to active or active to athlete (Kavanagh In summary, the data suggest that reduced & Shephard, 1990). Increases in strength and strength with age may result from factors in endurance result in increased function in activ- addition to decline in muscle mass. The loss of ities of independent living (Cress, 1997). power with age is a function of decreased neural The distribution of fibre types is similar for ability to generate muscle speed in addition to women participating in the same sport (Wilmore, decreased muscle strength. Preservation of 1984). Endurance athletes have the greatest pro- endurance performance is primarily due to the portion of slow-twitch fibres followed by short- characteristics of slow-oxidative fibres. distance runners, with the lowest in power athletes (Wilmore, 1984). A sport that stimulates slow-twitch oxidative muscle augments the Training effects on muscle natural course of muscle change. Perhaps The shift in muscle fibre distribution towards endurance masters athletes should engage in greater oxidative potential has implications for cross-training (strength and endurance) to performance. Chronic endurance training alters counter the decline in strength with age. Studies the morphological and metabolic characteristics in young individuals have suggested that re- of muscle. The mitochondria of masters athletes sistive combined with endurance training is do not show any indication of impairment and counter-productive for optimal performance in respond to training in the same way as in young endurance athletes (Sale et al., 1990). The impact athletes (Coggan et al., 1992b; Brierly et al., 1997). of the combination of these two training modali- In male masters athletes with similar 10-km per- ties on muscle performance in older women · formance times to young athletes, VO2max was needs further investigation. 11% lower, oxidative enzyme activity was 31% higher and capillary–fibre ratio was greater in Flexibility the masters athletes due to 34% larger slow- twitch fibres (Coggan et al., 1990). Research is Flexibility is the ability of muscle and other soft needed to evaluate the performance response of tissue to yield to a stretch force. Range of motion lactate in both young and masters athletes. is the amount of motion allowed between Resistive training of sufficient duration, inten- any two bony levers. Muscle shortening alters sity and progression results in metabolic, mor- the length–tension relationship of the muscle, phological and functional adaptations. Muscle decreasing the peak torque that can be generated, fibre area, particularly of fast-glycolytic fibres, known as tight weakness (Gossman et al., 1986). is increased with a concomitant increase in As discussed earlier, older women are not at strength and functional performance (Cress et al., the optimum on the force–velocity curve (Bassey 1991, 1996; Rogers & Evans, 1993). Female ath- & Short, 1990). The inability to generate force letes aged 66–85 years exhibit a greater cross- rapidly (decreased force–velocity) and tight sectional muscle area and less fat than their weakness (decreased length–tension force) are age-matched counterparts (Lexell, 1995). Fibre both mechanisms of reduced force in older size is larger in athletes than non-athletes; adults. Soft tissue responds to flexibility training however, whether this trait is due to a genetic (Bandy & Irion, 1994); however, understanding muscle function 151

of the relationship of flexibility and strength and letes, having higher peak performance, show a the impact on performance has not been ade- greater decline than the mass sport athletes, quately studied. whose lower peak performance shows a gentler and more linear decrease. In addition, the rate of decline is different for different disciplines Sports performance (1500m, 3000m, broad jump) (Okonek, 1996). Records compiled and published as Masters Age The following original dataset illustrates the Records are approved by the World Association interaction between cohort and performance. of Veteran Athletes and the Masters Track and E.W. has finished first, second or third in her age- Field Records Sub-committee of USA Track and group category in the same 15-km race (River Field (Masters Age Records, 1996). Records are Run, Jacksonville, Florida) for the past 20 years compiled by sex into 5-year categories, with most (1978–97). These data are unusual in several events beginning at age 35 and no upper age ways: (i) data are from the same race course; (ii) limit. The US National Senior Sports Classic was E.W. ranked locally allowing for verification of formed in 1985 to promote health and fitness and time; (iii) E.W. kept excellent training log records; competition for athletes from 50 to as high as 100 and (iv) 20 years of data are available. Figure 10.3 years of age (US National Senior Sports Classic shows E.W. on a long training run. Web Site). Athletes qualify in their state games In Fig. 10.4, the filled symbols indicate E.W.’s to compete at the US National Senior Sports performance time for a given year as a percent- Classic, which includes competition in 18 dif- ferent sports. As discussed in earlier sections on muscle characteristics and strength, performance data are mainly from cross-sectional studies. Cross- sectional data are used to predict the athletic performance for different age groups. In general, these predictions overestimate the performance in older age categories because only the most fit older subjects survive or are willing to provide data. However, many other cohort differences may elevate the scores of young compared with masters athletes, e.g. different nutritional, envi- ronmental and social exposure. From the mid- 1970s to the mid-1980s physical training was characterized by marked philosophical changes in the intensity of training in both men and women, as well as changes in social acceptance of women’s competition. With increased openness to competition in the younger age categories (<35 years), women’s 10000m and marathon times improved by about 15% (Joyner, 1993). Mass sport provided a venue for the non-élite athletes to compete. A study of German élite and mass sport athletes found that when using cross- sectional data there was an interaction effect between the cohort category, sports discipline and rate of decline. In longitudinal data, élite ath- Fig. 10.3 E.W. training for the 15-km race. 152 the masters athlete

Training after 20 years of running E.W. shows a 30% mileage increase (cross-sectional) or 0% (longitudinal) decline in 130 performance. Performance records are generally surpassed by younger individuals and not by the 110 same aged people, representing a ‘sport gain’ 90 (Stefani, 1989). To attribute this difference to the effects of ageing is misleading. 70 When the performance of older athletes is Injury 50 reported relative to the world record perfor- mance, factors such as improved training, better 30 nutrition, social attitudes and strategies in com- 10 petition may all factor into the better perfor- 0 mance of the young athlete. Yet this method of

% of performance time at age 35 years 36 38 4042 44 46 48 50 52 54 Age (years) reporting attributes the difference to age-related effects. These data also illustrate how comparing Fig. 10.4 Performance times for E.W. from age 35 to 54 people in different age categories can interact years: , performance time for a given year as a per- with longitudinal data to show different rates of centage of her time at age 35; , performance time for a change over the years, as in the cohort interaction given year as a percentage of the winning time in the 35-year-old category for that same year. effect in the cross-sectional analysis reported by Okonek (1996).

Injuries age of her winning time at 35 years of age, 72.83min or 4.86min·km–1, for the 15-km race. The prevalence of athletic injuries was high for Her improved performance at age 40–42 coin- women in the late 1970s. This may have been cides with an increase in training mileage by related to the increased number of positions 16km·week–1 to 64–80km·week–1. The dip in available for women athletes to fill (Hunter, training to 48–56km·week–1 and performance at 1988). Often collegiate women played multiple age 43 were due to a hip injury. E.W.’s time sports, e.g. volleyball, basketball and track. The improved throughout the 20 years of running, competitive process screens out individuals who allowing her to exceed her 35-year-old perfor- are not anatomically or physiologically suited mance, at times by as much as 18%. At age 54, for optimal performance in a given sport both her training of 56–64km·week–1 and her (Francis, 1988). Therefore, the stresses of perfor- race time were the same as at age 35. The 18% mance unique to a given sport are the major improvement in her performance time may be a determinants of injury for élite athletes rather measure of the improvements in the sport, train- than sex. Training specifically for the unique per- ing strategies, ergonomic aids, shoes and other formance requirements plus general condition- unknown factors. When her performance is ing can reduce sport injuries (Hunter, 1988). reported in the usual manner as a percentage of However, several anatomical and physiological the winning time in the 35-year-old category for conditions result in specific injuries for which each year (triangles in Fig. 10.4), her performance women are at greater risk (Baker, 1997). In the dips as low as 70% of the younger athlete’s time lower extremities these include bunions and for the same race. The winner of the 35-year-old injuries that result from poor knee alignment. category was often an élite athlete of national Objective screening procedures to test flexibility, rank brought in specifically to compete in the strength and gait have been used to address race. Depending upon the reporting method, training strategies and prevent injuries in young muscle function 153

athletes (Francis, 1988). Unless properly is a gradual reduction in growth hormone, addressed early in the athletic career, a predispo- testosterone and oestrogen levels that parallels sition to injury may result in early retirement the decline in muscle mass (Schwartz, 1995). from sports. Women who begin their athletic Young growth-hormone-deficient patients have careers later in life may not discover a predispo- changes in muscle and body composition similar sition to injury until they are in masters events. to those associated with the ageing process. Participating in sporting events may challenge These can be reversed with growth hormone the anatomical and musculoskeletal system, replacement therapy (Schwartz, 1995). Pre- which may not have otherwise been stressed in liminary evidence indicates that supplemental daily activities. Screening can provide the growth hormone can reverse the sarcopenia necessary direction for preventive conditioning found in healthy older adults (Papadakis et al., through strengthening and stretching. For 1996), yet growth hormone supplementation example, injuries may be prevented by maintain- has not been shown to enhance performance ing an appropriate balance between the quadri- (Papadakis et al., 1996). A multicentre research ceps and hamstrings, which are implicated in trial, funded by the US National Institute on anterior cruciate ligament injuries (Baker, 1997). Ageing, is currently underway to determine the Preventive screening procedures can help direct ill-effects and efficacy of growth hormone a woman to the appropriate specialist for further therapy (National Centre for Research Resources evaluation, proper footwear or in-sole orthotic Web Site). devices (Francis, 1988). The importance of oestrogen in the preserva- tion of bone mass in postmenopausal women has been well established (Cauley et al., 1995). It Effects of anabolic steroids and may also be useful in slowing the increased trophic factors deposition of fat associated with the menopause Natural steroids include testosterone, oestradiol (Schwartz, 1995). Oestrogen replacement ther- and cortisol; methandienone (Dianabol) is a apy has been suggested as a method of preven- chemically derived steroid. The muscle-building tion of loss of muscle mass and strength (Phillips or ‘anabolic’ effect of testosterone has been et al., 1993). However, no well-designed, ran- known for over 60 years (Hervy, 1982). The domized, controlled clinical trials have been preponderance of evidence, particularly from published on this important intervention. The animal models, is that anabolic steroids increase use of trophic factors as either a replacement muscle mass; however, their effect on athletic for declining levels or a supplement for normal performance is equivocal (Hervy, 1982). Sup- levels may become standard medical practice. If plementing the normal levels of these endoge- so, the line between therapeutic and athletic use nous factors is banned by the International of these ‘muscle-enhancing’ substances will be Olympic Committee (De Merode, 1988). As ambiguous. such, the benefits and deleterious side-effects of steroids in general use have not been systemati- Recommendations for future research cally studied in randomized controlled trials. In spite of the lack of scientific research and a ban on Studying the physical determinants of peak per- their use, these substances are used widely, par- formance in masters athletes may help decipher ticularly in young male athletes (Bamberger & some of the mechanisms that contribute to Yaeger, 1997). sarcopenia in older, diseased and/or sedentary · Trophic factors include endogenous growth adults. VO2max, lactate production and metabo- factors such as insulin-like growth factor I, lism, strength and economy of performance have insulin and growth hormone. With ageing there been suggested as the primary determinants of 154 the masters athlete

performance (Joyner, 1993). Research is needed towards acceptance of greater sport participation into the underlying mechanisms such as muscle (Schulz & Curnow, 1988). Peak performance in ultrastructure and the neural and cardiovascular masters athletes may become the arena for evalu- systems that contribute to optimal performance ating the potential of the human body in the in masters athletes. Flexibility testing has been older years. used to screen for risk of injury (Francis, 1988). Rehabilitation medicine uses flexibility to reha- Acknowledgements bilitate old injury and prevent new injury (Stanish et al., 1990), yet because of the lack of I am grateful to Val Stewart for her contributions research the contribution of flexibility training to to this chapter. She gathered literature and more performance and the prevention of injury is not performance records than were possible to understood. include, and offered her personal experiences, Physical activity is an important factor in expertise and friendship during the writing of public health. Many male college athletes this chapter. I also want to thank Peter Mundle, decrease their activity dramatically after their National Masters News, and Jana Porter for competitive career (Paffenbarger et al., 1992). sending performance records. Elfrieda B. Wyner However, this same pattern may not be true for is a lifetime athlete, dedicated historian and good female alumni of collegiate sports. Is there less friend whose devotion to her sport helped to likelihood for a college athlete to become seden- further our understanding of performance over tary in communities in which mass sport is avail- 20 years. I also thank Shannon Manuszewski for able? Competitive race events are scheduled preparation of the manuscript. year-round but they are most commonly held in the summer months. Participation by the com- munity in sponsoring mass sport events pro- References vides the opportunity for people to participate in Aniansson, A., Zetterberg, C., Hedberg, M. & Henriks- physical sport regardless of age, gender or physi- son, K. (1984) Impaired muscle function with aging. cal ability. Mass sport gives the community a A background factor in the incidence of fractures of venue for promoting sport, fund-raising and the proximal end of the femur. Clinical Orthopaedics community activism. It also provides the indi- and Related Research 191, 193–201. Baker, C.L. (1997) Lower extremity problems in female vidual with an increased opportunity for compe- athletes. Journal of the Medical Association of Georgia tition outside the customary school setting. What 86, 193–196. impact will the changing attitudes towards com- Bamberger, M. & Yaeger, D. (1997) Bigger, stronger, petition have on the overall health of the commu- faster. Sports Illustrated 14 April, 62–70. nity? Can competition provide older women Bandy, W.D. & Irion, J.M. (1994) The effect of time on static stretch on the flexibility of the hamstring with the motivation to train and preserve muscles. Physical Therapy 74, 845–852. function? Can sport contribute to the com- Bassey, E.J. & Short, A.H. (1990) A new method of mea- pression of morbidity in a segment of the popula- suring power output in a single leg extension: feasi- tion with the greatest proportion of disabled bility, reliability and validity. European Journal of individuals? Applied Physiology and Occupational Physiology 60, 385–390. The opportunity to study women masters ath- Bassey, E.J., Fiatrarone, M.A., O’Neill, E.F., Kelly, M., letes comprehensively is dawning as the ‘baby Evans, W.J. & Lipsitz, L.A. (1992) Leg extensor power boomers’, the children born after the Second and functional performance in very old men and World War, enter their fifties. World records women. Clinical Science 82, 321–327. plateau as athletes perform closer to their Brierly, E.J., Johnson, M.A., Bowman, A. et al. (1997) Mitochondrial function in muscle from elderly ath- maximal physical ability (Joyner, 1993). Older letes. Annals of Neurology 41, 114–116. adults have a great capacity for physiological Buchner, D.M., Cress, M.E., de Lateur, B.J. et al. (1997) plasticity and the social climate is moving The effect of strength and endurance training on gait, muscle function 155

balance, fall risk, and health services use in commu- duction. In K. Dyer (ed.) Sportswoman Toward 2000. nity-living older adults. Journal of Gerontology 52A, Hyde Park Press, Richmond, Australia. M218–M224. Essen-Gustavsson, B. & Borges, O. (1986) Histochemi- Buskirk, E.R. & Hodgson, J.L. (1987) Age and aerobic cal and metabolic characteristics of human skeletal power: the rate of change in men and women. Federa- muscle in relation to age. Acta Physiologica Scandinav- tion Proceedings 46, 1824–1828. ica 126, 107–114. Cauley, J.A., Seeley, D.G., Ensrud, K., Ettenger, B., Evans, W. (1995) What is sarcopenia? Journal of Geron- Black, D. & Cummings, S.R. (1995) Estrogen replace- tology 50A (Suppl.), 5–8. ment therapy and fractures in older women. Annals Fagius, J., Ellerfelt, K., Lithell, H. & Berne, C. (1996) of Internal Medicine 122, 9–16. Increase in muscle nerve sympathetic activity after Chick, T.W., Cagle, T.G., Vegas, F.A., Poliner, J.K. & glucose intake is blunted in the elderly. Clinical Auto- Murata, G.H. (1991) The effects of aging on submaxi- nomic Research 6, 195–203. mal exercise performance and recovery. Journal of Faulkner, J.A., Brooks, S.V. & Zebra, E. (1990) Skeletal Gerontology 46(1), B34–B38. muscle weakness and fat in old age: underlying Coggan, A.R., Spina, R.J., King, D.S. et al. (1990) Histo- mechanisms. Annual Review of Gerontology and Geri- logical and enzymatic characteristics of skeletal atrics 10, 147–166. muscle in master athletes. Journal of Applied Physiol- Faulkner, J.A., Brooks, S.V. & Zebra, E. (1995) Muscle ogy 68, 1896–1901. atrophy and weakness with aging: contraction- Coggan, A.R., Spina, R.J., King, D.S. et al. (1992a) Skele- induced injury as an underlying mechanism. Journal tal muscle adaptations to endurance training in of Gerontology 50A (Suppl.), 124–129. 60–70-year-old men and women. Journal of Applied Flynn, M.A., Nolph, G.B., Baker, A.S., Martin, W.M. & Physiology 72, 1780–1786. Krause, G. (1989) Total body potassium in aging Coggan, A.R., Spina, R.J., King, D.S. et al. (1992b) Histo- humans: a longitudinal study. American Journal of chemical enzymatic comparison on the gastro- Clinical Nutrition 50, 713–717. cnemius muscle of young and elderly men and Francis, P.R. (1988) Injury prevention through women. Journal of Gerontology 46B, 71–76. biomechanical screening: implications for female Conley, K.E. (1994) Cellular energetics during exercise. athletes. In J.L. Puhl, C.H. Brown & R.O. Voy Advances in Veterinary Science and Comparative Medi- (eds) Sports Science Perspectives for Women, pp. cine 38A, 1–39. 97–100. Human Kinetics Publishers, Champaign, Cress, M.E. (1997) Quantifying physical functional per- Illinois. formance in older adults. Muscle and Nerve 77, Fries, J.F. (1996) Physical activity, the compression of 1243–1250. morbidity, and the health of the elderly. Journal of the Cress, M.E., Thomas, D.P., Johnson, J. et al. (1991) Effect Royal Society of Medicine 89, 64–68. · of training on VO2max, thigh strength, and muscle Gerard, E.S., Vaccaro, P., Buckmeyer, P.J., Dummer, morphology in septuagenarian women. Medicine and G.M. & Vander Velden, L. (1986) Skeletal muscle pro- Science in Sports and Exercise 23, 752–758. files among elite long, middle, and short distance Cress, M.E., Conley, K.E., Balding, S.L., Hansen-Smith, swimmers. American Journal of Sports Medicine 14, F. & Konczak, J. (1996) Functional training: muscle 77–82. structure, function, and performance in older Going, S., Williams, D.P. & Lohman, T.G. (1995) Aging women. Journal of Orthopaedic and Sports Physical and body composition: biological changes and Therapy 24, 4–10. methodological issues. Exercise and Sports Medicine Cureton, K.J., Collins, M.A., Hill, D. & McElhannon, Review 23, 411–458. F.M. Jr (1988) Muscle hypertrophy in men and Gossman, M.R., Rose, S.J., Sahrmann, S.A. & Katholi, women. Medicine and Science in Sports and Exercise 20, C.R. (1986) Length and circumference measurements 338–344. in one-joint and multi-joint muscles in rabbits after Davies, G.J. (1984) A Compendium of Isokinetics in Clini- immobilization. Physical Therapy 66, 516–520. cal Usage. S & S Publishers, La Crosse, Wisconsin. Grimby, G. (1995) Muscle performance and structure in De Merode, P.A. (1988) The development, objectives the elderly as studied cross-sectionally and longitu- and activities of the IOC Medical Commission. In A. dinally. Journal of Gerontology 50A (special issue), Dirix, H.G. Knuttgen & K. Tittel (eds) The Olympic 17–22. Book of Sports Medicine, pp. 3–6. Blackwell Scientific Grimby, G. & Saltin, B. (1983) The aging muscle. Clinical Publications, Oxford. Physiology 3, 209–218. Drinkwater, B. (1984) Woman and exercise: physiologi- Guralnik, J.M., Simonsick, E.M., Ferrucci, L. et al. (1994) cal aspects. Exercise and Sport Sciences Reviews 12, A short physical performance battery assessing 21–51. lower extremity function: association with self- Dyer, K. (1989) Women’s sport and the law: an intro- reported disability and prediction of mortality and 156 the masters athlete

nursing home admission. Journal of Gerontology 49, Lexell, J. (1995) Human aging, muscle mass, and fiber M85–M94. type composition. Journal of Gerontology 50A (special Harries, U.J. & Bassey, E.J. (1990) Torque velocity rela- issue), 11–16. tionships for the knee extensors in women in their Masters Age Records (1996) National Masters News, 3rd to 7th decades. European Journal of Applied Physi- PO Box 16597, North Hollywood, CA 91615-6597, ology and Occupational Physiology 60, 187–190. USA. Hervy, G.R. (1982) What are the effects of anabolic Nakao, M., Ihoue, Y. & Murakami, H. (1989) Aging steroids? In B. Davies & G. Thomas (eds) Science and process of leg muscular endurance in males and Sporting Performance: Management or Manipulation, females. European Journal of Applied Physiology and pp. 120–136. Clarendon Press. Oxford. Occupational Physiology 59, 209–214. Hoffman, A. (1989) Integrating sport: the Canadian National Center for Research Resources, Computer experience. In K. Dyer (ed) Sportswoman Toward 2000, Retrieval of Information on Scientific United pp. 25–34. Hyde Park Press, Richmond, Australia. States Public Health Service (US-PHS) Web Site. Huczel, H.A. & Clarke, D.H. (1993) A comparison of http://www.ncrr.nih.gov/grants/crisp.htm strength and muscle endurance in strength trained Okonek, C.C. (1996) Langsschnittanalysen zur sport- and untrained women. In R. Shephard, J.A. Ander- lichen Leistungsentwicklung von Frauen im son, E.R. Eichner, F.J. George, J.R. Sutton & J.S. Torg alter zwischen 30 und 75 Jahren: ein Vergileich (eds) Yearbook of Sports Medicine, pp. 349–350. Mosby, zwischen dem Spitzen und dem Breitensport- St Louis. niveau. Zeitschrift für Gerontologie und Geriatrie 29, Hunter, L.Y. (1988) The frequency of injuries in 127–135. women’s sports. In J.L. Puhl, C.H. Brown & R.O. Voy Orlander, J., Kiessling, K.H., Larsson, L., Karlsson, J. & (eds) Sports Science Perspectives for Women, pp. 49–58. Aniansson, A. (1978) Skeletal muscle metabolism Human Kinetics Publishers, Champaign, Illinois. and ultrastructure in relation to age in sedentary Hurley, B.F. (1995) Age, gender, and muscular strength. men. Acta Physiologica Scandinavica 104, 249–261. Journal of Gerontology 50A, 41–44. Paffenbarger, R.S., Lee, I. & Wing, A.L. (1992) The influ- Joseph, J. & Watson, R. (1967) Telemetering electromyo- ence of physical activity on the incidence of site- graphy of muscles used in walking up and down specific cancers in college alumni. Advances in Experi- stairs. Journal of Bone and Joint Surgery 49B, 774–780. mental Medicine and Biology 322, 7–15. Joyner, M. (1993) Physiological factors and distance Papadakis, M.A., Grady, D., Black, D. et al. (1996) running. Exercise and Sport Sciences Reviews 21, Growth hormone replacement in healthy older men 103–133. improves body composition but not functional Kavanagh, T. & Shephard, R.J. (1990) Can regular ability. Annals of Internal Medicine 124, 708–716. sports participation slow the aging process? Data on Phillips, S.K., Bruce, S.A., Newton, D. & Woledge, R.C. masters athletes. Physician and Sportsmedicine 18, (1992) The weakness of old age is not due to failure 94–104. of muscle activation. Journal of Gerontology 47, Klitgaard, H., Marc, R., Brunet, A., Vanderwall, H. & M45–M49. Monod, H. (1989) Contractile properties of old rat Phillips, S.K., Rook, K.M., Siddle, N.C., Bruce, S.A. & muscles: effects of increased use. Journal of Applied Woledge, R.C. (1993) Muscle weakness in women Physiology 57, 684–690. occurs at an earlier age than in men, but strength is Klitgaard, H., Mantoni, M., Schiaffino, S. et al. (1990) preserved by hormone replacement therapy. Clinical Function, morphology and protein expression of Science 84, 95–98. ageing skeletal muscle: a cross-sectional study of Proctor, D. & Joyner, M. (1997) Skeletal muscle mass · elderly men with different training backgrounds. and the reduction of VO2max in trained older subjects. Acta Physiologica Scandinavica 140, 41–54. Journal of Applied Physiology 82, 1411–1415. Komi, P.V. (1988) The musculoskeletal system. In A. Riegel, P.S. (1981) Athletic records and human Dirix, H.G. Knuttgen & K. Tittle (eds) The Olympic endurance. American Scientist 69, 285–290. Book of Sports Medicine, pp. 15–39. Blackwell Scientific Rogers, M.A. & Evans, W.J. (1993) Changes in skeletal Publications, Oxford. muscle with aging: effects of exercise training. Exer- Kujala, U.M., Sarna, S., Kaprio, J. & Koskenvuo, M. cise and Sport Sciences Reviews 21, 63–102. (1996) Hospital care in later life among former Sale, D.G., MacDougall, J.D., Jacobs, I. & Garner, S. world-class Finnish athletes. Journal of the American (1990) Interaction between concurrent strength and Medical Association 276, 216–220. endurance training. Journal of Applied Physiology 68, Laforest, S., St Pierre, D.M., Cyr, J. & Gayton, D. (1990) 260–270. Effects of age and regular exercise on muscular Saltin, B. & Gollnick, P.D. (1983) Skeletal muscle adapt- strength and endurance. European Journal of Applied ability: significance for metabolism and perfor- Physiology and Occupational Physiology 60, 104–111. mance. In L.D. Peachy, R.H. Adrian & S.R. Geiger muscle function 157

(eds) Handbook of Physiology, Section 10, pp. 555–631. Stones, M.J. & Kozma, A.C. (1986) Age by distance Williams & Wilkins, Baltimore. effects in running and swimming records: a note Saltin, B., Henriksson, J., Nygaard, E., Anderson, P. & on methodology. Experimental Aging Research 12, Jansson, E. (1977) Part I. Metabolism in prolonged 203–206. exercise. Fiber types and metabolic potentials of US Department of Health and Human Services (1996) skeletal muscles in sedentary man and endurance Physical Activity and Health: A Report of the Surgeon runners. Annals of the New York Academy of Sciences General. US Department of Health and Human Ser- 301, 3–29. vices, Centers for Disease Control and Prevention, Sato, I., Akatsuka, H., Kito, K., Tokoro, Y. & Tauchi, H. National Center for Chronic Disease Prevention and (1984) Age changes in size and number of muscle Health Promotion, Atlanta. fibers in human minor pectoral muscle. Mechanisms US National Senior Sports Classic Web Site. of Ageing and Development 28, 99–109. http://www.fepblue.org/special4.html Schaufelberger, M., Eriksson, B.O., Grimby, G., Held, P. Vandervoort, A.A., Hayes, K.C. & Belanger, A.Y. (1983) & Swedberg, K. (1997) Skeletal muscle alterations in Strength and endurance of skeletal muscle in the patients with chronic heart failure. European Heart elderly. Physiotherapy Canada 8, 67–73. Journal 18, 971–980. Wang, N., Hikida, R.S., Staron, R.S. & Simoneau, J.A. Schulz, R. & Curnow, C. (1988) Peak performance and (1993) Muscle fiber types of women after resistance age among superathletes: track and field, swimming, training: quantitative ultrastructure and enzyme baseball, tennis, and golf. Journal of Gerontology 43, activity. Pflugers Archiv. European Journal of Physiology 113–120. 424, 494–502. Schwartz, R.S. (1995) Trophic factor supplementation: Wathen, D. (1994) Muscle balance. In T.R. Baeckle (ed.) effects on age-associated changes in body composi- Essentials of Training and Conditioning, pp. 424–430. tion. Journal of Gerontology 50A (Suppl.), 151–156. Human Kinetics Publishers, Champaign, Illinois. Shephard, R. (1986) Physiological aspects of sport and Wells, C.L. (1991) Women Sport and Performance. Human physical activity in the middle and later years of life. Kinetics Publishers, Champaign, Illinois. In B.D. McPherson (ed.) Sport and Aging, pp. 221–232. Wells, C.L. & Plowman, S.A. (1983) Sexual differences Human Kinetics Publishers, Champaign, Illinois. in athletic performance: biological or behavioral? Stanish, W.D., Curwin, S.L. & Bryson, G. (1990) The use Physician and Sportsmedicine 11, 52–63. of flexibility exercises in preventing and treating Wilmore, J.H. (1984) Morphologic and physiologic dif- sports injuries. In W.B. Leadbetter, J.A. Buckwalter ferences between men and women relevant to exer- & G.L. Gordon (eds) Sports-induced Inflammation, pp. cise. International Journal of Sports Medicine 5 (Suppl.), 731–745. American Academy of Orthopedic Sur- 193–194. geons, Park Ridge, Illinois. Women’s Sports Foundation Web Site. Women’s sports Stanley, S.N. & Taylor, N.A.S. (1993) Isokinematic facts 1997. http//www.lifetimetv.com/WoSport/ muscle mechanics in four groups of women of TOPICS/titleIX/descrip.htm increasing age. In R. Shephard, J.A. Anderson, B.L. Young, A. & Skeleton, D.A. (1994) Applied physiology Drinkwater, E.R. Eichner, F.J. George & J.S. Torg (eds) of strength and power in older age. International Yearbook of Sports Medicine, pp. 264–265. Mosby, St Journal of Sports Medicine 15, 149–151. Louis. Young, A., Stokes, M. & Crowe, M. (1984) Size and Stefani, R.T. (1989) Olympic winning performances: strength of the quadriceps muscles of old and young trends and predictions (1952–1992). Olympic Review women. European Journal of Clinical Investigation 14, 258, 157–161. 282–287. Chapter 11

Hormone Replacement Therapy

WENDY M. EY

Introduction 100m drops by 3.1% in women aged 45 and by 5.1% in women aged 50 and 55 compared with a Competitive sport for older women is a relatively drop of 1.7% and 3.4% in men of the same age new phenomenon. While large numbers of older (Table 11.1). The reasons for a general drop in men and women have been participating in performance can of course be attributed to the activities such as lawn bowls and golf for many ageing process. However, this does not explain years, their endeavours in other forms of com- the relative difference between men and women. petitive sport such as athletics, swimming and It could be hypothesized that it is due to the cycling have not been taken seriously. Although impact of the menopause and the changing there have been national and international com- hormonal status. petitions for veteran athletes and masters swim- mers, there has been little interest outside those Menopause who were directly involved. During the past 10 years, however, there has been a dramatic change The last menstrual period for most women in the acknowledgement of competitive sport for occurs between the ages of 48 and 53 years older people. Since 1985, when the first multi- but can happen quite normally five or so years sport World Masters Games was held in Toronto, earlier or later than this (Farrell & Westmore, we have witnessed the rapid growth of orga- 1993). There are some women who experience nized competitive structures in many sports for an earlier menopause and others who are those who wish to continue or resume their com- menopausal through medical intervention, e.g. petitive sport at an older age level. For those who the surgical removal of the ovaries. The reduc- have joined the ranks and become committed tion in circulating levels of oestrogen, proges- athletes there is often a time of frustration when terone and testosterone may be followed by a they seek advice or assistance from experts in number of physical and emotional symptoms, sports science, sports medicine or sports psy- such as hot flushes, night sweats, vaginal chology. Until now there has been very little dryness, depression and mood changes, irritabil- interest in athletes of this age group by health ity and forgetfulness, fatigue and loss of professionals and as a result almost no research strength. undertaken. There is convincing evidence that the ovaries The focus of this chapter is on the female continue to play an important role after the athlete who has reached the stage of life we know menopause because they can still produce small as the menopause. This is the time when a sig- quantities of oestrogen and testosterone for nificant drop in women’s athletic performance about 12 years. As the ovaries normally are a occurs. For example, the world record for the more potent source of testosterone than the 158 hormone replacement therapy 159

Table 11.1 Comparison of male and female records in women’s awareness of the menopause and the 100m event for competitors aged 45, 50 and 55 alerted women athletes to the potential for better years performance. Is it possible that by returning Age Male Female hormonal levels to their premenopausal status that the level of athletic performance can be 45 years 11.0s 12.5s maintained? A search of the literature reveals that this is an area that has not been investigated. 50 years 11.2s 12.9s For those women who experience some of 55 years 11.6s 13.6s the unpleasant symptoms of menopause, the relief resulting from HRT should mean that they will feel better and therefore be more likely to train harder and thus produce better perfor- adrenal glands, this continued function, albeit mances. Whether the changed hormonal status small, will be of particular importance to the per se will lead to better performance is another sportswoman in maintaining energy levels and matter. muscle strength. In addition, the loss of oestro- The implications of HRT for the drug-testing gen reduces the stimulation of sex hormone- programme are also relevant. The inclusion of binding globulin (SHBG) in the liver that androgens in HRT is not routine; however, it is controls the availability of circulating testos- recommended by some physicians in particular terone. This increases the availability of the circumstances, such as for sexual dysfunction, testosterone produced from the solid substance fatigue and after oophorectomy. There are also of the ovary and the adrenal glands. The produc- some forms of progestogens that have been pre- tion of ovarian testosterone is related to the size pared from androgens. Women athletes who of the ovary; as the ovary shrivels, the produc- have a legitimate need for these drugs should not tion of testosterone gradually reduces until it be deprived of them simply because of the appli- becomes minimal in established menopause, cation of drug-testing rules that have been although it continues to be produced by the designed for young athletes in open competition. adrenal glands. If the ovaries are removed, there Variations in the rules need to be made to allow is not only an abrupt loss of oestrogen but a total for postmenopausal women taking HRT when loss of testosterone secretion (Jones, 1994). Also, drug testing becomes mandatory. small amounts of oestrogen continue to be pro- duced in the adipose tissue. Heavier women Oestrogen therapy with more fatty tissue have higher total levels of oestrogen than thin women; therefore there is no In the untreated menopause, the ovary continues benefit in being underweight as women pass to produce some testosterone as a result of pitu- through the menopausal years (Cabot, 1991; itary hormone stimulation. With the introduction Farrell & Westmore, 1993). As most athletic of oestrogen replacement therapy this pituitary women are not overweight, they are at greater hormone is suppressed, which causes a synchro- risk of oestrogen deficiency and the associated nous loss of the production of testosterone from symptoms. the ovary. The administered oestrogen also After the menopause a woman’s total oestro- increases levels of SHBG and thereby any testos- gen production can decrease by 70–80% and terone that may be produced is largely inacti- androgen production from the ovaries and vated. Before the introduction of oestrogen adrenal glands by as much as 50% and by a replacement the woman’s testosterone level may further 30% if the ovaries are removed. The be quite high or normal, but after the instigation current developments and interest in hormone of oestrogen replacement testosterone availabil- replacement therapy (HRT) have heightened ity usually falls to zero. This loss of testosterone 160 the masters athlete

may be more pronounced in women taking cal activity during the summer months may find oestrogen by mouth because of enhanced liver that perspiration affects the adhesive power of stimulation of the binding protein (Jones, 1994). the patch and that body heat may cause a skin While it could be assumed that a greater avail- irritation. ability of testosterone would be an advantage for Sportswomen should also be aware that the women athletes, there is no research to demon- site of the patch may affect the rate of hormone strate that this adverse effect of oestrogen absorption into the system, i.e. during intensive replacement on ovarian testosterone production exercise expanding blood vessels under the skin is detrimental to performance. increase the rate of absorption. If a patch is placed on a part of the body that is moved fre- quently, such as the upper arm, the body absorbs Oral oestrogens the hormone faster than if the patch is attached to Studies carried out on the effectiveness of oral the abdomen (Farrell & Westmore, 1993). Women oestrogens have indicated that this form of involved in running activities or aerobics may HRT can produce unstable levels of oestrogen, need to consider applying the patch to the i.e. high concentrations of oestrogen, predomi- buttock or to the upper arm or removing the nantly oestrone, appear in the systemic circula- patch prior to exercise. tion within hours of ingestion after which concentrations rapidly decline (Studd & Smith, Oestrogen implant 1993). In view of these findings sportswomen may find it more beneficial to take oral oestro- The oestrogen implant consists of small pellets of gens at 12-hour intervals in order to maintain pure crystalline oestradiol and is available in adequate blood levels of oestrogen over a varying strengths to suit individual needs, e.g. 24-hour period. 20, 50 or 100mg. Depending on the strength of the implant it can release oestrogen directly into the bloodstream over a period of 4–12 months. Oestrogen patch The oestrogen pellet is usually inserted into Smaller doses of oestrogen can be used in the the fatty tissue of the lower abdomen, buttock patch and are far less likely to produce side- or upper thigh under a local anaesthetic. Sports- effects due to metabolic changes in the liver. The women should be mindful of the fact that train- small and relatively constant dose of hormone ing may be disrupted for up to 2 days after the released from the patch more closely resembles insertion of the pellet in order to allow the inci- the oestrogen secretions of the body than hor- sion to heal and the implant to settle. According mones taken orally, although oestradiol levels to Farrell and Westmore (1993) the amount of may still vary by more than 150% during the 3–4 hormone absorbed from the implant varies day lifetime of a single patch. according to: Although the patch is reported to be water- • how long it has been in place; proof and therefore should remain in place • its position (e.g. in a swimmer more hormone during bathing or showering, some women is absorbed if the implant is in the upper arm report that the patch does fall off in water. It may than if it is placed in the buttock); be advisable for sportswomen involved in • its depth under the skin (the deeper the aquatic activities to remove the patch prior to implant, the greater the absorption); bathing, apply it to the backing membrane that • physical activity levels (exercise increases comes with the patch and reapply it after bathing blood flow); when the skin is cool and quite dry. Heavily chlo- • the presence of inflammation or scar tissue rinated water and very hot water may also affect around the implant. the patch. Women involved in strenuous physi- The sportswoman who is involved in an inten- hormone replacement therapy 161

sive training programme that includes regular, considerable importance to good physiological deep tissue massage should avoid an implant functioning (Jones, 1994). Barbara Sherwin from near a major muscle group. It should be noted McGill University in Montreal, Canada, in an that implants can continue to release small address to the North American Menopause amounts of oestrogen for some time after the Society in 1992, reported that testosterone had expected expiration date and it is therefore profound effects on several female functions, a unwise to discontinue progestogen therapy in fact that has been largely ignored: those women with an intact uterus for 1–3 years We replaced oestrogen because we always after the last implant is inserted. knew what that did, and we totally ignored the fact that one-third of all circulating testos- terone in a woman’s body comes from the Progestins ovary. No one’s ever asked what testosterone Progestins differ in the potency of their oestro- does in a woman before! genic and androgenic properties and any Sherwin (1988) found that when women were adverse effects vary with the type of therapy and given oestrogen plus androgen (testosterone) the dose used. Some women cannot tolerate the subsequent to surgical menopause, they re- progestogen component of HRT and experience ported increased energy levels and feelings of side-effects not unlike those of the premenstrual well-being. They also reported fewer bouts of syndrome, e.g. breast tenderness, fluid retention, depression, mood swings, irritability and crying bloating, backache, abdominal cramps, break- than in women who received oestrogen alone. through bleeding, mood swings and depression. Henry Burger, from Prince Henry’s Institute of The sportswoman who finds that any of these Medical Research (Melbourne, Australia), sup- symptoms are disruptive to training and compe- ports the therapeutic use of testosterone as part tition may find that a progestogen with andro- of HRT for postmenopausal women, particularly genic properties may have less side-effects. those who have not responded adequately to oestrogen replacement alone (Burger et al., 1984, 1987). Androgen therapy While the current method for treating the Effect on sports performance menopause with oestrogen and progesterone is widely accepted, there is growing awareness of World records in 5-year age groups, starting from the significant role of testosterone in the total age 35, have been established over a period of 22 treatment of some women who have not years since the first World Veterans Champ- responded to normal hormone therapies. ionships were conducted. During that time there Despite this, there are still many medical practi- has been a dramatic refining of performances to tioners who doubt the validity of this therapy. the point now where they are ‘tough’ records and However, many specialists in this field do not infrequently reached. Therefore, the relative dif- have any doubts but this standpoint has not ference between men and women is well estab- always been conveyed to general practitioners. lished and unlikely to change markedly (Fig. Athletes and coaches should be prepared to seek 11.1). In the 100-m race, in the youngest age specialist advice at the highest level. group (35 years), the difference between men and There is a mistaken view that testosterone is women is 0.79s; this difference increases to 2.51s exclusively a male hormone and therefore at 70 years; at the time of the menopause a notice- should not be given to women. Testosterone is able drop of 0.70s occurs in the women, almost secreted by both males and females but obvi- double that seen in the men (0.37s). ously at lower levels in the female. While only a In the absence of any data on athletic perfor- small amount is produced in the female, this is of mance and HRT that includes an androgen, the 162 the masters athlete

following case study is presented as an example matic drop in performance that occurs around of an athlete dealing with surgical menopause menopause. and the impact on performance. The athlete There are many ‘older women’ who take their received both oestrogen and androgen therapy competitive sport seriously and train as hard as because of surgical menopause associated with younger athletes. These women and their cancer and demonstrated a hormonal profile coaches are keen to obtain information relating to consistent with the literature (Fig. 11.2). Figure their training and performances and how to 11.3 shows hormone levels plotted against per- reach their full potential. While many of the prin- formance and demonstrates that the best perfor- ciples of coaching apply to all athletes regardless mances occurred when both testosterone and of age, there are specific issues relating to the oestradiol levels were high, i.e. at the upper end postmenopausal woman. To determine how of the normal range and certainly higher than physiological changes following the menopause without the implants. Figure 11.4 illustrates the affect individual performance a specific training change in performance as a result of HRT and diary (Daly & Ey, 1993) was devised (Fig. 11.5). supports the theory that returning hormone This diary, which can be used both by women levels to premenopausal values reduces the dra- who have elected not to use HRT and those who have, was developed for the daily recording of physical activities alongside a measure of body weight, temperature, heart rate and menopausal 10 symptoms (recorded by the usual method, i.e. 0 11 indicates no problem, 1 mild problems, 2 moder- ate problems and 3 severe problems). At the end 12 of each month a graph can be drawn where the fluctuations in performance are compared with 13 the menopausal symptoms and physiological Time (s) 14 measures. The athlete and coach can then make appropriate adjustments to the training and 15 competition programmes and seek medical

16 assistance if the hormonal fluctuations are of 35 40 45 50 55 60 65 70 concern. The athlete should be encouraged not to Age (years) emphasize the negative aspects of the hormonal fluctuations and, by recording the positive times, Fig. 11.1 Comparison of male (—) and female (····) world 100-m veteran records for competitors aged should be able to determine the ‘strongest’ days 35–70 years. each month. Athletes who have used this diary

300 6 ) ) –1

250 5 l . –1 l . 200 4

150 3

100 2 Fig. 11.2 Hormone profile following oestradiol () and

Oestradiol (pmol 50 1 Testosterone (nmol testosterone () implants of 50 0 and 100 mg, respectively. (From 0 0.5 1 234 5 6 Thom et al., 1981 with Time since implant (months) permission.) hormone replacement therapy 163

13.0 12.3 13.1 12.4 13.2 12.5 12.6 13.3 12.7 13.4 12.8 13.5 12.9 13.6 13.0

Time (s) 13.1 Time (s) 13.7 13.2 13.8 13.3 13.9 13.4 14.0 13.5 14.1 13.6 13.7 0 1 23 4 56 7 45 50 55 (a) Serum testosterone (nmol.l–1) Age (years)

13.0 Fig. 11.4 Effect of oestrogen/androgen therapy on 13.1 100-m sprint times for veteran women. —, current 13.2 records; ---, androgen therapy. 13.3 13.4 13.5 13.6 Drug testing

Time (s) 13.7 The application of drug testing to masters sport 13.8 is a new concept. Occasional reference has been 13.9 14.0 made in events such as swimming, athletics and 14.1 weight-lifting, where the world games are con- ducted under the rules of their respective inter- 0 200 400 600 800 1000 national sports federations, that competitors are . –1 (b) Serum oestradiol (pmol l ) liable to be subjected to drug testing, although this has occurred infrequently. However, at the Fig. 11.3 (a) Relationship between serum testosterone concentration and 100-m sprint times in a 55-year-old World Masters Games in 1994 and the World Vet- menopausal athlete. (b) Relationship between serum erans Track and Field Championships in 1995, oestradiol concentration and 100-m sprint times in a 55- drug testing did take place. It is now assumed year-old menopausal athlete. that this will continue in the future. Competitors on medication were advised to present a medical certificate giving details of the medication, including dosage and the condition for which it have found it to be most helpful in identifying was prescribed, should they be selected for the relationship between their hormone levels testing. No reports have been released and there and athletic performance. It has enabled them to have been no public statements concerning the adjust their HRT and ensure optimum levels for tests. athletic performance. Drug-testing rules designed and intended for At this stage, there is a paucity of reliable infor- élite athletes in open competition are not appro- mation on the impact of HRT on athletic perfor- priate for masters competitors. The organizers of mance. There is still much to be learnt, much masters sport have adopted the rulings of the research to be done and some very real pioneer- International Olympic Committee rather than ing work to be undertaken by the present ath- devise their own. Many older athletes, women letes and their coaches. and men, have legitimate reasons to take medica- 164 the masters athlete

Month:...... Year:...... Menopausal symptoms

, Daily training notes Comments Injury/

illness ositive,

strong

changes P night sweats Fatigue Weight

BPR Hot flushes Date Anxiety

Insomnia Other

Mood Muscle Medication

joint pain a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

a.m.

p.m.

a.m. p.m.

a.m.

p.m.

Fig. 11.5 Training diary for menopausal athletes. BPR, basal pulse rate.

tion including drugs from the banned list. This will be written and will include, at a minimum, matter needs to be addressed before decisions a review of previous tests and results of are made to apply the present rules without endocrine investigations. ‘In the event that careful analysis of the implications. previous tests are not available, the athlete For women athletes on androgen therapy the should be tested unannounced at least once current rules relating to drug testing and testos- per month for three months. The results of terone are as follows: these investigations should be included in the The presence of a testosterone (T) to epitestos- report’ (IOC Web Site, Medical Code, article I, terone (E) ratio greater than six (6) to one (1) in (c) 1.b). the urine of a competitor constitutes an offence The concern about the rules governing testos- unless there is evidence that this ratio is due to terone in relation to postmenopausal athletes is a physiological or pathological condition. twofold: (i) it is a banned substance that no In order to assist in this evaluation the IOC athlete should be receiving; and (ii) the test is accredited laboratories shall report every case designed to detect any exogenous testosterone to the proper authorities in accordance with regardless of the overall level, so a menopausal the following criteria: athlete on HRT may have very low levels but A. Negative, if the ratio is less than 6, or would still test positive. B. T:E greater than 6. Even though drug-testing procedures are In the case of B, it is mandatory that additional improving all the time, there are still concerns studies be carried out under the guidance of over the legitimacy of the tests, particularly in the the responsible authority before considering light of the devastating effect it can have on an the case as positive or negative. A full report athlete’s career. Consequently, new tests and new hormone replacement therapy 165

definitions are continually being sought. In rela- This issue is now being addressed by a task tion to the concern over the situation for older force of WomenSport International, who are women athletes on androgen therapy, it is sig- taking it up on a global basis. They believe that nificant that the International Amateur Athletic ‘women should be encouraged to participate in Federation (IAAF) has recently adopted new def- sport at all levels and all ages. Masters athletes initions of testosterone, dihydrotestosterone and should not have to choose between sport and human chorionic gonadotrophin as follows: their health when they reach the menopause’. Testosterone—a sample will be deemed to be The outcome of the work of the task force, the positive for testosterone if the concentration of support of eminent scientists in the field of testosterone in urine so exceeds the range menopause and lobbying by women athletes to of values normally found in humans as not keep this on the agenda should see it brought to a to be consistent with normal endogenous successful conclusion. production. The feature of this new definition is that the con- Conclusion centration of testosterone will be considered in relation to the normal range, and menopausal With athletes continually seeking ways to women receiving androgen therapy as replace- improve their performances, it is of some sur- ment to restore their levels to normal should prise to realize that the potential impact of hor- have no problem. The question is how and who mones on the performance of postmenopausal will determine the normal range. In addition masters athletes has been ignored. It seems there is a clause in the IAAF ‘Procedural Guide- extraordinary that in the days of sophisticated lines for Doping Control’ to grant an exemption, training programmes, nutritional supplements, as follows: scientific technology, sports medicine and any An athlete may request the Doping Commis- number of other means to improve perform- sion to grant prior exemption allowing him to ance that the fundamental issue of how the take a substance normally prohibited under menopause and HRT affect athletic performance IAAF rules. Such an exemption will only be has not been addressed. granted in cases of clear and compelling clini- cal need. Details of the procedure for such an References application are to be found in the ‘Procedural Guidelines for Doping Control’. Burger, H.G., Hailes, J., Menelaus, M., Nelson, J., IAAF legal adviser Mark Gay was unable to Hudson, B. & Balazs, N. (1984) The manage- comment upon the implications for masters ath- ment of persistent menopausal symptoms with oestradiol–testosterone implants: clinical, lipid and letes but did say that ‘Cases concerning hormone hormonal results. Maturitas 6, 351–358. replacement therapy in veteran women athletes Burger, H.G. et al. (1987) Effect of combined implants will, I think, be viewed sympathetically’. of oestradiol and testosterone on libido in post- It has been suggested that the use of hormone menopausal women. replacement that includes androgen therapy in Cabot, S. (1991) Menopause: You Can Give It a Miss. Australian Print Group, Melbourne, Australia. some older women athletes who are very serious Daly, J. & Ey, W. (1993) Training Diary for Women. about their training and competition could Department of Recreation and Sport, Adelaide, present them with the opportunity to cheat, Australia. using an ‘overdose’ in order to produce a better Farrell, E. & Westmore, A. (1993) The HRT Handbook: performance. There will always be some athletes How to Decide if HRT is Right for You. Anne O’Dono- van P/L, Australia. who will abuse the system; however, unlike Jones, R.A. (1994) Testosterone: An Information Leaflet young athletes, older women tend to be cautious for Women. Adelaide Private Menopause Clinic, about drugs and more interested in good health Memorial Hospital, Adelaide, Australia. than short-term athletic performance. Sherwin, B.B. (1988) Affective changes with oestrogen 166 the masters athlete

and androgen replacement therapy in surgically testosterone implants in menopause management. menopausal women. Journal of Affective Disorders 14, In H.G. Burger (ed.) The Menopause. 177–187. Thom, M.H., Collins, W.P. & Studd, T.W. (1981) Hor- Sherwin, B. (1992) Researcher backs androgen for monal profiles in postmenopausal women after women. Australian Doctor Weekly, 28 February. therapy with subcutaneous implants. British Journal Studd, J.W.W. & Smith, R.N.J. (1993) Oestradiol and of Obstetrics and Gynaecology 88, 426–433. PART 5

MEDICAL ISSUES

Chapter 12

Preparticipation Examination

MIMI D. JOHNSON

Introduction drug and alcohol use, seat belt use, birth control and the prevention of sexually transmitted Over the last decade, the number of female ath- diseases. letes participating in organized sports has risen exponentially. As a result, physicians and other Timing and setting of the healthcare providers are being asked to perform preparticipation examination preparticipation examinations on an increasing number of female athletes in the junior high, high Ideally, the PPE should take place 6 weeks prior school and college age groups. Although the to the beginning of the sports season. This allows basics of this examination are the same for both time to evaluate abnormal or questionable find- male and female athletes, there are some special ings further and to correct most musculoskeletal issues that require consideration when dealing problems. There are differing opinions as to how with the female athlete. often the school-age athlete should be evaluated. The objectives of the preparticipation exami- Some feel that the health maintenance examina- nation (PPE) are: (i) to determine the general tion should be performed every year. Others rec- health of the athlete; (ii) to detect any medical or ommend that a full physical examination be musculoskeletal conditions that may limit sports performed at each school entry level (junior participation or predispose the athlete to injury high, high school, college), with an interim or illness during participation; (iii) to institute history and limited examination (as indicated treatment that will bring the athlete to the by the history) to be performed annually optimal level of performance before the season (Lombardo, 1984; McKeag, 1985). The annual begins; and (iv) to meet legal and insurance visits provide an opportunity for guidance and requirements (Allman, 1974; Shaffer, 1978; counselling. Linder et al., 1981; Lombardo, 1984). Although The two most common settings for per- the PPE is not intended to substitute for an forming the PPE are the station-based screen- athlete’s regular health maintenance examina- ing environment and the physician’s office tion, studies show that for over 78% of athletes (Lombardo, 1984; McKeag, 1985; American the PPE is their only periodic contact with a Academy of Family Physicians et al., 1997). The physician (Goldberg et al., 1980; Risser et al., station-based mass examination can be a time- 1985). Therefore, depending on the setting and and cost-effective method of screening athletes. available time, the PPE may also be used as However, the office-based examination provides an opportunity to counsel the athlete on health the opportunity to counsel the athlete and and personal issues. Topics of discussion answer questions about health and personal may include healthy eating patterns, tobacco use, issues. 169 170 medical issues

Growth and Growth can result in decreased flexibility and development considerations increased strength that may not be uniform in distribution. This results in muscle–tendon Changes that occur during the growth and imbalances that can place the athlete at risk for pubertal development of the adolescent athlete injury. In addition, the epiphyseal plate, the artic- may affect injury patterns (Micheli, 1983) and ular cartilage of the joint surface and the apophy- alter expectations of sports participation (e.g. seal insertions of the major muscle–tendon units puberty in the élite gymnast, height concerns in are at increased risk for injury (Micheli, 1983). the basketball player). With an understanding of Repetitive forces at the epiphyseal plate may these changes, the physician is able to explain the result in damage, such as the irregularity, widen- aetiology and prevention of some growth-related ing and premature closure of the distal radial injuries, and counsel the young athlete on future physis in the young gymnast (Roy et al., 1985; growth and developmental expectations. Albanese et al., 1989). Osteochondritis dissecans Pubertal growth accounts for 20–25% of final may be associated with repetitive forces at the adult height. Pubertal weight gain accounts for joint surface (Adams, 1965). Traction apophysi- 50% of an individual’s ideal adult body weight tis, such as that occurring at the tibial tubercle (Barnes, 1975). Peak weight velocity occurs (Osgood–Schlatter disease) (Ogden & South- approximately 6months after peak height veloc- wick, 1976) or the os calcis (Sever’s disease) ity in girls (Tanner, 1962). Menarche occurs at (Micheli, 1983), may be exacerbated by tight about the time of maximum deceleration of muscle–tendon units at these sites. The physician linear growth following peak height velocity performing the PPE can assess flexibility and (Barnes, 1975). Growth after menarche is limited, strength in the growing athlete, check for signs of with a median height gain of 7.4cm (Roche & growth-related injuries and counsel the athlete Davila, 1972). Figure 12.1 demonstrates the inter- on preventative measures such as stretching. relationship of pubertal stage, height spurt and menarche in the female adolescent. Although Female athlete triad pubertal staging is not a necessary part of the PPE, it can be helpful in determining an athlete’s The young female athlete, desiring a thin stage of growth and maturation and its appropri- physique or driven to excel in her sport, may ateness as well as the need to address nutritional attempt to lose weight or body fat by developing issues. patterns of disordered eating. These may include

Height spurt 9.5–14.5 Menarche 10–16.5 Bud Breasts 2 3 4 5 8–13

Pubic hair 2 34 5 8–14 Fig. 12.1 Biological maturity in 9101112 13 14 15 16 girls. (From Tanner, 1962 with Age (years) permission.) preparticipation examination 171

food restriction, bingeing and/or purging, and both parent and athlete provide the history compulsive overexercise. The caloric deprivation (Risser et al., 1985). The history can be obtained resulting from disordered eating behaviour may from a questionnaire similar to the one shown in lead to menstrual dysfunction (Loucks & Heath, Fig. 12.2. The general history should address 1994a) and subsequent premature bone loss or general health, past hospitalization and surgery, osteoporosis (Drinkwater et al., 1984; White chronic disease, medication use, immunization et al., 1992). These three conditions—disordered status, allergies, missing organs and family eating, amenorrhoea and osteoporosis—form history of cardiovascular disease. A more specific what has been termed the female athlete triad history concerned with conditions that most (Yeager et al., 1993). The practitioner performing commonly affect, or are affected by, sports activ- the PPE should be watchful for physical signs ity should also be obtained. These conditions and symptoms of these conditions (Johnson, typically involve the respiratory, cardiovascular, 1992, 1994). neurological, dermatological and musculoskele- tal systems. Further, the athlete is questioned about heat-related illness, eyewear and the use Medical history of protective equipment. The female athlete The medical history is considered to be the most should also be questioned about menstrual and important component of the PPE and can iden- gynaecological history in addition to nutritional tify up to 75% of all problems (Goldberg et al., history (Johnson, 1992). A supplemental history 1980; Risser et al., 1985). There is evidence that for the female athlete can be used to obtain this the information obtained is more accurate when information (Table 12.1).

Table 12.1 Health history for the female athlete

Name: Age: Directions: please answer the following questions to the best of your ability. 1 How old were you when you had your first menstrual period? 2 How long do your periods last? 3 How many periods have you had in the last year? 4 Have you ever gone for 3 or more months without having a period? 5 When was your last period? 6 Do you ever have trouble with heavy menstrual bleeding? 7 Do you ever experience cramps during your period? 8 If so, how do you treat them? 9 Have you ever been on birth control pills or hormones? 10 When was your last pelvic examination? 11 Have you ever been treated for anaemia? 12 How many meals do you eat each day? How many snacks? 13 What have you eaten in the last 24 hours? 14 Are there certain food groups you do not eat (i.e., meats, sweets)? 15 Have you ever been on a diet? 16 What is the highest your weight has ever been? 17 What has been your lowest weight in the last year? 18 What is your present weight? 19 Are you happy with this weight? If not, what would you like to weigh? 20 Have you ever tried to lose weight by vomiting/using laxatives/diuretics/diet pills? 21 Have you ever been diagnosed as having an eating disorder? 22 Do you have questions about healthy ways to control weight? 172 medical issues

HISTORY Date of exam

Name Sex Age Date of birth Class School Sport(s) Address Phone Personal doctor In case of emergency, contact: Name Relationship Phone (H) (W)

Explain 'Yes' answers below. Yes No Circle questions you don't know the answers to. 10. Do you use any special protective or corrective Yes No equipment or devices that aren't usually used for 1. Have you had a medical illness or injury since your your sport or position (e.g. knee brace, special last check up or sports physical? neck roll, foot orthotics, brace on your teeth, Do you have an ongoing or chronic illness? hearing aid)? 2. Have you ever been hospitalized overnight? 11. Have you had any problems with your eyes or vision? Have you ever had surgery? Do you wear glasses, contact or protective eyewear? 3. Are you currently taking any prescription or 12. Have you ever had a sprain, strain or swelling after non-prescription (over-the-counter) medications or injury? pills or using an inhaler? Have you broken or fractured any bones or dislocated Have you ever taken any supplements or vitamins to any joints? help you gain or lose weight or improve your Have you had any other problems with pain or performance? swelling in muscles, tendons, bones or joints? 4. Do you have any allergies (e.g. to pollen, If yes, check appropriate box and explain below. medicine, food or stinging insects)? Head Elbow Hip Have you ever had a rash or hives develop during or Neck Forearm Thigh after exercise? Back Wrist Knee 5. Have you ever passed out during or after exercise? Chest Hand Shin/calf Have you ever been dizzy during or after exercise? Shoulder Finger Ankle Have you ever had chest pain during or after exercise? Upper arm Foot Do you get tired more quickly than your friends do 13. Do you want to weigh more or less than you do now? during exercise? Do you lose weight regularly to meet weight Have you ever had racing of your heart or skipped requirements for your sport? heartbeats? 14. Do you feel stressed? Have you had high blood pressure or high cholesterol? 15. Record the dates of your most recent immunizations Have you ever been told you have a heart murmur? (shots) for: Has any family member or relative died of heart Tetanus Measles problems or of sudden death before age 50? Hepatitus B Chickenpox Have you had a severe viral infection (e.g. myocarditis Females only or mononucleosis) within the last month? 16. When was your first menstrual period? Has a doctor ever denied or restricted your When was your most recent menstrual period? participation in sports for any heart problems? How much time do you usually have from the start of one 6. Do you have any current skin problems (e.g. itching, period to the start of another? rashes, acne, warts, fungus or blisters)? How many periods have you had in the last year? 7. Have you ever had a head injury or concussion? What was the longest time between periods in the last year? Have you ever been knocked out, become unconscious or lost your memory? Explain 'Yes' answers here: Have you ever had a seizure? Do you have frequent or severe headaches? Have you ever had numbness or tingling in you arms, hands, legs or feet? Have you ever had a stinger, burner or pinched nerve? 8. Have you ever become ill from exercising in the heat? 9. Do you cough, wheeze or have trouble breathing during or after activity? Do you have asthma? Do you have seasonal allergies that require medical treatment?

I hereby state that, to the best of my knowledge, my answers to the above questions are complete and correct Signature of athlete Signature of parent/guardian Date

Fig. 12.2 History questionnaire for the preparticipation examination. (From American Academy of Family Physi- cians et al., 1997 with permission.) preparticipation examination 173

Respiratory history Eyewear

During the PPE an attempt should be made to An athlete requiring correction of vision needs to identify athletes who have asthma or exercise- have lenses and frames that are safe for sports. A induced bronchospasm. These athletes often history of eye injury or surgery is important. need medication prior to exercise, particularly during cold weather or allergy seasons. Protective equipment

This question can often alert the examiner to a Cardiovascular history musculoskeletal problem that the athlete may Although the risk of sudden death is lower for have failed to remember. Status of the current women than for men, over 95% of sudden deaths equipment can be evaluated for efficacy. in athletes under the age of 30 are due to cardiac Although mouth-guards are currently required conditions (Van Camp, 1988). Therefore, careful in most collision sports, they are also recom- attention must be paid to the cardiac history. mended for all athletes wearing braces on their Family cardiac history is important because teeth. several causes of sudden cardiac death may be familial (i.e. hypertrophic cardiomyopathy, Musculoskeletal history Marfan syndrome, lipid abnormalities). Syncope or near-syncopal episodes, chest pain on exer- The history alone has been shown to be 92% sen- tion, palpitations, or dyspnoea on exertion all sitive in detecting significant musculoskeletal warrant further evaluation. injuries (Gomez et al., 1993). Ahistory of previous musculoskeletal injuries that limited sports participation should be obtained, in addition to Neurological history treatment received and adequacy of rehabilita- History of neurological conditions or injuries, tion. Unrehabilitated previous injuries are strong such as concussion, seizures, ‘burners’, severe or predictors of subsequent injuries. Previous stress recurrent headaches, transient quadriplegia or fractures should prompt inquiries about biome- ‘pinched nerves’ warrant thorough review and chanical evaluation as well as menstrual dys- possible further evaluation. function. A history of scoliosis, which is more common in females than males, should be obtained. Finally, history of a recent growth spurt Dermatological history may alert the physician to possible growth- History of infectious conditions, such as herpes related injuries. simplex, scabies and molluscum contagiosum, can be important for athletes involved in Menstrual and gynaecological history contact/collision sports or in sports that share mats, towels, etc. Acne can also be potentiated Menstrual and gynaecological history should from sweating and wearing constrictive clothing. include age of menarche, length and frequency of periods, date of the last period and use of hor- monal therapy. Past history of amenorrhoea or Heat-related illness oligomenorrhoea should be obtained. Heat-related illness is often recurrent and there- Athletes with menstrual irregularity require fore information should be obtained about further evaluation. If the athlete is aged 14 hydration and medications that may increase the and prepubertal, or 16 and premenarcheal, she risk for heat-related disorders (e.g. antihista- should be evaluated for primary amenorrhoea. If mines, caffeine). she is menarcheal and has missed three consecu- 174 medical issues

tive menstrual periods or has not had a period in highest risk. The athlete requires further evalua- 6 months, she should be evaluated for secondary tion if she is normal or underweight and wants to amenorrhoea (Speroff et al., 1989). The athlete lose weight, her caloric intake is lower than her should also be evaluated if she has irregular caloric expenditure, she avoids groups of food menses or is bleeding more frequently than once (i.e. all fats or all meats) or admits to disordered every 25 days or less frequently than once every eating behaviour. If an eating disorder is sus- 35 days (Shangold, 1986). Athletes with primary pected, referral to a physician, nutritionist and amenorrhoea, oligomenorrhoea and secondary therapist trained in the management of eating amenorrhoea may be in ‘energy deficit’ (exercise disorders is appropriate. If the athlete has ques- calorie expenditure is greater than dietary calorie tions regarding weight control, guidelines about intake), although other medical causes of these appropriate nutrition and weight management conditions need to be ruled out (Loucks & may dissuade her from developing disordered Callister, 1993; Loucks & Heath 1994a,b). eating behaviours. The amount of menstrual flow should be ascertained. If it is unusually heavy, one should Health habits ask about symptoms of, and previous treatment for, anaemia. Dysmenorrhoea, which can inter- In the physician’s office setting, the health habits fere with sports activities, can usually be treated of the athlete can be assessed in a non- successfully with antiprostaglandin therapy. judgemental way. Topics such as alcohol, tobacco Young athletes may have questions about and drug use, safe sex and birth control, seat belt tampon use during sports activities. If the athlete and helmet use, gun control and use of ergogenic is 18years of age or older or has been sexually aids can be addressed. The athlete can be asked if active, she should be encouraged to undergo a she feels stressed, if she has an adequate support pelvic examination if one has not been previ- system to deal with stressors and if there are ously performed. It is also appropriate to ask other topics she would like to address (American about frequency of urinary tract infections; some Academy of Family Physicians et al., 1997). athletes restrict fluids, which could aggravate such an infection. Physical examination Adequate breast support should be encour- aged, especially in running and jumping activi- The physical examination emphasizes the areas ties. Women can be advised to obtain a sport bra of greatest concern with regard to the athlete’s that is firm, made mostly of non-elastic material particular sport and areas identified as problems and has good absorptive qualities. in the athlete’s history. Ideally, the athlete should be dressed in a T-shirt or gown and shorts. Nutritional history General assessment All female athletes should be questioned about their eating patterns. Disordered eating patterns During the assessment of body habitus, the have been reported in up to 32% of female college physician has an opportunity to make an initial athletes (Rosen et al., 1986) and are seen in estimation of maturity, nutritional status, body younger athletes as well (Benson et al., 1985; fat and the presence of any syndromic features. Loosli et al., 1986; Dummer et al., 1987). Athletes Evidence for an eating disorder or exogenous from all sports can develop eating disorders, hormone use may be seen. but those involved in sports that emphasize a lean appearance (gymnastics, diving, ballet, ice Vital signs skating), body leanness for optimal performance (long-distance running, swimming) or weight Height and weight measurements are useful for classifications (rowing, martial arts) may be at evaluating overall growth and development and preparticipation examination 175

nutritional status. Most athletes should weigh any diastolic murmur or any murmur that gets between the 25th and 50th percentiles for height louder with a Valsalva manoeuvre should be and age because of the presence of increased further evaluated (American Academy of Family muscle mass, compared with the non-athletic Physicians et al., 1997). population. Resting heart rate may be elevated in anaemia and may be abnormally low (30–50 Abdominal examination beats·min–1) in anorexia nervosa. Hypertension in the 10–12 year old is defined as a blood pres- In addition to the general assessment, enlarge- sure of ≥ 126/82mmHg (16.8/10.9kPa); in the ment of the liver and spleen should be evaluated 13–15 year old as a blood pressure of ≥ 136/ in the athlete with recent history of Epstein–Barr 86mmHg (18.1/11.4kPa); and in the 16–18 year virus infection, viral illness or haematological old as a blood pressure of ≥ 142/92mmHg disorder. (18.9/12.2kPa) (Task Force on Blood Pressure Control in Children, 1987). To confirm elevated Dermatological examination blood pressure, abnormal measurements should be found on three different occasions. The athlete should be examined for rashes, infec- tions and infestations. Head, eyes, ears, nose and throat examination Neurological examination Visual acuity should be 20/40 or better in each eye, with or without corrective lenses. Pupils In the athlete with a history of concussion, severe should be examined for anisocoria (unequal or recurrent headaches, or nerve impairment, a pupil size). The swimmer should be evaluated thorough neurological evaluation is appropriate. for otitis externa and tympanic membrane per- foration. Decreased tooth enamel may be seen Pubertal staging and in the athlete with longstanding bulimia. The gynaecological examination remainder of this examination should assess for the general health of these areas. Pubertal staging may be appropriate in the pubescent female athlete, not only to evaluate development but also to educate the athlete on Respiratory examination future developmental expectations (Table 12.2). Respiratory examination should reveal clear If the physical examination is part of the health breath sounds. A normal examination does not maintenance examination, a breast inspection exclude exercise-induced bronchospasm. with instructions on self-examination is appro- priate. A pelvic examination can be performed if warranted. Cardiovascular examination

Palpation of the radial and femoral pulses and Musculoskeletal examination auscultation of the heart should be performed. Auscultation should be carried out with the The musculoskeletal examination may include a athlete in supine and sitting or standing posi- general screen (Table 12.3). It should also include tions (the murmur of hypertrophic cardiomy- joint-specific testing of those areas of previous opathy may be louder in the standing position). injury, pain, swelling, locking, weakness, Murmurs are commonly heard in the adolescent. atrophy or joint instability that may have been Deep inspiration and Valsalva’s manoeuvre can detected in the history or on the general screen. help differentiate a functional murmur from a Joint-specific testing of those areas at increased pathological murmur (Lembo et al., 1988). Any risk of injury in the athlete’s specific sport can systolic murmur greater than II/VI in severity, also be performed (Table 12.4) . The joint-specific 176 medical issues

Table 12.2 Classification of pubertal staging in girls. (Adapted from Tanner, 1962)

Stage Pubic hair Breasts

1 None Prepubertal, no glandular tissue 2 Sparse, long, straight, Breast bud, small amount of lightly pigmented on glandular tissue labia majora 3 Darker, beginning to Breast mound and areola curl, extend laterally enlarge, no contour separation 4 Coarse, curly, abundant, Breast enlarged, areola less than adult and papilla form mound projecting from breast contour 5 Adult type and quantity, Mature, areola part of breast extending to medial contour thigh

Table 12.3 General musculoskeletal screen. (Adapted from American Academy of Pediatrics Committee on Sports Medicine and Fitness, 1991 and American Academy of Family Physicians et al., 1997)

Instructions Points of observation

Stand facing examiner General habitus, trunk and upper extremity symmetry Look at ceiling, floor, over both shoulders; touch Cervical spine motion ears to shoulders Shrug shoulders (examiner resists) Trapezius strength Abduct shoulders 90° (examiner resists) Deltoid strength Full external and internal rotation of arms Shoulder motion Flex and extend elbows Elbow motion Arms at sides, elbows 90°flexed; pronate and Elbow and wrist motion supinate wrists Spread fingers; make fist Hand or finger motion and deformities Contract/relax quadriceps Inspect lower extremities for symmetry, alignment ‘Duck walk’ four steps (away from examiner with Hip, knee and ankle motion; strength and balance buttocks on heels) Back to examiner Upper extremity and trunk symmetry Knees straight, touch toes Back and hip motion, spine curvature, hamstring tightness Extend back toward examiner Lumber spine for spondylolysis/spondylolisthesis Raise up on toes, raise heels Calf symmetry, leg strength, balance preparticipation examination 177

Table 12.4 Sport-specific areas of increased risk Rehabilitation, evaluation and treatment of Ballet Feet, ankles, knees, hips, abnormal findings lumbar spine Basketball Feet, ankles, knees, shoulders The athlete with musculoskeletal conditions Gymnastics Ankles, knees, lumbar spine, requiring rehabilitation can be instructed in the wrists, elbows, shoulders appropriate exercise programme by the physi- Ice skating Feet, ankles, shins, lumbar cian knowledgeable in sports medicine, or by a spine physical therapist or athletic trainer. The athlete Racquet sports Shoulders, elbows, wrists, knees, ankles, feet with medical conditions requiring treatment Rowing Spine, Achilles tendon, knees, should be started on therapy or referred for hands, shoulders, elbows, further evaluation. A follow-up visit should be wrists planned to ensure that appropriate treatment Soccer Feet, ankles, shins, knees, was received and to give clearance for sports thighs, pelvis, lumbar spine, neck participation. Softball Shoulders, elbows, ankles, The female athlete with disordered eating knees behaviour often requires an additional office visit Swimming Shoulders, lumbar spine to allow the physician to assess whether her Track/cross-country Shoulders, feet, ankles, shins, behaviour can be changed with nutritional edu- knees, thighs, hips Volleyball Ankles, knees, shoulders, cation alone or whether she requires psychologi- hands cal intervention as well (Johnson, 1994). The athlete with an eating disorder may need to be withheld from sports participation when there is evidence or concern that continued participation examination includes inspection and range of could cause injury or increased morbidity. motion of the indicated joint(s) (i.e. neck, spine, The athlete with exercise-associated amenor- shoulders, elbows, wrists, fingers, hips, knees, rhoea will usually experience a resumption of ankles and feet). Stability of the shoulders, menses with increased caloric intake (Loucks & elbows, knees and ankles can also be assessed. Callister, 1993). She can be counselled on this at Symmetry of joint appearance and motion is the time of the PPE or at a subsequent visit. If she noted, and general strength and flexibility has difficulty changing her eating patterns, around the joint(s) should be assessed. despite nutritional and psychological coun- selling, hormone replacement therapy may be considered, depending on her age, in order to Laboratory assessment preserve her bone mineral density (Emans & Routine screening laboratory tests in the asymp- Goldstein, 1990; Marshall, 1994; Hergenroeder, tomatic athlete are not recommended for the 1995). PPE (Goldberg et al., 1980; American Academy of Pediatrics Committee on Sports Medicine Clearance for sports participation and Fitness, 1991; American Academy of Family Physicians et al., 1997). However, findings from Clearance can be divided into three categories: (i) the history or physical examination may indicate unrestricted clearance; (ii) clearance after com- a need for specific diagnostic tests. For example, pletion of further evaluation or rehabilitation; if the athlete has a history of anaemia, fatigue, and (iii) not cleared for certain types of sport or poor dietary intake or increased menstrual flow, for all sports. Clearance for a particular sport a haematological profile and ferritin level would may be based on guidelines established by the be appropriate. A urinalysis may be diagnostic if American Academy of Pediatrics Committee on she complains of dysuria, urgency or frequency. Sports Medicine and Fitness (1994) (Table 12.5) 178 medical issues

Table 12.5 Medical conditions affecting sports participation. (From American Academy of Pediatrics Committee on Sports Medicine and Fitness, 1994 with permission)

Condition May participate?

Atlantoaxial instability (instability of the joint between cervical vertebrae 1 and 2) Qualified yes Explanation: athlete needs evaluation to assess risk of spinal cord injury during sports participation Bleeding disorder Qualified yes Explanation: athlete needs evaluation Cardiovascular diseases Carditis (inflammation of the heart) No Explanation: carditis may result in sudden death with exertion Hypertension (high blood pressure) Qualified yes Explanation: those with significant essential (unexplained) hypertension should avoid weight and power lifting, body building and strength training. Those with secondary hypertension (hypertension caused by a previously identified disease), or severe essential hypertension, need evaluation Congenital heart disease (structural heart defects present at birth) Qualified yes Explanation: those with mild forms may participate fully; those with moderate or severe forms, or who have undergone surgery, need evaluation Dysrhythmia (irregular heart rhythm) Qualified yes Explanation: athlete needs evaluation because some types require therapy or make certain sports dangerous, or both Mitral valve prolapse (abnormal heart valve) Qualified yes Explanation: those with symptoms (chest pain, symptoms of possible dysrhythmia) or evidence of mitral regurgitation (leaking) on physical examination need evaluation. All others may participate fully Heart murmur Qualified yes Explanation: if the murmur is innocent (does not indicate heart disease), full participation is permitted. Otherwise the athlete needs evaluation (see congenital heart disease and mitral valve prolapse above) Cerebral palsy Qualified yes Explanation: athlete needs evaluation Diabetes mellitus Yes Explanation: all sports can be played with proper attention to diet, hydration and insulin therapy. Particular attention is needed for activities that last 30min or more Diarrhoea Qualified no Explanation: Unless disease is mild, no participation is permitted, because diarrhoea may increase the risk of dehydration and heat illness. See Fever Eating disorders Qualified yes Anorexia nervosa Bulimia nervosa Explanation: these patients need both medical and psychiatric assessment before participation Eyes Functionally one-eyed athlete Qualified yes Loss of an eye Detached retina Previous eye surgery or serious eye injury Explanation: a functionally one-eyed athlete has a best corrected visual acuity of < 20/40 in

Continued preparticipation examination 179

Table 12.5 (Continued)

Condition May participate?

the worse eye. These athletes would suffer significant disability if the better eye was seriously injured as would those with loss of an eye. Some athletes who have previously undergone eye surgery or had a serious eye injury may have an increased risk of injury because of weakened eye tissue. Availability of eye-guards approved by the American Society for Testing Materials and other protective equipment may allow participation in most sports, but this must be judged on an individual basis Fever No Explanation: fever can increase cardiopulmonary effort, reduce maximum exercise capacity, make heat illness more likely and increase orthostatic hypotension during exercise. Fever may rarely accompany myocarditis or other infections that may make exercise dangerous Heat illness, history of Qualified yes Explanation: because of the increased likelihood of recurrence, the athlete needs individual assessment to determine the presence of predisposing conditions and to arrange a prevention strategy HIV infection Yes Explanation: because of the apparent minimal risk to others, all sports may be played that the state of health allows. In all athletes, skin lesions should be properly covered, and athletic personnel should use universal precautions when handling blood or body fluids with visible blood Kidney: absence of one Qualified yes Explanation: athlete needs individual assessment for contact/collision and limited contact sports Liver: enlarged Qualified yes Explanation: if the liver is acutely enlarged, participation should be avoided because of risk of rupture. If the liver is chronically enlarged, individual assessment is needed before collision/contact or limited contact sports are played Malignancy Qualified yes Explanation: athlete needs individual assessment Musculoskeletal disorders Qualified yes Explanation: athlete needs individual assessment Neurological History of serious head or spine trauma, severe or repeated concussions, or craniotomy Qualified yes Explanation: athlete needs individual assessment for collision/contact or limited contact sports, and also for non-contact sports if there are deficits in judgement or cognition. Recent research supports a conservative approach to management of concussion Convulsive disorder, well controlled Yes Explanation: risk of convulsion during participation is minimal Convulsive disorder, poorly controlled Qualified yes Explanation: athlete needs individual assessment for collision/contact or limited contact sports. Avoid the following non-contact sports: archery, riflery, swimming, weight or power lifting, strength training, or sports involving heights. In these sports, occurrence of a convulsion may be a risk to self or others

Continued p. 180 180 medical issues

Table 12.5 (Continued)

Condition May participate?

Obesity Qualified yes Explanation: because of the risk of heat illness, obese persons need careful acclimatization and hydration Organ transplant recipient Qualified yes Explanation: athlete needs individual assessment Ovary: absence of one Yes Explanation: risk of severe injury to the remaining ovary is minimal Respiratory Pulmonary compromise including cystic fibrosis Qualified yes Explanation: athlete needs individual assessment, but generally all sports may be played if oxygenation remains satisfactory during a graded exercise test. Patients with cystic fibrosis need acclimatization and good hydration to reduce the risk of heat illness Asthma Yes Explanation: with proper medication and education, only athletes with the most severe asthma will have to modify their participation Acute upper respiratory infection Qualified yes Explanation: upper respiratory obstruction may affect pulmonary function. Athlete needs individual assessment for all but mild disease. See Fever Sickle cell disease Qualified yes Explanation: athlete needs individual assessment. In general, if status of the illness permits, all but high-exertion, collision/contact sports may be played. Overheating, dehydration and chilling must be avoided Sickle cell trait Yes Explanation: it is unlikely that individuals with sickle cell trait (AS) have an increased risk of sudden death or other medical problems during athletic participation except under the most extreme conditions of heat, humidity and possibly increased altitude. These individuals, like all athletes, should be carefully conditioned, acclimatized and hydrated to reduce any possible risk Skin: boils, herpes simplex, impetigo, scabies, molluscum contagiosum Qualified yes Explanation: while the patient is contagious, participation in gymnastics with mats, martial arts, wrestling or other collision/contact or limited contact sports is not allowed. Herpes simplex virus probably is not transmitted via mats Spleen, enlarged Qualified yes Explanation: patients with acutely enlarged spleens should avoid all sports because of risk of rupture. Those with chronically enlarged spleens need individual assessment before playing collision/contact or limited contact sports Testicle: absent or undescended Yes Explanation: certain sports may require a protective cup

This table is designed to be understood by medical and non-medical personnel. In the Explanation section, ‘needs evaluation’ means that a physician with appropriate knowledge and experience should assess the safety of a given sport for an athlete with the listed medical condition. Unless otherwise noted, this is because of the variability of the severity of the disease or of the risk of injury among the specific sports or both. preparticipation examination 181

or, for cardiovascular abnormalities, on the 26th Medicine and Fitness (1994) Medical conditions Bethesda Conference (1994). Occasionally, an affecting sports participation. Pediatrics 94, 757–760. Barnes, H. (1975) Physical growth and development athlete will wish to participate despite medical during puberty. Medical Clinics of North America 59, recommendations to the contrary. In this situa- 1305–1317. tion, the athlete, parents, coach and school/pro- Benson, J., Gillien, D., Bourdet, K. & Loosli, A. (1985) gramme administrators should all understand Inadequate nutrition and chronic calorie restriction the potential long-term consequences of partici- in adolescent ballerinas. Physician and Sportsmedicine 13, 79–90. pation and the appropriate legal documentation Bethesda Conference, 26th (1994) Recommendations should be prepared. for determining eligibility for competition in athletes with cardiovascular abnormalities. Medicine and Science in Sports and Exercise 26 (Suppl.), S223–S283. Conclusion Drinkwater, B., Nilson, K., Chesnut, C., Bremner, W., Shamholtz, S. & Southworth, M. (1984) Bone mineral When performing a PPE on the female athlete it content of amenorrheic and eumenorrheic athletes. is helpful to keep in mind her developmental New England Journal of Medicine 311, 277–280. stage, so that appropriate guidance can be given Dummer, G., Rosen, L., Heusner, W., Roberts, P. & about expectations for growth and maturation Counsilman, J. (1987) Pathogenic weight control and the avoidance of growth-related injuries. behaviors of young competitive swimmers. Physician and Sportsmedicine 15, 75–86. The female athlete striving to attain a thin Emans, S. & Goldstein, D. (1990) Pediatric and Adolescent physique is at risk for the development of disor- Gynecology. Little, Brown, Boston. dered eating patterns, menstrual dysfunction Goldberg, B., Saraniti, A., Witman, P., Gavin, M. & and potential loss of bone mineral density. Nicholas, J. (1980) Pre-participation sports assess- Careful evaluation for, and treatment and pre- ment: an objective evaluation. Pediatrics 66, 736–745. Gomez, J., Landry, G. & Bernhardt, D. (1993) Critical vention of, these and other conditions that may evaluation of the 2-minute orthopedic screening affect sport participation will result in a healthier examination. American Journal of Diseases of Children athlete on and off the field. 147, 1109–1113. Hergenroeder, A. (1995) Bone mineralization, hypo- thalamic amenorrhea, and sex steroid therapy in References female adolescents and young adults. Journal of Pedi- atrics 126, 683–689. Adams, J. (1965) Injury to the throwing arm: a study of Johnson, M. (1992) Tailoring the preparticipation traumatic changes in the elbow joints of boy baseball examination to female athletes. Physician and Sports- players. California Medicine 102, 127–132. medicine 20, 61–72. Albanese, S., Palmer, A., Kerr, D., Carpenter, C., Lisi, D. Johnson, M. (1994) Disordered eating in active and ath- & Levinsohn, M. (1989) Wrist pain and distal growth letic women. Clinics in Sports Medicine 13, 355–369. plate closure of the radius in gymnasts. Journal of Lembo, N., Dell’Italia, L., Crawford, M. & O’Rourke, R. Pediatric Orthopedics 9, 23–28. (1988) Bedside diagnosis of systolic murmurs. New Allman, F. (1974) Medical qualification for sports par- England Journal of Medicine 318, 1572–1578. ticipation. In A. Ryan & F.L. Allman (eds) Sports Linder, C., DuRant, R., Seklecki, R. & Strong, W. (1981) Medicine, pp. 86–111. Academic Press, New York. Preparticipation health screening of young athletes. American Academy of Family Physicians, American American Journal of Sports Medicine 9, 187–193. Academy of Pediatrics, American Medical Society Lombardo, J. (1984) Pre-participation physical evalua- for Sports Medicine, American Orthopaedic Society tion. Primary Care Clinics 11, 3–21. for Sports Medicine & American Osteopathic Loosli, A., Benson, J., Gillien, D. & Bourdet, K. (1986) Academy of Sports Medicine (1997) Preparticipation Nutrition habits and knowledge in competitive Physical Evaluation, 2nd edn. McGraw-Hill Health- adolescent female gymnasts. Physician and care, Minneapolis. Sportsmedicine 14, 118–130. American Academy of Pediatrics Committee on Sports Loucks, A. & Callister, R. (1993) Induction and preven- Medicine and Fitness (1991) Sports Medicine: Health tion of low-T3 syndrome in exercising women. Care for Young Athletes, 2nd edn. American Academy American Journal of Physiology 264, R924–R930. of Pediatrics, Elk Grove Village, Illinois. Loucks, A. & Heath, E. (1994a) Induction of low-T3 syn- American Academy of Pediatrics Committee on Sports drome in exercising women occurs at a threshold of 182 medical issues

energy availability. American Journal of Physiology Roy, S., Caine, D. & Singer, K. (1985) Stress changes of 266, R817–R823. the distal radial epiphysis in young gymnasts. Loucks, A. & Heath, E. (1994b) Dietary restriction American Journal of Sports Medicine 13, 301–308. reduces luteinizing hormone (LH) pulse frequency Shaffer, T. (1978) The health examination for participa- during waking hours and increases LH pulse ampli- tion in sports. Pediatric Annals 7, 666–675. tude during sleep in young menstruating women. Shangold, M. (1986) How I manage exercise-related Journal of Clinical Endocrinology and Metabolism 78, menstrual disturbances. Physician and Sportsmedicine 910–915. 14, 113–120. McKeag, D. (1985) Preseason physical examination for Speroff, L., Glass, R. & Kase, N. (eds) (1989) Clinical the prevention of sports injuries. Sports Medicine 2, Gynecologic Endocrinology and Infertility, 4th edn. 413–431. Williams & Wilkins, Baltimore. Marshall, L. (1994) Clinical evaluation of amenorrhea Tanner, J. (1962) Growth at Adolescence, 2nd edn. Black- in active and athletic women. Clinics in Sports Medi- well Scientific Publications, Oxford. cine 13, 371–387. Task Force on Blood Pressure Control in Children Micheli, L. (1983) Overuse injuries in children’s sports: (1987) Report of the Second Task Force on Blood the growth factor. Orthopedic Clinics of North America Pressure Control in Children 1987. Pediatrics 79, 1– 14, 337–360. 25. Ogden, J. & Southwick, W. (1976) Osgood–Schlatter’s Van Camp, S. (1988) Sudden death in athletes. In W.A. disease and tibial tuberosity development. Clinical Grana & J.A. Lombardo (eds) Advances in Sports Orthopedics 116, 180–189. Medicine and Fitness. Year Book Medical Publishers, Risser, W., Hoffman, H. & Bellah, G. (1985) Frequency Chicago. of preparticipation sports examinations in secondary White, C., Hergenroeder, A. & Klish, W. (1992) Bone school athletes: are the University Interscholastic mineral density in 15 to 21 year old eumenorrheic League guidelines appropriate? Texas Medicine 81, and amenorrheic subjects. American Journal of Dis- 35–39. eases of Children 146, 31–35. Roche, A. & Davila, G. (1972) Late adolescent growth in Yeager, K., Agostini, R., Nattiv, A. & Drinkwater, B. stature. Pediatrics 50, 874–880. (1993) The female athlete triad: disordered eating, Rosen, L., McKeag, D., Hough, D. & Curley, V. (1986) amenorrhea, osteoporosis. Medicine and Science in Pathogenic weight-control behavior in female ath- Sports and Exercise 25, 775–777. letes. Physician and Sportsmedicine 14, 79–86. Chapter 13

Gender Verification

ARNE LJUNGQVIST

Introduction such responsibility. It may seem an easy problem to solve, but this chapter shows that it is a com- Competitive sport was created by men for men. plicated matter. However, once sport for women became recog- nized it developed rapidly. In many sports, Methods for gender verification women’s competitions at the world élite level, such as the Olympic Games, are as prestigious as Historical background men’s competitions and meet with the same degree of interest. A number of cases are known of athletes with Sports achievements are to a large extent, testes who have competed as women. One although not in all sports, based on the physical famous case from the 1930s was revealed in capacity and muscular strength, and also aggres- 1980 when an autopsy was performed on the siveness, of the individual. Because these char- women’s 100m sprint champion of the 1932 acteristics are usually considerably more Olympic Games. The autopsy was said to show developed in men than women, due to the effects the existence of testes, the coroner’s report of the androgenic steroids (testosterone) secreted stating that ‘the problem is a subtle one which by the testes, it is important to be certain that requires chromosome tests to settle once and for no men compete in women’s competitions. This all the questions of her gender’ (Anon., 1981, does not seem to have been an issue in earlier cited in Ferguson-Smith & Ferris, 1991). days (i.e. before the Second World War). In In 1957 a German athlete confessed openly the postwar years, however, success in high- to having been forced during the Nazi era in level international sports competitions became Germany to compete as a woman. The athlete increasingly important and prestigious for the actually broke the world record in women’s high individual athlete as well as for the country he jump in 1938. It seems never to have been clari- or she represented. In our time, international fied whether this was a case of true hermaphro- élite sport is also growing more professional and ditism (both male and female sex organs) as many successful athletes earn their living and/or claimed by Donohoe and Johnson (1986) or a make great fortunes from their sport. Therefore, male imposter as claimed by Ryan (1976). The the authorities who govern sport feel very person was later disqualified from female com- strongly the responsibilities they have to make petition by the German Athletic Federation. sure that fair play prevails, that rules are adhered There are also examples in which successful to and that any unfair advantage sought be iden- athletes in women’s events have later under- tified and counteracted. To prevent men from gone sex-change operations to become men. participating in women’s competitions is one Such examples include a runner who was the 183 184 medical issues

women’s 800m world record holder in 1931 at the test. It was widely speculated that these (Tachezy, 1969). Furthermore, two members of a athletes withdrew knowing that they would women’s relay team that finished second in the have problems in passing the test, speculations European Athletics Championships in 1946 also which have remained unproven (Larned, 1976; underwent sex-change operations later and one Donohoe & Johnson, 1986). Despite the experi- of these individuals even became a father (Ryan, ence in Budapest, physical examination was 1976; Donohoe & Johnson, 1986). The most again conducted on the female athletes at the famous case in this context would probably be Commonwealth Games in Kingston, Jamaica the winner of the 1966 women’s world downhill in 1966 and at the Pan American Games in Win- skiing title who retired after medical examina- nipeg in 1967. On the former occasion manual tion in 1967. Later, after surgery this athlete examination of the external genitalia was con- married a woman and became a father (Ryan, ducted on all women athletes by a gynaecologist 1976). There are also reports of transsexual indi- (Turnbull, 1988). viduals who were brought up as boys or young The experience with physical examination as men but later competed in women’s competi- a method for verification of female gender at tions after sex reassignment to female (Ryan, sports competitions was not encouraging. The 1976; Higdon, 1992). humiliation inflicted on the individuals involved All the above-mentioned individual cases was widely resented and less humiliating fuelled the rumours that men actually did methods had to be found in order to verify eligi- compete in women’s events in the early postwar bility for women’s competitions. era. Means were sought to prevent this from hap- pening in the future. Sex chromatin testing

At the European Athletics Cup in Kiev in 1967 Physical examination attempts were first made to determine the The first attempt to make sure that only women gender of the female athletes on the basis of chro- participate in women’s competition seems to mosome constitution. This type of investigation have been made by the British Women’s is based on the assumption that cells from men Amateur Athletic Association. In 1948 they normally carry 46 chromosomes including one X decided to require a doctor’s certificate from and one Y sex chromosome (46,XY individuals); athletes who entered women’s athletics competi- the sex chromosomes in cells from women com- tions. This measure was soon recognized as prise twoXchromosomes (46,XX individuals). insufficient and abandoned. Due to persistent In Kiev one individual was found with a chro- rumours in the 1950s and 1960s a new attempt mosomal abnormality that was judged to render was made at the European Athletics Cham- her ineligible for participation in women’s com- pionships in Budapest in 1966. Female partici- petitions. This happened to be a high-profile pants were required to undergo physical athlete, namely the Polish world record holder inspection. Reportedly this meant that the 243 for 100m. She had also won one gold and one female participants had to parade more or less bronze medal in the Tokyo Olympic Games 3 nude in front of a panel of female doctors years earlier and had successfully passed the (Larned, 1976). All participants were reported to examination in Budapest in 1966. When the have passed this test successfully, but the result- result of the investigation in Kiev was officially ing humiliation was widely resented. However, announced, major unrest developed. In 1970 it is of some interest to know that no less than five the results were annulled by the International or six athletes (information varies), who until Amateur Athletic Federation (IAAF) (Krawczyn- 1966 had participated in women’s athletics ski, 1978; Turnbull, 1988). This particular athlete events at the world élite level, did not show up was found to have ‘one chromosome too many’ gender verification 185

(Larned, 1976), probably a case of 46,XX/47,XXY referred to as the buccal smear test. Obtaining a mosaicism. There is no evidence that this would smear of cells from the buccal mucosa is afford her any physical advantage over normal extremely simple and non-invasive; thus the test XX females. The athlete is reported by friends to seemed to have raised no major objection be still suffering from the incident both mentally amongst female athletes when it was introduced. and socially. It was therefore quickly adopted by other inter- After some years of preparatory work (Hay, national sports organizations, becoming the 1972), the International Olympic Committee principal gender verification test in sport for a (IOC) tentatively introduced genetic tests for long period of time. gender verification at the Winter Olympic Games in Grenoble in 1968 and made it compulsory for all female athletes at the Games in Mexico City later the same year. The laboratory investigation performed (the so-called sex chromatin test) was again based on the difference between male and female sex chromosome patterns. The test involves staining interphase cells to detect sex chromatin, which is located in the nucleus (Fig. 13.1). The presence of sex chromatin reflects the inactivation of one of the X chromosomes. This requires the presence of two X chromosomes in the cell, one of which remains active. Therefore in XY individuals no chromatin body will be identi- fiable. For this reason the test will be positive (present) in XX individuals and negative (absent) in XY individuals. Cells for this test are most easily obtained by scraping epithelial cells from the inside of the cheek (the buccal area) with a Fig. 13.1 X-chromatin (arrow). (From Simpson & spatula (Fig. 13.2). The test is therefore often also Golbus, 1976 with permission of W.B. Saunders.)

Fig. 13.2 Obtaining a sample of epithelial cells from the buccal area inside the cheek for gender verification. (© CIO / Jean-Paul Maeder.) 186 medical issues

Gender verification as developed and prac- tised by the IOC thus included the sex chromatin test as a screening procedure. Should this be neg- ative or inconclusive a full chromosome analysis on a blood sample (determination of the kary- otype) would follow. Should this also be in- conclusive the athlete would be subjected to a gynaecological examination before a final deci- sion. Once an athlete passed the test, whether the screening procedure only or the full three-stage investigation, she would be issued with a sex cer- tificate. A carrier of such a certificate would not be required to undergo the gender verification test again. This approach has remained essentially unchanged and only the screening procedure has been modified, as explained below (Comité International Olympic, 1995). However, as the science of medical genetics developed it became obvious that chromosomal aberrations occur in otherwise healthy men and women. Thus, individuals with a male pheno- type (physical appearance of a man) may well have two X chromosomes, whereas individuals with a female phenotype (physical appearance of Fig. 13.3 The Spanish hurdler Maria José Martinez a woman) may have only one X chromosome Patiño, who publicly challenged the sex test proce- and may even carry a Y chromosome. Both false- dures in sport after having tested ‘male’ (46,XY). (Cour- positive and false-negative results may thus tesy of Maria José Martinez Patiño.) occur in the sex chromatin test. Furthermore, quite complex aberrations in the sex chromo- some pattern have been identified, e.g. University Games in Kobe in 1985, this athlete mosaicism, where cells with either XX or XY sex was found to have a negative sex chromatin test. chromosome complements are found in the same Therefore she was judged ineligible for female individual (de la Chapelle, 1986; Ferguson-Smith competition. This was particularly frustrating for & Ferris, 1991; Simpson et al., 1993). Ironically, it the athlete since she had already passed the same would seem that in retrospect the Polish sprinter test 2 years earlier at the World Championships disqualified in 1967 would in all probability have in Helsinki. Unfortunately, she had left her sex passed the gender verification test employed in certificate from that test at home in Spain and Mexico City. was therefore tested again in Kobe. The athlete It should be borne in mind that in a buccal- then suffered extreme hardship both socially and smear specimen not all cells will stain favourably financially. She courageously challenged the or show a clear picture. Usually some 30% of the system publicly and later had her female gender cells will be positive and thus judged as ‘female’. re-established. In fact, she is an example of a Therefore, a certain subjectivity on the part of 46,XY female with testicular feminization syn- the examiner is inevitable. This is exemplified by drome or androgen insensitivity syndrome. the well-known case of the Spanish hurdler Although these individuals carry the typical Maria José Martinez Patiño, which was widely chromosome pattern of normal men, they are publicized in the media (Fig. 13.3). In the World actually physically women (Ferguson-Smith, gender verification 187

1998). Moreover, they are resistant to androgenic Target Double-stranded hormones and therefore cannot benefit from the sequence DNA template administration (doping) or endogenous presence of such hormones. Although data from previous Olympic Games are incomplete, Ferguson-Smith and Ferris (1991) estimated the frequency of such Cycle 1 female athletes to be at least 1 in 500 at high-level international competitions. The inadequacy of the sex chromatin test, and indeed genetic tests as screening methods, raised Cycle 2 growing and serious objections within the scien- tific community, particularly in the USA but also in Europe (de la Chapelle, 1986; Simpson, 1986). Others defended the procedure despite its short- Cycle 3 comings (Bassis, 1987). Today the sex chromatin test is no longer conducted in genetics labora- Oringinal DNA tories. However, numerous petitions were deliv- Oligonucleotide primer ered to sports organizations, including the IOC, Newly synthesized urging abandonment of genetic gender verifica- DNA strand tion tests in sport. Fig. 13.4 Polymerase chain reaction. Addition of the DNA in question, unique primers and Taq polymerase Identification of the Y determinant gene by results in amplification (cycle 1). When the temperature polymerase chain reaction is raised, denaturation into single-stranded DNA occurs. On cooling, a second amplification cycle occurs. Under pressure from the scientific community, Continued amplification increases the DNA between sports organizations attempted to find alterna- primers in logarithmic fashion. (From Simpson, 1996 tive ways for gender verification. Believing that with permission of Churchill Livingstone.) screening for female gender is important for the integrity of the Olympic Games but recognizing the shortcomings of the sex chromatin test, the IOC adopted a new method for determination even further. In addition to genetic tests, FIS of the presence of the Y chromosome (Fig. 13.4). included both physical inspection and determi- Using the polymerase chain reaction (PCR), nation of serum sex hormone levels. These pro- minute amounts of DNA material (e.g. from cedures are supposed to be conducted at the buccal cells) can be amplified for a specific national level, following which a sex certificate is sequence, in this case one on the Y chromosome. issued. Should a female athlete appear at the FIS This method was used in the Olympic Games world championships without a sex certificate, in Albertville in 1992 to identify the sex- the organizing committee would arrange for the determining region on the Y chromosome (SRY) tests to be conducted. (Dingeon et al., 1992), the main candidate for the The IAAF went in the opposite direction from testis-determining gene (Sinclair et al., 1990). the IOC and FIS. After having conducted gender This screening procedure has since been used verification tests in accordance with the IOC pro- in the Olympic Games in Barcelona (1992), tocol, the IAAF convened a conference com- Lillehammer (1994), Atlanta (1996) and Nagano posed of scientists, sports leaders and athletes. (1998). If laboratory results are abnormal, a This conference was held in 1990 in Monaco, gynaecological examination is performed. where recommendations were issued. Member The International Skiing Federation (FIS) went federations of IAAF who enter athletes for 188 medical issues

international competitions should have both 2 Is gender verification in sport necessary? men and women checked before the competition 3 What is the view of the female athletes? for general health; health certificates should 4 What is the view of the scientific and legal be issued by the authorized national doctor authorities? (Ljungqvist & Simpson, 1992). This check would 5 Are there any alternative procedures for automatically include a determination of gender gender verification? and thus no specific screening for female gender would be required. This approach was regarded Gender definition as a step in the right direction (Wilson, 1992) and was tentatively used at the major IAAF com- The identification of female and male individu- petitions in 1991, including the World Athletics als would seem to be an easy matter. However, Championships in Tokyo. However, the protocol on delving more deeply into the question, it proved unworkable due to insufficient admin- becomes evident that determining gender is istrative infrastructure in many member fed- quite complex. In fact, the medical community erations. Therefore, another conference was has agreed that eight criteria determine a convened in London in May 1992, at which a new person’s sexual status (Fastiff, 1992): (i) sex chro- recommendation called for the IAAF to abandon mosome constitution; (ii) sex hormonal pattern; sex testing at their competitions. This was agreed (iii) gonadal sex, i.e. testes or ovaries; (iv) internal by the IAAF Council later that month, and since sex organs; (v) external genitalia; (vi) secondary that time no gender verification tests have taken sexual characteristics; (vii) apparent sex, as pre- place at IAAF competitions. Should suspect sumed by others and consequently the role in cases occur, however, the medical committee (or which a person is reared; (viii) psychological sex medical delegate) is authorized to intervene. or gender identity, i.e. that which a person pre- Health checks are recommended but no longer sumes himself or herself to be. compulsory. For most of the population the above criteria The 1990 IAAF conference also addressed the pose no difficulties; their sexual identity (man or delicate question of sex reassignment and issued woman) is quite clear. For certain individuals, the following recommendations, which were however, one or more of the criteria may be adopted by the IAAF Council: (i) individuals vague and the assigned sex therefore question- undergoing a sex reassignment of male to female able. Although no single criterion should be before puberty should be regarded as girls and regarded as more important than any other, women; and (ii) sex reassignment of transsexuals courts have been reported to state that criterion who change from male to female after puberty (viii), i.e. the individual’s perception of his/her should be decided upon by the relevant medical gender identity, may be of greatest importance body within the sports organization concerned (Fastiff, 1992). and after consultation with experts in the field, Because most sports organizations that should such persons not be available within the conduct gender testing base their screening pro- sports body itself. cedure on only one of the eight criteria (i.e. the chromosome pattern), the actual purpose of gender testing has to be clarified. In 1991 the Discussion IOC convened a working group that met twice. Controversy exists concerning gender verifica- Although no major conclusions were reached, it tion tests in sport. Different sports organizations emerges from the minutes of both meetings that have taken different standpoints and the interna- the sole purpose of gender testing in Olympic tional sports community is not united in this Games is to ensure that men do not masquerade respect. This raises five fundamental questions. as women. Thus, the purpose of gender testing is 1 How is male and female gender defined? not to identify ambiguous cases. gender verification 189

Is gender testing at sports men. Admittedly this would result in further competitions needed? investigations but many claim that such screen- ing is ethically unacceptable and can inflict per- With reference to the purpose of gender testing, sistent harm on the individual (de la Chapelle, what is the likelihood that men would mas- 1986; Simpson et al., 1993). The case of the querade as women in high-level competition? Spanish athlete referred to earlier is just one such Some feel that today there is no realistic reason to example. Moreover, there is evidence that female fear that men will try to compete as women. athletes have silently withdrawn after having However, others feel that abolition of gender been informed about an adverse screening result testing in sport would open the door for such (Ferguson-Smith & Ferris, 1991). It was on the misuse. Fastiff (1992) states that the IOC has to basis of these arguments that a resolution passed evaluate whether gender testing is deemed nec- at the first IOC World Conference on Women essary and, if necessary, whether all eight criteria and Sport in October 1996 urged the IOC ‘to dis- for gender identity should be tested. This is, of continue the current process of gender verifica- course, not practically possible. The IOC, on the tion during the Olympic Games’ (Mascagni, other hand, has defended its position by making 1996/97). Should the IOC decide accordingly it clear that the chromosome analysis only serves can be assumed that the five remaining Olympic as a screening procedure and that any case that federations still conducting gender verification produces a pathological result (i.e. presence of tests at their own world championships will a Y chromosome) will be subjected to further follow. (See ‘Note added in proof’, p. 192.) investigations including clinical/gynaecological examination. Therefore the IOC feels that the View of the female athletes most important of the eight criteria are met, enabling it to establish whether the competitor The attitude of the female athletes themselves to is a man or a woman. FIS has taken a differ- the gender verification procedure is, of course, ent standpoint, requiring an assessment of the of central interest in the ongoing discussion. As anatomical, hormonal and chromosomal sex. mentioned earlier the test does not seem to have Most federations seem to have found that gender raised any spontaneous opposition from this testing is not needed or will serve no purpose: group. Furthermore, enquetes performed during of the 34 international federations with their both the Albertville Games in 1992 and the sport on the Olympic programme only five Atlanta Games in 1996 showed great support for still conduct gender verification tests at their the test from those who were subjected to it own world championships (Ljungqvist, 1997). (Dingeon, 1993; Elsas et al., 1997). Gender verification tests have recently been On the other hand, there has been practically abolished at the World University Games and no request from female athletes to introduce (or Commonwealth Games. reintroduce) such testing in the many Olympic As discussed above, different screening sports that do not conduct gender verification methods have been tried and, with the exception tests at their own world championships. This has of physical examination (which met with great only happened once. In 1994, a group of female resistance and could not be further conducted), road runners urged the IAAF to reintroduce have been based on analysis of the chromosome gender tests in high-stakes competitions and pattern of the individual. The IOC screening road races with prize money (Heinonen, 1994a). procedure, which identifies a DNA sequence Because of the inadequacy of the usual screening from the Y chromosome, will not eliminate the procedure a different protocol was proposed, possibility of phenotypic men participating in with blood analysis for hormone and chromo- women’s competitions. Moreover, females with a some assessments (Heinonen, 1994b). The sub- Y chromosome will be singled out as if they were sequent debate showed that the athletes had not 190 medical issues

understood the procedure or had not received physical appearance and sports achievements to correct information. The trigger for their a questionable or male sex seems far-fetched. request was the sudden success of Chinese female runners, particularly at the World View of scientific and legal authorities Athletics Championships in Stuttgart in 1993. Moreover, the frequently expressed suspicion The commendable efforts of sports organizations regarding these athletes never concerned ques- to protect women’s sport from male imposters tions of gender but rather of new performance- and the unfortunate fact that there is no such enhancing substances. This suspicion was not thing as a simple laboratory method for gender addressed. screening are the main reasons for the present The silence of female athletes and the support controversy. While support has been expressed from this group when questioned is due in all for the gender verification procedures (Dingeon, probability to the fact that the test is very simple 1993; Heinonen, 1994a), most scientists in the and that the athletes believe that it protects field who have participated in the recent their sport. This is supported by the detailed debate oppose genetic screening (e.g. de la interviews conducted by the Norwegian Chapelle, 1986; Ferguson-Smith et al., 1992; Sports University on behalf of the IOC at the Wilson, 1992; Simpson et al., 1993; McDonald, Lillehammer Games in 1994 (B. Skirstad, unpub- 1996; Stephenson, 1996). Before the Albertville lished observations). It was confirmed that, in Games a group of 20 French scientists issued a general, athletes supported the tests, although public statement in which they protested against this basically reflected lack of information and the test being conducted in France with reference knowledge. The more informed the athletes to the Comité Consultif National d’Ethique. In were, the more likely they were to object to the Spain, scientific and ethical arguments were test. There is an obvious need for education of raised against the test before the Barcelona female athletes, and their entourage of sports Games (Anderson, 1991). physicians, team leaders and coaches also need At the Lillehammer Games in 1994 this contro- education in this field. versy came to a head. The Norwegian scien- Any education programme should include tific community simply refused to conduct the information that female athletes may look the screening procedure required by the IOC. quite masculine for genetic or endocrinological Instead, the IOC brought the Albertville team reasons. It is highly probable that most of the into Norway to conduct the testing. At the junior female athletes who caused rumours in the past world championships in alpine skiing in Voss, were in fact women with varying degrees of Norway in 1995 the controversy continued and it congenital adrenal hyperplasia. This disorder is was argued that genetic gender testing for sports far from uncommon in its milder forms (New purposes is against Norwegian law. After further & Levine, 1984; Speiser et al., 1985), the most study an amendment to the current law was pro- common being due to 21-hydroxylase deficiency. posed to the Norwegian parliament in January In an attempt to overcome the enzyme defect, 1997 in which it was clarified that this type increased production of adrenocorticotrophic of testing is indeed illegal in Norway. Under hormone occurs, leading to increased androgenic these circumstances FIS decided not to insist on hormones. Affected women tend to develop hir- gender testing at the world championships in sutism and a muscular and male body habitus. Nordic skiing in Trondheim in February 1997. Alternatively, some of the masculine-looking The amended law was passed by the Norwegian female athletes from the 1950s, 1960s and 1970s parliament in April 1997. To my knowledge, the may well have been users of anabolic steroids legality of this has not been tested in other coun- (which were banned in 1974). To attribute their tries; however, the group of French scientists gender verification 191

who protested before the Albertville Games also However, there are acceptable procedures questioned whether the test is in accordance with already available to deter men from entering the French constitution. women’s competitions, at least at the élite level Since it has been clarified scientifically that where this would be most likely to occur genetic testing for the sex chromosomes will not (Simpson et al., 1993). The present procedure fulfil the aims of gender testing in sport, such for drug testing requires that large numbers of testing is also considered by many as unethical athletes, particularly those who are finalists or (de la Chapelle, 1986; Fastiff, 1992; Simpson et al., medallists at Olympic Games, be selected for 1993) and therefore not acceptable. If sports drug testing. According to the rules, the athletes organizations feel that there is need for gender must provide a sample of urine under the super- testing, other methods for screening should be vision of officials. This means that male competi- found. It has been argued generally that the tors have to present themselves at the men’s easiest and most scientifically acceptable way doping station and female competitors at the to prevent men from masquerading as women women’s doping station. There they will be would be by means of clinical examination and asked to provide a urine sample under the super- not genetic laboratory tests. This view was vision of a male or a female observant. According endorsed by the American Medical Association, to the rules these observants have to make sure whose House of Delegates adopted such a reso- that the urine actually derives from the athlete. lution in December 1992. From the practical This, together with the close coverage of élite point of view, however, this solution has proved sport by the media, would seem to make special impossible to implement. Sport has, therefore, screening for gender unnecessary. been in a dilemma. Conclusion Alternative solutions • There is past evidence that intersex individu- Based on the experience at the Olympic Games als (with testes) have participated in women’s in Atlanta in 1996, Elsas et al. (1997) suggested sports competitions, but none in recent decades. that the present protocol for gender verification • It is agreed by the IOC that the sole reason for be abandoned. They proposed the institution gender verification tests is to prevent men from of a protocol in which female entries are selected participating in women’s events. at random before the Games and subjected to • There is no current evidence that males are a medical examination by an IOC-recognized masquerading as females. medical organization. This would obviously • Gender should not be confused with genetic eliminate the criticism against the present pro- sex as determined by chromosomal tests. cedures. Although the protocol is based on • There is no evidence that females with a Y random selection and a central medical body, in chromosome have any advantage over chromo- principle it is not very different from the system somally normal (46,XX) females in sport. that the IAAF tried in 1991 and found unwork- • 46,XX true hermaphrodites (external genitalia able. Moreover, there would be organizational and sex of rearing predominantly male) usually problems since the examinations would have to pass genetic tests as females, as will some 20% of be conducted within the short period between 46,XX males. the entry of athletes for the Games and the actual • Female athletes with a Y chromosome will be competition. Despite these reservations, the sug- singled out as if they were men by the current gested protocol may be worth trying if the IOC screening method. still feels that there is a need for a special gender • For the above reasons, genetic tests (chromo- verification procedure. somal analysis) will not fulfil the aims of gender 192 medical issues

verification in sport, not even as screening Fastiff, P.B. (1992) Gender verification testing: balanc- methods. ing the rights of female athletes with a scandal- free Olympic Games. Hastings. Constitutional Law • There is no single and adequate laboratory Quarterly 19, 937–961. method for screening for gender. Ferguson-Smith, M.A. (1998) Gender verification and • Although physical examination has been pro- the place of XY females in sport. In M. Harries, C. posed as the only adequate method for gender Williams, W.D. Stanish & L.J. Mitchell (eds) Oxford verification in sport, it has proved unworkable. Textbook of Sports Medicine, 2nd edn, pp. 355–365. Oxford University Press, Oxford. • It is suggested that the close media coverage Ferguson-Smith, M.A. & Ferris, E.A. (1991) Gender of today’s élite sport and the current drug-control verification in sport: the need for a change? British procedures when properly followed will toge- Journal of Sports Medicine 25, 17–21. ther serve as a sufficient deterrent to attempts by Ferguson-Smith, M.A., Carlson, A., de la Chapelle, A. males to masquerade as female athletes. et al. (1992) Olympic row over sex testing. Nature 355, 10. Hay, E. (1972) Sex determination in putative female Note added in proof athletes. Journal of the American Medical Association 221, 998–999. In June 1999, the IOC decided to abandon the Heinonen, J. (1994a) A decent proposal. Keeping genetic-based screening for female gender of the Track. International Track and Field Newsletter no. 24 (March). female participants at the Olympic Games and Heinonen, J. (1994b) Give-and-take on gender verifica- to replace it with a system that allows the tion. Keeping Track. International Track and Field IOC Medical Commission to arrange for a Newsletter no. 26 (May). scientifically and ethically proper investigation Higdon, H. (1992) Is she or isn’t she? Runners World 27, of any suspect individual case. 54–59. Krawczynsky, M. (1978) Zagadnienie intersekusu- lizmu w sporcie kwalifokwanum. Wiadomoski References Lekarskie 3, 189–191. Larned, D. (1976) The femininity test: a woman’s first Anderson, C. (1991) Olympic row over sex testing. Olympic hurdle. Women Sports 3, 8–11. Nature 353, 784. Ljungqvist, A. (1997) Gender verification in sport: Anonymous (1981) Athlete’s sex secret. Guardian, 26 the so called ‘femininity test’. The Starting Line. January 1981. WomenSports International Newsletter no. 3. Bassis, L.M. (1987) Sex chromatin screening of female Ljungqvist, A. & Simpson, J.L. (1992) Medical examina- athletes. Journal of the American Medical Association tion for health of all athletes replacing the need for 257, 1896–1897. gender verification in international sport. Journal of Comité International Olympic (1995) Code Medical du the American Medical Association 267, 850–852. CIO. Comité International Olympic. McDonald, K.A. (1996) Olympics pose difficult ques- de la Chapelle, A. (1986) The use and misuse of sex tions for sports-medicine experts. Chronicle of Higher chromatin screening for gender identification of Education 43, A23–A24. female athletes. Journal of the American Medical Associ- Mascagni, K. (1996/97) World conference on women ation 256, 1920–1923. and sport. Olympic Review XXVI-12, 23–31. Dingeon, B. (1993) Gender verification and the next New, M. & Levine, L.S. (1984) Recent advances in 21- Olympic Games. Journal of the American Medical Asso- hydroxylase deficiency. Annual Review of Medicine ciation 269, 357–358. 35, 649–653. Dingeon, B., Harnon, P., Robert, M., Schamash, P. & Ryan, A.J. (1976) Sex and the singles player. Physician Pugeat, M. (1992) Sex testing at the Olympics. Nature and Sportsmedicine 4, 39–41. 358, 447. Simpson, J.L. (1986) Gender testing in the Olympics. Donohoe, T. & Johnson, N. (1986) Drugs and the female Journal of the American Medical Association 256, 1938. athlete. In Foul Play, pp. 66–79. Basil Blackwell, Simpson, J.L. (1996) Genetic counseling and prenatal Oxford. diagnosis. In S.G. Gabbe, J.R Niebyl & J.L. Simpson Elsas, L.J., Hayes, R.P. & Muralidharan, K. (1997) (eds) Obstetrics, Normal and Problem Pregnancies, 3rd Gender verification at the Centennial Olympic edn, p. 236. Churchill Livingstone, Edinburgh. Games. Journal of the Medical Association of Georgia 86, Simpson, J.L. & Golbus, M.S. (1976) Disorders of 50–54. sexual differentiation: etiology and clinical delin- gender verification 193

eation. In J.L. Simpson & M.S. Golbus (eds) Genetics deficiency. American Journal of Human Genetics 37, in Obstetrics and Gynaecology, 2nd edn, p. 10. W.B. 650–667. Saunders Company, New York. Stephenson, J. (1996) Female olympian’s sex tests out- Simpson, J.L., Ljungqvist, A., de la Chapelle, A. et al. moded. Journal of the American Medical Association (1993) Gender verification in competitive sport. 276, 177–178. Sports Medicine 16, 305–315. Tachezy, R. (1969) Pseudohermaphroditism and physi- Sinclair, A.H., Besta, P., Plamer, M.S., Hawkins, J.R. & cal efficiency. Journal of Sports Medicine and Physical Griffiths, B.L. (1990) A gene from the human sex Fitness 9, 119–122. determining region encodes a protein with known Turnbull, A. (1988) Woman enough for the Games? New homology to a conserved DNA-binding motif. Scientist 119(1630), 61–64. Nature 346, 240–244. Wilson, J. (1992) Sex testing in athletics: a small step Speiser, P.W., Dupont, B. & Rubinstein, P. (1985) High forward. Journal of the American Medical Association frequency nonclassical steroid 21-hydroxylase 267, 853. Chapter 14

The Pregnant Athlete

MICHELLE F. MOTTOLA AND LARRY A. WOLFE

Introduction shown that maternal exercise, especially in late pregnancy, may decrease maternal blood glucose In the past, during pregnancy the medical advice values (Clapp et al., 1987; Bonen et al., 1992; Soul- for women was to rest (Wolfe et al., 1994a). tanakis et al., 1996). Soultanakis et al. (1996) eval- However, this outdated medical opinion does uated late gestational women and non-pregnant not address the increasing population of women women in response to 1hour of prolonged · actively engaged in sports and recreational activ- moderate-intensity exercise (55% VO2max). Blood ities. Pregnancy is a unique process in which glucose values in the pregnant women decreased almost all the control systems of the body are at a faster rate and to a significantly lower level modified in an attempt to maintain both mater- after exercise compared with the non-pregnant nal and fetal homeostasis. In theory, the addition women. Since the fetus utilizes maternal blood of exercise may represent a significant challenge glucose as the main energy source for growth to maternal and fetal well-being, especially at and development, regular exposure to reduced higher intensities of physical work (Wolfe et al., maternal blood glucose levels may lead to fetal 1994a). Several potential risks have been identi- malnutrition, intrauterine growth restriction and fied in the literature and each appears to have a reduced birth weight (Clapp et al., 1987). dose–response relationship to the intensity of The fetus may be protected to some extent maternal exercise, i.e. as the intensity of maternal from low maternal blood glucose levels because exercise increases, the risk of hypothetical effects the placenta can utilize alternate fuels in times of also increases. Wolfe et al. (1989, 1994a), Clapp maternal hypoglycaemia (Hay et al., 1983). The (1996a) and Stevenson (1997) provide excellent placenta has been shown to use maternal blood reviews on the effects of maternal exercise on lactate as an energy source; it can also produce maternal and fetal well-being. lactate from glucose metabolism and this may Figure 14.1 is a flow diagram of three hypo- enter the fetal circulation for use as a fuel in times thetical risks to the fetus during maternal exer- of glucose deficiency (Sparks et al., 1982; Hay et cise, for which three different mechanisms have al., 1983). Placental lactate may be an important been proposed (Wolfe et al. 1989, 1994a). The first fetal fuel, second only to glucose (Burd et al., hypothetical effect results from an increase in the 1975; Hay et al., 1983). utilization of maternal blood glucose as a meta- The second hypothetical risk (Fig. 14.1) is due bolic fuel by the muscles of the mother during to increased catecholamine release into the exercise. Strenuous maternal exercise, especially maternal blood as a result of exercise. This causes in the third trimester, may lead to maternal hypo- a redistribution of maternal blood flow from glycaemia after exercise, which would decrease the gut and uterus to the working muscles fetal glucose availability. Recent studies have (Lotgering et al., 1983a). Maternal blood flow 194 the pregnant athlete 195

Maternal aerobic exercise 12 3 Insulin resistance (late gestation) Maternal Sympathetic neural activity Maternal carbohydrate Maternal circulating core temperature utilization catecholamines Acute exercise effects Maternal Maternal peripheral hypoglycaemia vasoconstriction

Fetal glucose Transient in availability uterine blood flow Haemoconcentration

Fetal glucose Transient fetal Fetal temperature utilization hypoxia

Fetal malnutrition Placental Teratogenic effects diffusing capacity Chronic exercise effects Altered fetal development (varying degrees, depending on exercise intensity, duration, frequency, posture, environmental conditions, maternal age and health status)

Fig. 14.1 Hypothetical effects of aerobic exercise on fetal development. (From Wolfe et al., 1989 with permission of Williams & Wilkins.) redistribution during exercise appears to obey a is not working as hard. Webb et al. (1994) demon- dose–response relationship. As the intensity and strated that physically conditioned pregnant duration of maternal exercise increases, the women can perform at a higher exercise work amount of blood shunted from the uteroplacen- rate than sedentary pregnant women to achieve tal area to the working muscles of the mother is the same absolute heart rate. also augmented (Jones et al., 1991). Maternal The amount of blood flowing to the placenta training does not seem to alter this phenomenon. and fetus is important because oxygen delivery Jones et al. (1990) showed that chronic maternal to the uteroplacental area is directly proportional exercise in rats did not change the amount of to uterine blood flow (Mostello et al., 1991). In an blood shunted from the gut to the working experiment using pregnant sheep, a hydraulic muscles of the mother during acute maternal occluder was placed on the uterine vasculature. exercise compared with sedentary control Quantitative assessments of acute placental animals. However, in the trained state at any blood flow and fetal responses showed that the given absolute work rate there may be less blood changes in fetal PO2 and oxygen content were flow redistributed because the trained individual directly related to the magnitude of vascular 196 medical issues

occlusion. Fetal b-endorphin (a marker for fetal The final hypothetical risk, an increase in distress) was not released until uteroplacental maternal body core temperature (Fig. 14.1), may blood flow was reduced by 65% (Skillman & occur with maternal exercise. As the intensity Clark, 1987). Equating this to a specific maternal and duration increases, maternal body core exercise intensity must be verified through scien- temperature may increase in proportion to the tific study; however, it appears to occur at about intensity of exercise. At rest, fetal body core · 80% VO2max in the exercising pregnant sheep temperature is normally about 0.6°C higher (Jones et al., 1991). With a reduced uteroplacental than maternal body temperature because of blood flow, there may be a reduction in fetal oxy- the increase in fetal metabolic rate due to fetal genation and decreased placental oxygen diffu- growth and development (Lotgering et al., sion capacity, which may lead to altered fetal 1983b). This maintains the normal heat gradient growth and development (Wolfe et al., 1994a). and ensures that heat dissipation is from higher Several studies have shown that women who to lower, namely fetal to maternal heat dissipa- exercise at higher intensities and who exercise tion. As maternal body temperature increases, past 28 weeks of gestation give birth to smaller maternal body core temperature becomes higher babies (Clapp & Dickstein, 1984; Clapp & than that in the fetus. This reverses the normal Capeless, 1991; Bell et al., 1995; Clapp, 1996b). In temperature gradient between fetus and mother contrast, Hatch et al. (1993) analysed a cohort so that the fetus may now receive heat from the of 800 pregnant women and found that, with mother (Lotgering et al., 1983b). The reversal in heavy exercise, there was an increase of 300g in the normal heat gradient may delay fetal body birth weight in women who expended about heat dissipation and may alter fetal develop- 8400kJ·week–1 (2000kcal·week–1). ment, especially if the exposure to heat occurs The fetus may be somewhat protected during during early fetal life (Bell et al., 1983; Mottola et moderate maternal exercise because fetal blood al., 1993; Sasaki et al., 1995). However, Clapp et al. has a higher affinity for oxygen, which would (1987), after analysing 10 fit recreationally active promote oxygen transfer across the placental women before pregnancy and during the second barrier from maternal to fetal blood (Gilbert et al., and third trimesters, suggested that the effi- 1985). The fetal oxygen–haemoglobin dissocia- ciency of heat dissipation may be increased tion curve (i.e. the relationship between percent- during pregnancy because of pregnancy- age saturation of haemoglobin with oxygen and induced increases in blood volume and skin the partial pressure of oxygen) lies to the left blood flow. These changes occur because of of the maternal curve, which promotes better vasodilation of peripheral vessels and may extraction of oxygen from haemoglobin at a promote a thermoneutral environment in exer- given partial pressure (Gilbert et al., 1985). The cising pregnant women as long as the mother fetal curve lies to the left of the maternal curve is well hydrated and exercises in a cool because of the differential effect of 2,3- environment. diphosphoglycerate on the oxygen-binding char- The hypothetical effects of maternal exercise acteristics of fetal haemoglobin compared with illustrated in Fig. 14.1 may be offset by many pro- adult haemoglobin. In addition, other protective tective mechanisms during pregnancy, as dis- fetomaternal adaptive mechanisms are in place cussed above. These protective mechanisms to ensure oxygen transfer. These include haemo- are summarized in Fig. 14.2. Unfortunately, no concentration of maternal blood during exercise threshold has been determined for intensity and (Webb et al., 1994; Wolfe et al., 1994a) and the duration of maternal exercise above which prob- redistribution of uterine blood flow so that the lems may occur and, because of this, it is impor- placenta is favoured over the myometrial vascu- tant that medical screening take place to ensure lature (Webb et al., 1994; Wolfe et al., 1994a). a healthy pregnancy. The literature on animal the pregnant athlete 197

Effects of moderate maternal exercise

Hypoglycaemia Increased Decreased body temperature uterine blood flow

Redistribution Use of alternate fuels to favour placenta Haemoconcentration Increased blood flow to skin

Placenta Maternal adaptations

Facilitated oxygen transfer

Higher affinity to oxygen

Blood Fetal adaptations

Fig. 14.2 Fetoprotective mechanisms to counterbalance the effects of moderate-intensity exercise. The dashed arrows indicate the protective mechanisms and the solid arrows the hypothetical risks to the fetus as a result of maternal exercise. studies suggests that the higher the intensity and Medical prescreening duration of maternal exercise, the greater the risk of these potential effects occurring. Current An important medical screening tool that physi- guidelines recommend exercise intensities of cians can use to monitor patients performing · about 60–70% VO2max (moderate exercise) and exercise during pregnancy is the Physical Activity these guidelines are well accepted as safe for Readiness Medical Examination for Pregnancy most healthy pregnant women. Scientific data (PARmed-X for Pregnancy) document. This was are lacking for pregnant women who wish to developed by Dr Larry Wolfe of Queen’s Univer- engage in strenuous exercise above the accepted sity, Kingston, Ontario and Dr Michelle Mottola guidelines and for pregnant athletes participat- of the University of Western Ontario. The Cana- ing in various sports. Regardless of the exercise dian Society for Exercise Physiologists (CSEP) intensity, it is important for all pregnant women now holds the copyright for this document, to be medically screened before engaging in any which is also endorsed by Health Canada. It exercise programme. includes a prescreening questionnaire to identify 198 medical issues

contraindications to exercise during pregnancy, The contraindications to exercise are divided a list of safety considerations, and aerobic and into conditions in which no exercise should muscle conditioning guidelines. This docu- occur (absolute contraindications) and relative ment can be ordered from CSEP, 185 Somerset contraindications. With regard to relative con- St. West, Suite 202, Ottawa, Ontario, Canada traindications, the risk of regular exercise may K2P OJ2 (tel. (613) 234 3755; fax (613) 2343565). exceed the benefits. The conditions listed under In addition, the Canadian Academy of Sports relative contraindications may change with Medicine published a position paper on exercise medical treatment, at which point exercise may during pregnancy in the summer of 1999 and this be encouraged. The decision to engage in exer- includes the PARmed-X for Pregnancy document. cise or not should be made with qualified medical advice. In Table 14.2, the safety considerations listed Contraindications for exercise and are common sense. The American College of safety considerations Obstetricians and Gynecologists (1994) has rec- Table 14.1 shows the contraindications to exer- ommended avoidance of exercise in the supine cise during pregnancy, Table 14.2 indicates safety position past 4 months of pregnancy because of considerations for maternal exercise and Table possible blocking of the inferior vena cava 14.3 shows reasons to discontinue exercise and and/or the abdominal aorta by the gravid consult a physician. uterus. Symptoms associated with blockage of the inferior vena cava are light-headedness and dizziness; there are no symptoms for blockage of Table 14.1 Contraindications to exercise in pregnant the abdominal aorta, which may decrease blood women. (Modified from PARmed-X for Pregnancy flow to the uteroplacental area. The footnote document, 1996 with permission of the Canadian to Table 14.2 suggests that the temperature of Society for Exercise Physiology) heated pools be monitored. This is based on an Absolute contraindications Ruptured membranes, premature labour Table 14.2 Safety considerations for pregnant women Persistent second- or third-trimester bleeding/ performing exercise. (Modified from PARmed-X for placenta praevia Pregnancy document, 1996 with permission of the Pregnancy-induced hypertension, pre-eclampsia or Canadian Society for Exercise Physiology) toxaemia Incompetent cervix Avoid prolonged or strenuous exertion during the first Evidence of intrauterine growth restriction trimester Multiple pregnancy (e.g. triplets) Avoid isometric exercise or straining while holding Uncontrolled type 1 diabetes, hypertension or thyroid your breath disease; other serious cardiovascular, respiratory or Maintain adequate nutrition and hydration: drink systemic disorder liquids before and after exercise Avoid exercising in warm/humid environments Relative contraindications Avoid exercise while lying on your back past the History of spontaneous abortion or premature labour fourth month of pregnancy in previous pregnancies Avoid activities that involve physical contact or Mild/moderate cardiovascular or respiratory disease danger of falling (e.g. chronic hypertension, asthma) Periodic rest periods may help to minimize possible -1 Anaemia or iron deficiency (haemoglobin < 10g·dl ) low-oxygen or temperature stress to the fetus Very low body fat, eating disorder (anorexia, bulimia) Know the reasons to stop exercise and consult a Twin pregnancy after 28th week qualified physician immediately if they occur Other significant medical condition It is important to monitor the temperature of heated pools. During exercise, maternal body temperature Note: Risk may exceed benefits of regular physical may be increased more by exercising in a warm activity. The decision to be physically active or not environment should be made with qualified medical advice. the pregnant athlete 199

Table 14.3 Reasons for pregnant women to discontinue exercise and consult a physician. (Modified from PARmed- X for Pregnancy document, 1996 with permission of the Canadian Society for Exercise Physiology)

Persistent uterine contractions (more than six to eight per hour) Bloody discharge from vagina Any ‘gush’ of fluid from vagina (suggesting premature rupture of the membranes) Unexplained pain in abdomen Sudden swelling of extremities (ankles, hands, face) Swelling, pain and redness in the calf of one leg (suggesting phlebitis) Persistent headaches or disturbances of vision Unexplained dizziness or faintness Marked fatigue, heart palpitations or chest pain Failure to gain weight (less than 1kg per month during last two trimesters) Absence of usual fetal movement

animal study (Mottola et al., 1993) that found an Table 14.4 Target heart rate zones for healthy increase in teratogenic problems in animals exer- pregnant women. (Modified from PARmed-X for Pregnancy document, 1996 with permission of the cised (swim-trained) in warm water (37.4°C). In Canadian Society for Exercise Physiology) Table 14.3, the reasons for consulting a physician are also based on common sense. Heart rate zone Age (years) (beats·min-1)

Exercise prescription < 20 140–155 20–29 135–150 Healthy sedentary pregnant women who wish to 30–39 130–145 start an exercise programme should be treated ≥ 40 125–140 differently from the recreational athlete or the well-conditioned pregnant athlete. Aerobic and muscular conditioning exercises for the previ- ously sedentary pregnant woman are described maximum of five times per week in the second in the PARmed-X for Pregnancy document. Exer- trimester. Increasing frequency, intensity or cise prescription for sedentary women is not dis- duration of exercise is not recommended in the cussed here. Women who have been exercising first or the third trimester because of fatigue and prior to pregnancy have been advised by the because the risks may outweigh the benefits of medical profession to continue exercise during exercise. The intensity of exercise should be mon- pregnancy. However, it is necessary to determine itored by heart rate (pulse rate), which should be the frequency, intensity, duration and type of targeted within specific heart rate zones based on exercise before advising pregnant women to con- age (Table 14.4). These target heart rate zones · tinue exercising. In addition, medical prescreen- are approximately 60–70% VO2max based on age ing must occur to rule out contraindications. The (Wolfe & Mottola, 1993). At the start of a new following guidelines for aerobic and muscular exercise programme and in late pregnancy, exer- conditioning are suggested for active healthy cise intensity should be targeted at the lower end pregnant women (taken from PARmed-X for of the heart rate zone. The rating of perceived Pregnancy). exertion (Borg, 1962) should be used in conjunc- tion with the heart rate target zones. On a scale of 20, pregnant women should be exercising at an Aerobic guidelines intensity of between 12 and 14 (‘somewhat Pregnant women who have been exercising hard’). On the 10-point scale, an intensity about three times per week may increase to a between 3 and 4 is recommended (Wolfe & 200 medical issues

Mottola, 1993). In addition, one final check of supported exercise would be recommended. All intensity is the ‘talk test’: if the pregnant woman pregnant women should know the safety signs is out of breath while talking during exercise, she and consult a physician should any contraindica- should reduce the intensity. tions to exercise occur (see Tables 14.2 & 14.3). The duration of exercise should be a minimum of about 15min per session at the target heart rate Precautions for muscle conditioning exercise to a maximum of about 30min per session at the target heart rate. Intensity or duration of exercise The precautions listed in Table 14.5 for mus- should not be increased past week 28 of gestation cular conditioning exercise suggest modifica- (Wolfe & Mottola, 1993) due to fatigue; again, the tions during pregnancy. It is important to avoid risks may exceed the benefits of exercise. exercise in the supine position past 4 months of Each exercise session should start with 5– pregnancy as has been suggested previously 15min of warm-up and 5–15min of cooling (American College of Obstetricians and Gynecol- down at a lower intensity. Recommended ogists, 1994). Abdominal exercises should be per- aerobic exercise modalities include walking, formed lying on one side or in a standing low-impact aerobics and exercise where body position. weight is supported, such as cycling and swim- Joint laxity may occur during pregnancy. ming. However, if a woman has been jogging Schauberger et al. (1996) suggested that joint before pregnancy, she may continue within the laxity was found in five of the seven peripheral aerobic exercise guidelines, unless she develops joints studied over the course of pregnancy and joint problems or is uncomfortable with this after birth but there was no correlation with mode of exercise. Switching to stair climbing serum relaxin values. Joint laxity was not altered (with no jarring movements) or to body weight- by maternal age, parity or prenatal exercise

Table 14.5 Precautions for muscular conditioning during pregnancy. (Modified from PARmed-X for Pregnancy document, 1996 with permission of the Canadian Society for Exercise Physiology)

Variable Effects of pregnancy Exercise modifications

Body position In the supine position (lying on the back), Past 4 months of gestation, exercises the enlarged uterus may decrease the normally done in the supine position flow of blood returning from the lower should be done lying on one side or half of the body as it presses on a major standing vein (inferior vena cava) Joint laxity Ligaments become relaxed due to Avoid rapid changes in direction and increasing hormone levels bouncing during exercises Joints may be prone to injury Stretching should be performed with controlled movements Abdominal muscles Presence of a rippling (bulging) of Abdominal exercises are not connective tissue along the midline of the recommended if diastasis recti develops pregnant abdomen (diastasis recti) may be seen during abdominal exercise Posture Increasing weight of enlarged breasts Emphasis on correct posture and uterus may cause a forward shift in the centre of gravity and may increase the arch in the lower back This may also cause shoulders to slump forward the pregnant athlete 201

levels (Schauberger et al., 1996). Thus, it is impor- Weight-lifting or resistance exercise is another tant to avoid ballistic movements and rapid area that sparks controversy. Weight-lifting per- changes in direction. In addition, stretching formed while lying on the back should be modi- should be controlled. fied to either a sitting, standing or side-lying If diastasis recti develops during pregnancy, position. The use of a resistive tool such as abdominal exercises are not recommended. low-weight free weights or a Dynaband are re- Tearing of the linea alba (connective tissue) commended. Low-resistance weight and high occurs with this condition, which causes the repetitions are also recommended for free bulging or rippling along the midline. Con- weights and weight machines. Correct breathing tinuing to strengthen the rectus abdominis should be emphasized, with exhalation on exer- muscles through abdominal exercises may tion and inhalation on relaxation. The Valsalva worsen this condition as the pregnant abdomen manoeuvre (breath-holding while working continues to protrude, because tearing will occur against a resistance) causes an increase in blood at the weakest point, i.e. along the connective pressure and therefore should be avoided. Table tissue. 14.6 describes examples of exercises for muscular Posture is important and a ‘neutral’ pelvic conditioning. alignment is suggested rather than the pelvic tilt position. The use of the pelvic tilt is controversial The well-conditioned athlete because this position may decrease the normal lordotic curvature in the spine, which may place Pregnancy is not the time for engaging in sports excessive stress on the vertebral ligaments in the competition or strenuous activity that would lumbar region. To find the neutral pelvic posi- place the mother at risk for bodily injury. In addi- tion, it is suggested that women over-accentuate tion, there are no known benefits to the fetus · the lordotic curve, then push the pelvis into an during maternal exercise >80% VO2max. In fact, exaggerated pelvic tilt position and find the studies on animals, as previously discussed, neutral pelvic position midway between these indicate that beyond this intensity the fetus may two postures. be stressed and uteroplacental blood flow may

Table 14.6 Exercise prescription for muscular conditioning. (Modified from PARmed-X for Pregnancy document, 1996 with permission of the Canadian Society for Exercise Physiology)

Category Purpose Example

Upper back Promotion of good posture Shoulder shrugs, shoulder blade pinch Lower back Promotion of good posture Modified standing opposite leg and arm lifts Abdomen Promotion of good posture, Abdominal tightening, abdominal curl-ups, head prevention of low-back pain, raises, lying on side or standing position prevention of diastasis recti, strengthen muscles of labour Pelvic floor (‘Kegels’) Promotion of good bladder ‘Wave’, ‘elevator’ control, prevention of urinary incontinence Upper body Improve muscular support for Shoulder rotations, modified push-ups against a wall breasts Buttocks, lower limbs Facilitation of weight-bearing, Buttocks squeeze, standing leg lifts, heel raises prevention of varicose veins 202 medical issues

be reduced by 65% (Skillman & Clark, 1987). The of gestation gave birth to babies weighing 315g physician must ask the athlete why she wants to lower than control patients (Bell et al., 1995). pursue such high-intensity training while preg- nant. In this situation, the risks to the fetus far Maternal physiological responses to outweigh any maternal benefits and reduction in strenuous exercise intensity and duration would be highly recom- mended. The physician or exercise professional As described above, it is well established that can utilize the ‘talk test’ for a highly motivated healthy pregnant women experiencing a normal athlete, as this may be a safe way to prescribe pregnancy can participate safely in regular, mod- exercise to an individual who may not fall within erate aerobic and muscular conditioning pro- the guidelines suggested above for aerobic exer- grammes. Unfortunately, very little information cise. For the well-conditioned athlete the precau- exists on the effects of strenuous physical condi- tions for muscle conditioning are the same as tioning involving competitive and recreational above. female athletes (Wolfe et al., 1994a; Hale & Milne, The literature describing the effects of high- 1996). intensity exercise on mother and fetus are In recent years, a number of studies have been limited. Historically, most of the data presented published that describe maternal and fetal are from case studies of women athletes or retro- responses to single bouts of maximal or near- spective reports, not randomly designed trials. maximal exercise. The effects of pregnancy on Pregnancy outcome in athletic women has been maximal aerobic power remain controversial reviewed by Wolfe et al. (1989). Briefly, Zaharieva and results may depend on whether or not (1972) studied pregnancy outcome in women women change their level of habitual exercise who participated in the Olympic Games between (Wolfe et al., 1989). The results of Clapp and 1952 and 1972 (n=27), women who were masters Capeless (1991), who studied active women of sport (n=59) and those who were ‘first-grade’ before pregnancy and 6–8, 12–20 and 36–44 athletes (n=64); the percentage of women who weeks after giving birth, indicated that continua- continued to train during pregnancy was 63%, tion of moderate training throughout pregnancy 76% and 77%, respectively. Of the Olympic ath- and the early postpartum period may result in · letes, 70% had no pregnancy complications and small but significant increases in VO2max in the the remainder had only ‘mild complaints’. The postpartum period compared with before preg- masters of sport athletes had somewhat higher nancy. Anecdotal reports have also shown that rates of birth complications. Erdelyi (1962) found élite endurance athletes may enhance their per- shorter labour times on average and lower fre- sonal best performances after childbirth. quencies of toxaemia, Caesarean section and Other studies of performance during strenu- threatened abortion in 172 Hungarian athletes ous exercise suggest that maximal exercise heart compared with 150 sedentary women. Two- rate is moderately attenuated in mid to late ges- thirds of the athletes continued to exercise tation (Lotgering et al., 1991, 1992). Since resting during the first 3–4 months of pregnancy, but heart rate is already augmented, heart rate the average level of intensity and the number increases at a slower rate in response to increases · of women who continued to exercise for the in VO2max (Sady et al., 1989; Pivarnik et al., 1990; remainder of pregnancy were not reported Wolfe et al., 1990; Lotgering et al., 1992) and (Erdelyi, 1962). Amore recent retrospective study maximal heart rate reserve is reduced (Wolfe & (also not randomly controlled) assessed the Mottola, 1993) in late gestation compared with effects of a vigorous exercise programme into the non-pregnant state. late pregnancy on birth weight. The results indi- Important pregnancy-induced changes in cated that women who exercised vigorously lactate metabolism have also been described. more than four sessions per week past 25 weeks Two laboratories have recently reported that the the pregnant athlete 203

ventilatory anaerobic threshold (an indicator of mild fetal hypoxia or a combination of these the onset of blood lactate accumulation) is not factors. Fetal deceleratory responses (bradycar- significantly altered by pregnancy (Wolfe et al., dia, increased FHR decelerations that may indi- 1994b; Lotgering et al., 1995). However, peak cate significant fetal hypoxia) appear to be values for the respiratory exchange ratio (RER) rare during moderate maternal exercise where (Lotgering et al., 1991, 1995; Wolfe et al., 1994b) maternal heart rate does not exceed about 150 during maximal exercise tests and peak post- beats·min–1. exercise blood lactate concentrations (Clapp et Recent studies suggest that FHR responses to al., 1987; McMurray et al., 1988; Wolfe et al., 1994b; maximal exercise testing may differ in sedentary Spinnewijn et al., 1996) appear to be blunted. Pre- vs. athletic populations. For example, Carpenter sumably, the blunted peak RER values reflect a et al. (1988) reported fetal bradycardia (defined reduced need for respiratory compensation for as FHR <110beats·min–1 for ≥10s) following 15 lactic acidosis (Wolfe et al., 1994b; Lotgering et al., of 79 maximal cycling tests (16.2%). Subjects 1995). Reduced blood lactate levels following were healthy sedentary women studied at 25±3 strenuous exercise in late gestation may result weeks’ gestation using two-dimensional echo- from dilution of lactate produced in an expanded cardiography. Similarly, Watson et al. (1991) maternal blood volume (McMurray et al., 1988), studied the FHR responses of 13 healthy inactive fetal use of lactate as a metabolic fuel (Burd et al., women (gestational ages 25 and 35 weeks) to 1975) or increased maternal peripheral insulin maximal cycling and tethered swimming tests. resistance which appears in late pregnancy. Some Transient fetal bradycardia (defined as a decrease evidence also suggests that aerobic conditioning in FHR ≥20beats·min–1 from pre-exercise base- may help to preserve the ability to exercise anaer- line) was observed following about 15% of these obically and produce lactate in late gestation tests and was more frequent during cycling than (Wolfe et al., 1994b). Finally, the recent findings of swimming and at 35 vs. 25 weeks’ gestation. Kemp et al. (1997) confirm that pregnant women Three more recent studies that involved maximal are able to maintain lower blood hydrogen cycle ergometer testing of moderately active ion concentrations both at rest and following pregnant subjects (Lotgering et al., 1992; maximal exercise stress compared with the non- Spinnewijn et al., 1996; Kemp et al., 1997) have pregnant state. reported transient exercise-induced increases in FHR baseline but no incidences of fetal bradycar- dia. In our experience, such tests are also accom- Fetal responses to strenuous maternal exercise panied by a transient postexercise reduction in As described in a recent review on maternal exer- FHR reactivity. cise, fetal well-being and pregnancy outcome Some evidence exists to support the concept (Wolfe et al., 1994a), a substantial body of evi- that maternal physical conditioning may cause dence exists to confirm that the most common beneficial fetal and placental effects. For fetal response to sustained aerobic exercise is a example, Webb et al. (1994) employed a con- transient increase in fetal heart rate (FHR) from trolled longitudinal study design to examine the baseline. The findings of Clapp et al. (1993) effects of moderate aerobic conditioning on FHR suggest that the degree of elevation of FHR responses to exercise in healthy, previously is related directly to the intensity and duration sedentary women. During steady-state exercise of exercise and becomes more pronounced tests (maternal heart rate target 145beats·min–1) with advancing gestational age. Increased FHR conducted in late gestation, FHR responses to during and following such exercise may be the exercise (gradual increase in FHR normal vari- result of increased fetal temperature, transfer of ability and reactivity) were similar even though maternal catecholamines across the placenta, an the conditioned subjects were exercising at sig- increased state of fetal wakefulness or activity, nificantly higher work rates. Clapp and Rizk 204 medical issues

(1992) have also reported that increases in pla- formed in the supine position. Women who have cental volume during the first 24 weeks of preg- experienced diastasis recti during pregnancy are nancy were significantly greater in recreational advised to proceed with extra care and start athletes (n=18) who continued to exercise regu- abdominal exercise slowly, gradually building larly compared with previously active women (n up the number of repetitions. =16) who discontinued regular exercise during pregnancy. Although much more research is Lactation and the athlete needed, these studies suggest that maternal and/or placental responses to physical condi- Altemus et al. (1995) studied the responses of 10 tioning may have important fetoprotective lactating and 10 non-lactating women between 7 effects. and 18 weeks after birth to 20min of graded treadmill exercise; the last 5min of exercise was · to elicit 90% VO for each subject. The lactating Postpartum exercise 2max women had attenuated responses for plasma Many women are concerned about when they adrenocorticotrophic hormone, cortisol and can safely return to exercise after the baby is glucose due to the exercise. Basal noradrenaline born. The interval before returning to an aerobic levels were also decreased in the lactating exercise regimen depends upon the number women. The authors suggested that lactating of complications during labour and delivery. women may have neurohormonal systems that If labour and delivery are uncomplicated, a are restrained during stress-responsive tasks woman can usually return to aerobic exercise such as treadmill exercise (Altemus et al., 1995). after vaginal bleeding from delivery has stopped This may explain why mild to moderate exercise and/or her postpartum check-up from her has little adverse effect on milk quality or quan- physician is normal. It is recommended that she tity or on infant weight gain (Dewey et al., 1994). begin her exercise programme by aiming for the Infants are able to detect sweet and sour tastes same target heart rate zone (Table 14.4) and by (Wallace et al., 1992). The literature has suggested following the same guidelines as if she were that after exercise infants may refuse to nurse or pregnant. Avoiding unnecessary fatigue is an may fuss during a feeding because of an increase important consideration for any new mother and in the lactic acid content of the milk, producing a returning to exercise too quickly and exercising sour taste (Wallace et al., 1992). Maximal exercise too intensely are not recommended. If the has been shown to increase the amount of lactic woman has had a Caesarean section or complica- acid in breast milk, which leads to diminished tions during labour and delivery, it is suggested acceptance of the milk after exercise (Wallace that she wait at least 10 weeks or until labour and et al., 1992). In addition, animal studies have delivery complications have healed or returned suggested that strenuous exercise continued to normal. through lactation exaggerated further the Muscular conditioning exercises are also rec- growth restriction seen in the offspring (Pinto ommended after birth. It is suggested that these & Shetty, 1995). However, aerobic exercise at · exercises be resumed after the first postpartum 60–70% VO2max performed four or five times per check-up and vaginal bleeding due to delivery week beginning at 6–8 weeks after birth had no has stopped. Kegel exercises for the pelvic floor adverse effect on lactation (Dewey et al., 1994), · are important and can be continued as soon as nor did an aerobic programme (VO2max improved the woman feels well enough to start them. These 25%) performed for 45min, 5 days per week for exercises may help to strengthen pelvic floor 12 weeks (Lovelady et al., 1995). It seems that muscles weakened during a vaginal delivery and mild to moderate exercise is well tolerated in may help postpartum incontinence. Abdominal lactating women (Dewey & McCrory, 1994; exercises can also be started and may be per- Prentice, 1994; Spaaij et al., 1994), although the pregnant athlete 205

strenuous (near-maximum) aerobic activity post partum period. ACOG Technical Bulletin 189, should be avoided until lactation is terminated. 2–7. Bell, A.W., Hales, J.R.S., King, R.B. & Fawcett, A.A. (1983) Influence of heat stress on exercise-induced Conclusion changes in regional blood flow in sheep. Journal of Applied Physiology 55, 1916–1923. Healthy pregnant women with no contraindica- Bell, R.J., Palma, S.M. & Lumley, J.M. (1995) The effect tions to exercise may perform mild- to moderate- of vigorous exercise during pregnancy on birth- weight. Australian and New Zealand Journal of intensity activity safely within the current Obstetrics and Gynaecology 35, 46–51. guidelines with no adverse effects on fetal Bonen, A., Campagna, P., Gilchrist, L., Young, D.C. growth and development. There are limited sci- & Beresford, P. (1992) Substrate and endocrine entific data on the effects of high-intensity train- responses during exercise at selected stages of preg- ing on pregnancy and fetal outcome. Studies nancy. Journal of Applied Physiology 73, 134–142. Borg, G. (1962) A category scale with ratio properties examining the effects of maximal and peak exer- for intermodal and interindividual comparision. In cise on maternal and fetal well-being are few in H.G. Geissler and P. Petzold (eds) Psychophysical number but are becoming more common. At Judgement and the Process of Perception. Deutscher present, with limited information, it would seem Verlag der Wissenschaften, Berlin. that the healthy pregnant woman and the fetus Burd, L.I., Jones, M.D., Simmons, M.A., Makowski, E.L., Meschia, G. & Battaglia, F.C. (1975) Placental appear to tolerate the effects of an acute bout of production and foetal utilisation of lactate and pyru- peak to maximal exercise satisfactorily, although vate. Nature 254, 710–711. more studies must be completed. The effects of Canadian Society for Exercise Physiology (1996) high-intensity endurance training on pregnancy PARmed-X for Pregnancy. CSEP, Health Canada, and fetal outcome are largely unknown and must Ottawa, Ontario, Canada. Carpenter, M.W., Sady, S.P., Hoegsborg, B. et al. (1988) be determined before advice can be given to the Fetal heart rate response to maternal exertion. Journal pregnant athlete. Common sense suggests that of the American Medical Association 259, 3006–3009. women athletes should not compete while preg- Clapp, J.F. III (1996a) Pregnancy outcome: physical nant, especially in sports where bodily injury or activities inside vs. outside the workplace. Seminars contact may occur. In addition, the intensity of in Perinatology 20, 70–76. Clapp, J.F. III (1996b) Morphometric and neurodevel- exercise training should be reduced to moderate opmental outcome at age five years of the offspring because the effects of strenuous exercise on the of women who continued to exercise regularly pregnant athlete and on fetal outcome are largely throughout pregnancy. Journal of Pediatrics 129, unknown. 856–863. · Clapp, J.F. III & Capeless, E. (1991) The VO2max of recre- ational athletes before and after pregnancy. Medicine Acknowledgement and Science in Sports and Exercise 23, 1128–1133. Clapp, J.F. III & Dickstein, S. (1984) Endurance exercise The authors have received financial support for and pregnancy outcome. Medicine and Science in exercise/pregnancy research from the US Army Sports and Exercise 16, 556–562. Medical Research and Material Command Con- Clapp, J.F. III & Rizk, K.D. (1992) Effect of recrea- tional exercise on midtrimester placental growth. tract #DAMD-17–96-C-6112. American Journal of Obstetrics and Gynecology 167, 1518–1521. References Clapp, J.F. III, Wesley, M. & Sleamaker, R.H. (1987) Thermoregulatory and metabolic responses to Altemus, M., Deuster, P.A., Galliven, E., Carter, C.S. & jogging prior to and during pregnancy. Medicine and Gold, P.W. (1995) Suppression of hypothalamic– Science in Sports and Exercise 19, 124–130. pituitary–adrenal axis responses to stress in lactating Clapp, J.F. III, Little, K.D. & Capeless, E.L. (1993) Fetal women. Journal of Clinical Endocrinology and Metabo- heart rate response to sustained recreational exercise. lism 80, 2954–2959. American Journal of Obstetrics and Gynecology 168, American College of Obstetricians and Gynecolo- 198–206. gists (1994) Exercise during pregnancy and the Dewey, K.G. & McCrory, M.A. (1994) Effects of dieting 206 medical issues

and physical activity on pregnancy and lactation. in pregnant women. Journal of Applied Physiology 78, American Journal of Clinical Nutrition 59, 446S–452S. 1772–1777. Dewey, K.G., Lovelady, C.A., Nommsen-Rivers, L.A., Lovelady, C.A., Nommsen-Rivers, L.A., McCrory, M.A. McCrory, M.A. & Lonnerdal, B. (1994) A randomized & Dewey, K.G. (1995) Effects of exercise on plasma study of the effects of aerobic exercise by lactating lipids and metabolism of lactating women. Medicine women on breast-milk volume and composition. and Science in Sports and Exercise 27, 22–28. New England Journal of Medicine 330, 449–453. McMurray, R.G., Katz, V.L., Berry, M.J. & Cefalo, R.C. Erdelyi, G.J. (1962) Gynecological survey of female ath- (1988) The effect of pregnancy on metabolic letes. Journal of Sports Medicine and Physical Fitness 2, responses during rest, immersion and aerobic exer- 174–179. cise in the water. American Journal of Obstetrics and Gilbert, R.D., Lis, L. & Longo, L.D. (1985) Temperature Gynecology 158, 481–486. effects on oxygen affinity of human fetal blood. Mostello, D., Chalk, C. & Khoury, J. (1991) Chronic Journal of Developmental Physiology 7, 299–304. anemia in pregnant ewes: maternal and fetal effects. Hale, R.W. & Milne, L. (1996) The elite athlete and American Journal of Physiology 261, R1075–R1083. exercise in pregnancy. Seminars in Perinatology 20, Mottola, M.F., Fitzgerald, H.M., Wilson, N.C. & Taylor, 277–284. A.W. (1993) Effect of water temperature on exercise- Hatch, M.C., Shu, X., McLean, D.E. et al. (1993) Mater- induced maternal hyperthermia on fetal develop- nal exercise during pregnancy, physical fitness and ment in rats. International Journal of Sports Medicine fetal growth. American Journal of Epidemiology 137, 14, 248–251. 1105–1114. Pinto, M.L. & Shetty, P.S. (1995) Influence of exercise- Hay, W.W., Myers, S.A., Sparks, J.W., Wilkening, R.B., induced maternal stress on fetal outcome in Wistar Meschia, G. & Battaglia, F.C. (1983) Glucose and rats: inter-generational effects. British Journal of lactate oxidation rates in the fetal lamb. Proceedings of Nutrition 73, 645–653. the Society for Experimental Biology and Medicine 173, Pivarnik, J.M., Lee, W., Clark, S.L., Cotton, D.B., 553–563. Spillman, H.T. & Miller, J.F. (1990) Cardiac output Jones, M.T., Norton, K.I., Dengel, D.R. & Armstrong, responses of primigravid women during exercise R.B. (1990) Effects of training on reproductive tissue determined by the direct Fick technique. Obstetrics blood flow in exercising pregnant rats. Journal of and Gynecology 75, 954–959. Applied Physiology 69, 2097–2103. Prentice, A. (1994) Should lactating women exercise? Jones, M.T., Rawson, R.E., Riplog, S. & Robertshaw, D. Nutrition Reviews 52, 358–360. (1991) Oxygen consumption and uterine blood flow Sady, S.P., Carpenter, M.W., Thompson, P.D., Sady, in exercising pregnant sheep (Abstract). Medicine and M.A., Haydon, B. & Coustan, D.R. (1989) Cardiovas- Science in Sports and Exercise 23, S169. cular response to cycle exercise during and after Kemp, J.G., Greer, F.A. & Wolfe, L.A. (1997) Acid–base pregnancy. Journal of Applied Physiology 66, 336–341. regulation following maximal exercise testing in late Sasaki, J., Yamaguchi, A., Nabeshima, Y., Shigemitsu, gestation. Journal of Applied Physiology 83, 644–651. S., Mesaki, N. & Kubo, T. (1995) Exercise at high tem- Lotgering, F.K., Gilbert, R.D. & Longo, L.D. (1983a) perature causes maternal hyperthermia and fetal Exercise responses in pregnant sheep: oxygen con- anomalies in rats. Teratology 51, 233–236. sumption, uterine blood flow and blood volume. Schauberger, C.W., Rooney, B.L., Goldsmith, L., Journal of Applied Physiology 55, 834–841. Shenton, D., Silva, P.D. & Schaper, A. (1996) Periph- Lotgering, F.K., Gilbert, R.D. & Longo, L.D. (1983b) eral joint laxity increases in pregnancy but does not Exercise responses in pregnant sheep: blood gases, correlate with serum relaxin levels. American Journal temperatures and fetal cardiovascular responses. of Obstetrics and Gynecology 174, 667–671. Journal of Applied Physiology 55, 842–850. Skillman, C.A. & Clark, K.E. (1987) Fetal beta- Lotgering, F.K., Van Doorn, M.K., Struijk, P.C., Pool, J. endorphin levels in response to reductions in uterine & Wallenberg, H.C.S. (1991) Maximal aerobic exer- blood flow. Biology of the Neonate 51, 217–223. cise in pregnant women: heart rate, O2 consumption, Soultanakis, H.N., Artal., R. & Wiswell, R.A. (1996) Pro- CO2 production, and ventilation. Journal of Applied longed exercise in pregnancy: glucose homeostasis, Physiology 70, 1016–1023. ventilatory and cardiovascular responses. Seminars Lotgering, F.K., Struijk, P.C., Van Doorn, M.B. & in Perinatology 20, 315–327. Wallenberg, H.C.S. (1992) Errors in predicting Spaaij, C.J., van Raaij, J.M., deGroot, L.C., vander maximal oxygen consumption in pregnant women. Heijden, L.J., Boekholt, H.A. & Hautvast, J.G. (1994) Journal of Applied Physiology 72, 562–567. Effect of lactation on resting metabolic rate and on Lotgering, F.K., Struijk, P.C., Van Doorn, M.B., diet- and work-induced thermogenesis. American Spinnewijn, W.E.M. & Wallenberg, H.C.S. (1995) Journal of Clinical Nutrition 59, 42–47. Anaerobic threshold and respiratory compensation Sparks, J.W., Hay, W.W., Bonds, D., Meschia, G. & the pregnant athlete 207

Battaglia, F.C. (1982) Simultaneous measurements of Wolfe, L.A. & Mottola, M.F. (1993) Aerobic exercise in lactate turnover rate and umbilical lactate uptake in pregnancy: an update. Canadian Journal of Applied the fetal lamb. Journal of Clinical Investigation 70, Physiology 18, 119–147. 179–192. Wolfe, L.A., Ohtake, P.J., Mottola, M.F. & McGrath, M.J. Spinnewijn, W.E.M., Wallenberg, H.C.S., Struijk, P.C. & (1989) Physiological interactions between pregnancy Lotgering, F.K. (1996) Peak ventilatory responses and aerobic exercise. Exercise and Sport Sciences during cycling and swimming in pregnant and non- Reviews 17, 295–351. pregnant women. Journal of Applied Physiology 81, Wolfe, L.A., Ohtake, P.J., George, K.A. & McGrath, M.J. 738–742. (1990) Aerobic training effects on exercise hemody- Stevenson, L. (1997) Exercise in pregnancy. Part 1: namics during pregnancy (Abstract). Medicine and update on pathophysiology. Canadian Family Physi- Science in Sports and Exercise 22, S28. cian 43, 97–104. Wolfe, L.A., Brenner, I.K.M. & Mottola, M.F. (1994a) Wallace, J.P., Inbar, G. & Ernsthausen, K. (1992) Infant Maternal exercise, fetal well-being and pregnancy acceptance of postexercise breast milk. Pediatrics 89, outcome. Exercise and Sport Sciences Reviews 22, 1245–1247. 145–194. Watson, W.J., Katz, V.L., Hackney, A.C., Gall, M.M. & Wolfe, L.A., Walker, R.M.C., Bonen, A. & McGrath, M.J. McMurray, R.G. (1991) Fetal responses to maximal (1994b) Effects of pregnancy and chronic exercise on swimming and cycling exercise during pregnancy. respiratory responses to graded exercise. Journal of Obstetrics and Gynecology 77, 382–386. Applied Physiology 76, 1928–1934. Webb, K.A., Wolfe, L.A. & McGrath, M.J. (1994) Effects Zaharieva, E. (1972) Olympic participation by women. of acute and chronic maternal exercise on fetal heart Effects on pregnancy and child birth. Journal of the rate. Journal of Applied Physiology 97, 2207–2213. American Medical Association 221, 992–995. Chapter 15

Musculoskeletal Injuries

ELIZABETH ARENDT AND LETHA GRIFFIN

Introduction remembering protection of the injured part, rest or relative rest of the injured part, ice, compres- The musculoskeletal system is composed sion and elevation. In general, acute injuries to of bones and their articulated surfaces (joints) the musculoskeletal system should be evaluated and surrounding soft tissues, including liga- by trained personnel who understand the magni- ments, muscles and tendons. Acute and overuse tude of the injury before return to activity is injuries to the periarticular soft tissues are the advised. most common sports injuries. The pertinent An overuse injury is characterized by the anatomy and physiology of these structures are absence of a specific injury, or at least no injury discussed as these concepts provide a central and significant enough to explain the current clinical recurrent theme in evaluation of acute and situation. An overuse injury is repetitive overuse injuries of soft-tissue musculoskeletal submaximal/subclinical trauma that results in structures. macroscopic or microscopic damage to an area. This is thought to result from damage to a struc- Pathophysiology of injured tural unit and/or its blood supply. This injury is musculoskeletal tissue characterized by a change of circumstance. The transitional athlete (an athlete with a change in An acute injury is created by a single episode of her internal or external environment) is at high force that results in damage to musculoskeletal risk for the development of overuse injuries tissue. This force can be external, such as a direct (Table 15.1). blow to a limb, or internal, such as a non-contact Treatment of overuse injuries typically rotational injury of a limb. An acute injury is typ- requires time for healing. Rest or relative rest of ically characterized by immediate onset of pain the injured part by reducing activities, substitut- and dysfunction of varying degrees. Swelling is ing activities and/or protecting the injured part typically present immediately or within several during activities is advised Further treatment hours of the injury. An acute injury to the recommendations are reviewed in Table 15.2. knee joint is a common sports experience; the Important elements in the treatment of overuse approach to and evaluation of this complex injuries are education of the athlete in the joint can be directed towards individual intra- causative factors of injury, understanding of the articular structures (Arendt, 1995). progression from injury to health including Treatment for an acute injury to the muscu- activity modification, and implementation of a loskeletal system varies with the magnitude of paced return to activity. Education is also the best the injury, the location and the structure injured. treatment for prevention of future overuse However, the acronym PRICE is useful for injuries. 208 musculoskeletal injuries 209

Table 15.1 Characterization of the transitional athlete Table 15.2 Treatment of overuse injuries

Change in training Reduce inflammation/pain Intensity (distance/time, frequency, duration) Non-steroidal anti-inflammatory drugs Footwear changes Physical therapy modalities Surface changes, including material composition Relative rest of injured part and slope Ice Change in competitive climate Compression if swelling is present Weather conditions Life-cycle changes Correct anatomical problems when possible Puberty Patella sleeve Ageing Orthotics to control foot overpronation Pregnancy and after birth Surgery (rare) Menopause Correct biomechanical errors Training sequence Sports style and form Tendons Stretching and strengthening of musculoskeletal units (agonist/antagonist) Tendons are strong, closely packed collagen bundles that attach muscle to bone. Tendons are Correct environmental concerns when possible Shoes and equipment concerns some of the strongest soft-tissue structures in the Environmental concerns including running surface body and their nutrition is primarily provided by Adequate clothing in the cold the vascular system. However, in heavily sheathed regions where the tendon is avascular, Sports-specific rehabilitation nutrition can come from diffusion of synovial Recovery of strength (emphasis on closed-chain/eccentric strengthening) fluid. Tendons are connected to muscles and due Maintenance of endurance and aerobic fitness to their strength most can withstand tensile Maintenance of flexibility of the kinematics (motion) forces greater than those exerted by their linkage system muscles. Therefore, it is uncommon to have a mid-substance rupture of tendons. When a mid- substance tendon rupture occurs, most physi- cians feel it requires a pre-existing pathological increase the frequency and severity of overuse condition. This is seen in chronic overuse injuries injuries in this age group. where there is intersubstance weakening of that After an acute injury to a tendon, inflamma- tendon. Exercise has a positive long-term effect tory products brought to the area by blood on the mechanical properties of tendons, increas- vessels invade the area around the injured ing stiffness, ultimate force and weight. Age can tendon. Collagen and fibroblast production alter these mechanical properties by increasing increase significantly in the first several weeks. collagen cross-linkage and other factors that Secondary remodelling begins approximately adversely affect the ultimate biomechanical 3–4 weeks after injury. This remodelling can con- strength of tendons. These biomechanical and tinue up to 4–5 months after injury, when the vas- material changes occur by the third decade of life cularity and cellularity of the healing tendon are and may contribute to chronic overuse tendon minimally different from that of normal tendon. injuries. The role of unique cyclical hormones in Overuse injuries to tendons are common in women and their effect on the biology of muscu- sport. Few data exist concerning the healing loskeletal soft tissues is not well understood. The response in soft tissues exposed to repetitive decline in oestrogen levels that occurs in the overuse or overload. This is an area of intense fourth and fifth decades of a woman’s life may investigation since such injuries commonly negatively affect the health of tendons and occur in the workplace as well as in sport. There 210 medical issues

is currently no well-defined animal or cellular and competition, and the role each individual model for the study of overuse or overload syn- tendon plays in the complex orchestration of dromes. Chronic tendon overload and injury other muscle tendon units in the limb. A number occur at sites of high exposure to repetitive of other factors, including anatomical location, tensile load. Common sites are the rotator cuff vascular supply of the tissue, magnitude of the tendons of the shoulders, Achilles tendon applied force and position of the limb at the time complex of the calf muscles, and medial and of the applied force, all come together to create an lateral epicondylar regions of the elbows. injury. Alterations in the vascular supply to the Although traditionally overuse and overload tendon due to age or repetitive load may affect injuries were seen in middle-aged recreational the capacity for a tendon to heal in minor repeti- athletes and thought to be related to the ageing tive injuries, instituting the development of process, overuse injuries are now documented in chronic degenerative change. Intrinsic repair virtually every age group, particularly young may be affected by growth or hormonal factors, élite athletes exposed to high levels of repetitive including oestrogen, although these changes are load and young athletes involved in pro- not well understood. grammes that emphasize an intense training The vast majority of tendon overuse injuries schedule. respond to a combination of rest or relative rest of Tendon overuse injuries near the bony end of the injured part, stretching, passive physical the tendon insertion, i.e. the tendo-osseus junc- therapy modalities and intermittent use of tion, are attributed to tendinitis or a low-grade non-steroidal anti-inflammatory medication. inflammatory condition. Tendinitis is rare at the Selective strengthening of the muscle, particu- musculotendinous junction, the junction where larly eccentric strengthening, is thought to be muscle meets tendon. It is in this region that helpful in the repair process. A grading system of muscle strain is most common (see section on sports-induced inflammation is provided in Muscle, p. 211). Despite the fact that these tendon Table 15.3. This grading scheme is useful for the injuries are called tendinitis, the role that inflam- clinician as it is designed to quantify subjective mation plays is not clear. Chronic degenerative symptoms and relate them to physical findings, changes and the absence of inflammation are with a strategy for relevant therapeutic mea- typically found on pathological review of sur- sures. However, little pathological or scientific gical cases of these tendon injuries. These chronic documentation exists for this grading system. degenerative changes and the absence of inflam- Of patients with an overuse injury, 15–20% mation are more appropriately termed ‘tendi- may present with multiple sites of tendinopathy nosis’. Tendinosis is frequently observed in cases and have been classified as having a mesenchy- of spontaneous tendon rupture and may be clini- mal syndrome. Rheumatological evaluation typ- cally silent until rupture occurs. The causes of ically shows no abnormality. The cause of this tendon failure remain speculative. It is probable mesenchymal syndrome is not known at present. that a focal microscopic tendon injury occurs or This syndrome is more common in women and perhaps a microscopic tear. Incomplete healing usually presents in the third to fourth decade of follows. The physiological range of load neces- life (Griffin, 1994). sary for maintenance of normal tendon function is not known. Similarly, the threshold and condi- Ligaments tions responsible for tendon injury are not known. The kind of environment that might be Ligaments are short bands of fibrous connective pertinent to a sports-related injury cannot be tissue that connect and stabilize bones at their completely duplicated. Such an environment articulated surfaces (joints). Ligaments and involves a complex interaction between temper- tendons are biomechanically and structurally ature, hormonal factors secondary to excitement different: ligaments contain a lower percentage musculoskeletal injuries 211

Table 15.3 Grading of sports-induced inflammation. (From Leadbetter, 1990 with permission)

Grade Pain pattern Physical signs Relevant therapeutic measures

I Pain only after activity; duration Generalized soreness Proper warm-up and conditioning; of symptoms < 2 weeks avoidance of abrupt transition in activity level II Pain during and after activity; Localized pain; minimal Analysis of technique and efficiency; no significant functional or no other signs of decrease in abusive training; improved disability inflammation conditioning III Pain during and after activity; Intense point tenderness Structural vulnerability; protected significant functional disability; with prominent activity with sports modification; duration of symptoms > 6 weeks inflammation (oedema, substitutions of sports activity to avoid effusion, erythema, excessive load crepitus, etc.) IV Constant pain; significant Grade III symptoms plus Surgery (fibrogenesis, repair, functional disability; unable to tissue breakdown, structural alteration); possible train or compete; impending atrophy, etc. permanent withdrawal from activity tissue failure (as in degenerative joint disease)

of collagen and a higher percentage of extracellu- minimal amount of load necessary to increase the lar matrix with a more random collagen align- strength of the ligament without compromising ment. Ligaments rely on diffusion as well as a its length or function is not well understood. vascular supply for adequate nutrition. Recovery of normal function is affected by age Healing of an acute ligament injury is a and other local and systemic factors, including complex process and is influenced by both local hormonal influences. The role of oestrogen in and systemic factors. However, it appears that normal and pathological states of ligament func- healing of extra-articular ligaments more closely tion is currently being investigated (Hart et al., parallels that of tendons. This includes ligament 1996; Sciore et al., 1997; Slaughterbeck et al., 1997). injuries around the finger and ankle, as well as collateral ligament injuries around the knee, in Muscle particular the medial collateral ligament. Healing of intra-articular ligaments is less well Muscle strain injuries account for more than half understood. However, it is known that pro- the injuries occurring in some sports. The most longed immobilization of a ligament results in common type of muscle injury is a muscle strain. significant compromise of ligament properties. If the magnitude of force and its direction of Resumption of joint motion and load application application is greater than a musculoskeletal unit results in a slow, progressive recovery of the can resist, an acute injury occurs. Certain material properties of ligaments. This process, muscles have several features in common that the recovery of normal ultimate force and energy predispose them to acute strain injuries. These absorbed to failure, can take 8–12 months for lig- include muscles that cross two joints, a configu- aments. The alterations in ligament properties ration that may facilitate passive restraint of one are reversible if immobilization is not prolonged. joint by the position of its adjacent joint (ham- Most treatment protocols for injured ligaments string muscle, rectus femoris muscle, groin try to incorporate mobilization and exercise into muscles, gastrocnemius muscle). These muscles the repair process. Reapplication of the load nec- tend to be composed of a large percentage of type essary for recovery of normal function and the IIB fibres that work primarily during eccentric 212 medical issues

contractions. Ultrastructurally, eccentric muscle hold this position for a count of 10. Increased contractions have been shown to cause severe intramuscular temperature, i.e. warm-up, bene- myofibrillar disorganization and cytoskeletal fits the biomechanical properties of muscle by segregation, commonly associated with ‘delayed decreasing the stiffness of the musculotendinous muscle soreness’. Forceful eccentric contractions, unit (Garrett, 1990). Within physiological range, particularly against a limb that is trying to stretch is resisted largely by myofibril interac- elongate, can place stresses on the muscle. tion. Beyond that range, most of the tension is The weakest component of the muscle–tendon taken up by connective tissue elements, particu- unit is typically the musculotendinous junction. larly at the musculotendinous junction. Clinical and experimental observations suggest that most of these strains do occur at the Sports injuries muscle–tendon junction, although the reasons for this are poorly understood. Sports injury results from a complex interaction An acute muscle strain initiates a complex of risk factors. Risk factors can be classified into sequence of cellular mechanisms. These can be two categories: (i) extrinsic factors, which are divided into inflammatory, proliferative and related to the type of sports activity, the manner maturation phases. The inflammatory phase in which a sport is practised, environmental con- begins immediately after injury with an influx of ditions and the equipment used to play a sport; blood and/or plasma into the injury site and and (ii) intrinsic factors, which are indivi- formation of a fibrin clot. Muscle maturation dual, physical and psychosocial characteristics and regeneration is complete approximately 6 (Lysens et al., 1984) (Table 15.4). months after injury in humans. Although indi- Increasing numbers of women and girls began vidual muscle fibres may contract normally after participating in sports in the 1970s. In the USA, regeneration, whole-muscle contractile function this increased participation in sports at the sec- rarely is normal after gross skeletal muscle injury ondary school and college levels paralleled the and repair. After a muscle strain has healed, there passage of Title IX. However, passage of Title IX can be stiffness and initial flexibility can be coincided with a more universal women’s move- limited in the muscle–tendon unit. Keeping the ment, which in turn led to increased recognition area warm, e.g. use of a thigh sleeve after a ham- for, and acceptance of, the talent and skill levels string strain, and emphasis on warm-up before of women both inside and outside the athletic intense play are critical in order to reduce the risk arena. of further muscle injury. Early studies maintained that sports injuries Muscle strengthening is thought to decrease sustained by female athletes were no different the likelihood of a strain injury by increasing the from those of men (Calvert, 1975/1976; Haycock energy-absorbing capacity of the muscle–tendon & Gillette, 1976). Whiteside (1980) and Clarke unit. Additionally, strain injury increases and Buckley (1980) independently concluded with muscle fatigue. Muscle strengthening, that, with regard to injury, there was a greater in particular endurance strengthening, will difference between different sports than between decrease muscle fatigue. Cyclic stretching of the the injuries of men and women within the muscle–tendon unit increases tissue compliance. same sport. Thus, it was felt that sports injury Any stretching that causes direct tissue damage was largely dictated by the type of sport and was must be avoided. Stretching should not be done not necessarily influenced by gender. Early ‘cold’, but rather after the body has warmed up. studies of the first female military cadets helped Stretching to pain sends a signal to the brain to establish women’s physiological capabilities contract the muscle; the muscle is trying to resist in conditioned and non-conditioned states, the pain. Therefore, the athlete should stretch just suggesting that many performance variables to the point of discomfort, back off a bit and then resulted from improper conditioning for young musculoskeletal injuries 213

Table 15.4 Risk factors for sports injury body strength, power and endurance, compared with men (Hoffman et al., 1979). Extrinsic factors • Men accomplish tasks with fewer injuries and Equipment Equipment worn, including protective equipment diseases and less apparent stress (Protzman, Footwear 1979). Free-standing equipment (e.g. the uneven parallel • Women may be capable of equal efficiency in bars in gymnastics, the high jump apparatus and aerobic metabolism (Protzman, 1979). pit in track and field) • Women may report injuries differently from Environment Type and condition of playing surface men (Jones et al., 1993). Weather conditions In the early 1980s, studies began to report a Time of day greater number of knee injuries among women Exposure participating in sports compared with men Playing time (Shively et al., 1981; Zelisko et al., 1982). Gray et al. Position on the team Knowledge of sport and its rules (1985) were among the first to focus on an appar- Training ently higher incidence of anterior cruciate liga- ment (ACL) injury among women basketball Intrinsic factors players. Recent studies continue to reveal the Physical characteristics differences in the total number of injuries Age Sex (Engstrom et al., 1991; Zillmer et al., 1991; de Loës, Somatotype 1995) and the incidence of serious knee injuries Previous injuries (Ireland & Wall, 1990; Ferretti et al., 1992; Joint instability Lindenfeld et al., 1994) among men and women Joint hypermobility (tissue-laxity factors) who participate in jumping and pivoting sports. History of previous injuries Alignment of the lower extremity In particular, there are increasing epidemiologi- Psychosocial characteristics cal data that support an increased incidence of non-contact ACL injury in women (Ireland & Wall, 1990; Arendt & Dick, 1995). Non-contact ACL injury in women has come women (Tomasi et al., 1977; Lenz, 1979; under extensive review. Numerous theories con- Protzman, 1979). cerning this injury have been discussed, with no The continuing challenge in sports medicine is conclusive evidence to support a reason for the injury prevention. Attempts to identify key risk increased injury rate. Examining injury risk factors involved in the pathogenesis of sports factors is complex, particularly as these relate to injuries have been sought in both past research gender. The role that certain factors may play in (Lysens et al., 1984) and more recent studies acute and overuse injuries is discussed below, (Milgrom et al., 1991). There appears to be agree- emphasizing possible relationships to gender ment that the history of previous injury is a strong variables. risk factor for recurrent injury. There have been few studies that have examined risk factors in Examining risk factors for relationship to specific sports injuries, probably gender-specific injury due to the difficulty of controlling studies with numerous variables and poor understanding of Much of the information concerning risk factors the interrelatedness of such variables. However, and injury has come from the military popula- studies support the following observations. tion. The risk factors for increased injury preva- • There are significant differences in upper body lence that have been identified include gender strength, power and endurance of women, and (Kowal, 1980), age (Gardner et al., 1988), level of lesser but significant differences in their lower past physical activity (Kowal, 1980; Gardner et 214 medical issues

al., 1988) and race. In non-military studies, the contact ACL injuries, it is apparent that it only positive risk factors for exercise-related injuries accounts for a small number of these injuries, that have been identified include higher amounts particularly when the diversity of sports that of training (Koplan et al., 1982, 1985; Blair et al., report a high incidence of female non-contact 1987; Macera et al., 1989a), past injuries and body ACL injuries is considered, e.g. gymnastics mass index (Macera et al., 1989b). (Jackson et al., 1980; de Loës, 1995), team hand- A recent well-designed study that investigated ball (de Loës, 1995; Myklebust et al., 1997), vol- the risk factors for exercise-related injuries leyball (Ferretti et al., 1992; de Loës, 1995) and among male and female military trainees con- alpine skiing (de Loës, 1995; Ettinger et al., 1995). cluded that female gender and lower aerobic The largest epidemiological study to date used fitness measured by run times are positive risk the National Collegiate Athletic Association factors for training injuries (Jones et al., 1993). Injury Surveillance System to review two sports, The author suggested that prior activity levels basketball and soccer (Arendt & Dick, 1995). This and height may affect men and women differ- study showed that non-contact ACL injury in ently. The authors further suggested that gender women was twice as likely in soccer and three per se may not be an independent risk factor for times more likely in basketball compared with injury, but rather that the underlying risk factor non-contact ACL injury in men over a 5-year may be physical fitness. Their data further indi- period (1989–93). These sports demand similar cated that women are more likely than men to body mechanics (deceleration, plant and pivot) report to the clinic for injury when both sexes are with widely different shoe–surface requirements engaged in the same types of activities under (field surface with a cleated shoe vs. court surface similar conditions for the same amount of time. with an uncleated shoe). This suggests that there may be some societal dif- The literature strongly supports the view that ferences in the way men and women seek help the primary mechanism of ACL injury is non- with regard to their injuries, adding yet another contact in nature (Noyes et al., 1983; Strand et al., variable to epidemiological studies of injury 1990; Arendt & Dick, 1995), with the injuries occurrence. Indeed, psychosocial factors have often occurring on landing from a jump, rarely been included as a variable in studies of cutting/pivoting or with sudden deceleration. risk factors and injury identification. Indeed, a single prospective study identified A review of specific extrinsic and intrinsic three ‘no hit’ mechanisms as being responsible risk factors is discussed below, with particular for ACL injury (Griffis et al., 1989): planting and emphasis on non-contact ACL injury. cutting, straight knee landing and one-step landing with a hyperextended knee. When a extrinsic factors modification of these techniques was prospec- tively taught to female basketball teams, the inci- Shoe–surface interface, in particular increased dence of ACL injury was reduced by 89% during friction between shoe and playing surface, has a 2-year period. been suggested as a cause of injury to both knees This strongly suggests that muscle function, and ankles (Heidt et al., 1996). More specifically, a muscle recruitment or some aspect of training is study of team handball players in Norway an important component in knee function and revealed that the friction rate of certain shoes on injury risk (Moore & Wade, 1989). Earlier studies certain materials, particularly a court shoe on looking at the role of quadriceps and hamstring green turf, showed a higher friction rate. This muscle strength in relationship to injury were increased friction rate correlated with a higher inconclusive (Grace et al., 1984; Colosimo et al., incidence of non-contact ACL injury (Myklebust 1991). However, a recent, more sophisticated et al., 1997). Although one could theorize that study that investigated tibiofemoral laxity as the shoe–floor interface accounts for some non- well as lower extremity muscle strength, musculoskeletal injuries 215

endurance, reaction time and muscle recruitment pants, history of sports participation, quality and suggests differences between female athletes and quantity of coaching instruction, and partici- male athletes as well as between female athletes pants matched for skill levels, will help to and non-athletic male and female controls support or dispel this belief. (Huston & Wojtys, 1996). The authors of this study hypothesized that the female athlete has a intrinsic factors ‘quadriceps-dominant’ knee. This might be responsible for increased anterior translation in In the orthopaedic literature, the most discussed certain activities, thus increasing the risk of ACL reason for ACL failure has been the dimensions stress and injury. It has been previously docu- of the intercondylar notch of the knee (the U- mented in studies of ligament failure that liga- shaped space in the middle of the knee through ments acting alone would not be able to which the ACL runs). The intercondylar notch withstand the levels of loading commonly seen has been implicated as a reason for ACL failure in with sport. The quadriceps muscles can produce both newly injured and ACL-reconstructed forces in excess of those needed for ligament knees (Table 15.5) (Arendt & Dick, 1995). The failure (Wojtys & Huston, 1994). Studies have exact role that a small notch plays in creating an found that there are sex differences in the rate of ACL tear remains speculative. However, some muscle force production (Komi & Karlsson, 1978; researchers theorize that a smaller notch creates Bell & Jacobs, 1986; Häkkinen, 1991; Winter & increased stress on the ACL in certain positions, Brookes, 1991). In particular, women require most particularly internal rotation and hyperex- more time than men to produce the same relative tension of the knee. Others theorize that a small muscle force levels. Some authors have sug- notch houses a small ACL, with concomitant gested that this lower rate of force development decrease in ligament strength (Shelbourne et al., in women is the result of structural differences in 1998). In looking for a gender difference in the the series elastic component of muscle (Komi & size of the notch, two prospective studies in large Karlsson, 1978; Winter & Brookes, 1991). This groups have agreed that athletes with smaller strongly suggests a prominent role for muscle notch width indices (the ratio of the femoral strength and the pattern of muscle recruitment in bicondylar width to the width of the intercondy- coordinated and safe knee function. The role that lar notch) are at risk for a non-contact ACL injury training may play in changing muscle pattern (Souryal & Freeman, 1993; LaPrade & Burnett, recruitment has come under recent review. For 1994). However, one study found no sex differ- example, women volleyball players have been ences in notch width index or rate of ACL injury shown to have decreased adduction moments on (LaPrade & Burnett, 1994), while the second jump landings after 6 weeks of intense training study found the notch width index in women to emphasizing plyometrics (Hewett et al., 1996). be less than that in men (Souryal & Freeman, Skill level continues to be implicated as a 1993). The role that the notch plays in causing causative factor in injuries in both men and non-contact ACL injury (Muneta et al., 1997; women. This concern is highlighted due to the Shelbourne et al., 1998) and whether size or recent increase in sport participation by women. gender is the determining factor in such injury Some feel that this has created an influx of needs further study before answers are known. players into a sport, potentially decreasing the The role of the unique cyclical hormones in average skill level of those playing. Studies com- women and their possible effects on ligaments paring the rate of injuries over time suggest that are being increasingly investigated. The effect of skill level is a reason for a decrease in the injury hormones, particularly oestrogen, on soft tissues rate (Engebretsen, 1985). Collection of further is not well understood. However, it is well injury data over time, with emphasis on more known that the hormone relaxin, found in direct measurement of skill level of the partici- women during pregnancy, is largely responsible 216 medical issues

Table 15.5 Intercondylar notch (ICN) vs. anterior cruciate ligament (ACL) injury

Measurement Reference Population technique Conclusion Gender differences

Anderson et al. Patients with bilateral CT scan An association exists (1987) ACL injury, between anterior unilateral outlet stenosis of injury and the ICN and ACL no known knee rupture injury. Retrospective study Houseworth et al. Patients with acute Computer graphic A narrow posterior (1987) ACL injury and no study notch may known knee injury. predispose to ACL Retrospective failure study Souryal et al. Patients with bilateral Notch radiographic NWI of bilateral No gender (1998) ACL injury, acute view: defines notch ACL injury < NWI difference ACL injury and width index (NWI) of acute ACL though normal knees. as ratio of width of injury and normal population Retrospective ICN to width of knees. NWI of largely male study femoral condyle, acute injuries using radiographic equals NWI of landmarks normal knees Good et al. Patients with acute Direct measurement Normal notch width (1991) and chronic of anterior notch 18.1–20.4mm. unilateral ACL opening using a Acute ACL injury injury. Normal calliper technique had narrower measured from notch cadaver knees. measurements Retrospective study Souyral & 902 high-school Notch radiographic Athletes with no NWI in females Freeman athletes. view: contact ACL < NWI in males (1993) Prospective study measurement injury have of NWI smaller notches Schickdatz & Patients with Eight different ICN measure- Weiker unilateral and mathematical ments from (1993) bilateral ACL measurements from X-rays may not be injury, and normal notch radiographic reliable predictors knees. view of ACL injury Retrospective study Lund-Hassen et al. Female Norwegian Notch radiographic Notch width Only females (1994) national team view: direct < 17mm are at studied handball players. measurement of high risk of injury Retrospective notch width study LaPrade & Burnett 213 Division I Notch radiographic Athletes with No significant (1994) athletes. view: stenotic notches difference Prospective study measurement playing certain between sex and of NWI sports are at high average NWI or risk for ACL rate of ACL tears injury musculoskeletal injuries 217

for the ligamentous relaxation of the pelvis specific tests of joint motion. A range of articular during childbirth. Several recent studies have movements of defined joints, i.e. knees, elbows, tried to uncover the relationship between liga- wrists, fingers, is measured. A ‘laxity scale’ is ment biology and hormones. A role for the hor- defined giving each joint motion a certain monal effects on ligament function continues to numerical value (Carter & Wilkinson, 1964; be investigated (Hart et al., 1996; Sciore et al., Breighton et al., 1973) (Table 15.6). Hypermobility 1997; Slaughterbeck et al., 1997). syndrome is said to be present if an individual Knee joint laxity, defined as an increase in has three or more positive laxity tests, together anterior–posterior motion of the tibia and with joint or muscle symptoms (Biro et al., 1983; femur, is most commonly measured using an in- Gedalia et al., 1985). A consistent relationship strumented arthrometer (Fig. 15.1). Arthrometer measurements of anterior–posterior motion have been reviewed in the knees of normal male and Table 15.6 Laxity scale for defining hypermobility. female basketball players (Weesner et al., 1986), (From Bird, 1993 with permission) normal knees in the population (Daniel et al., 1 Passive dorsiflexion of the little 2 points 1983), athletic knees before and after exercise fingers beyond 90∞ (one point for (Skinner et al., 1986; Steiner et al., 1986), ACL- each hand) intact and ACL-deficient knees (Grana & Muse, 2 Passive apposition of the thumbs to 2 points 1988) and in athletes across different sports the flexor aspects of the forearm (Steiner et al., 1986), all revealing no apparent (one point for each thumb) 3 Hyperextension of the elbows 2 points relationship between knee laxity, gender and beyond 10∞ (one point for each injury. Amore sophisticated review of knee laxity knee has been performed recently by Huston and 4 Hyperextension of the knees 2 points Wojtys (1996). This is the first study to show a dif- beyond 10∞ (one point for each ference in knee laxity between men and women knee) 5 Forward flexion of the trunk with 1 point and women athletes. knees extended so that the palms Multiple joint laxity, or hypermobility, has of the hands rest on the floor been implicated as a risk factor for injury. The Total 9 points most common way to define hypermobility is by

Fig. 15.1 A KT-1000 arthrometer, a portable device which is capable of measuring anterior tibial translation in millimetres when fixed loads of 6.75, 9 and 13.5kg force are applied. 218 medical issues

between hypermobility of the knee joint and injury has not been found. Nicholas (1970) reported that 28 of 39 football players (72%) with knee injuries had hypermobility. This incidence has yet to be substantiated in further studies. Other studies, using various modified laxity scales, have found no correlation between knee ligament injuries and laxity scores in college football players (Godshall, 1975; Kalenak & Morehouse, 1975; Moretz et al., 1982; Grana & Muse, 1988) or between knee and ankle ligament injuries and laxity scores in high-school athletes (Godshall, 1975; Grana & Moretz, 1978). Looking at musculoskeletal injuries in general, Diaz et al. (1993) studied 23 military recruits, cor- relating injury with a modified laxity scale. These authors concluded that lax individuals (those with three of five laxity tests positive) had more musculotendinous injuries than those who were not lax. Hypermobile joints, or an increased Fig. 15.2 Standing leg alignment of a young woman laxity scale, have been implicated principally in with an extreme case of the typical features of miser- the creation of overuse injuries. However, their able malalignment syndrome, including increased femoral anteversion (resulting in a standing posture of role in patellofemoral pain, overuse injuries increased internal rotation of the hip), high Q-angle, about the foot and ankle, and shoulder laxity tibial vara, external tibial torsion and pronated flat feet. syndromes has been poorly defined. Breighton et al. (1973) felt that musculoskeletal symptoms, as judged by laxity scales, are positively related to mobility scores. This relationship is most evident often quoted as a reason for overuse injuries of for females. The fact that, using laxity scales, the lower extremity in females. A variation in women demonstrate more joint laxity than men limb alignment has been termed ‘miserable has been confirmed by others (Klemp et al., 1984; malalignment syndrome’ (Fig. 15.2), which is a Larsson et al., 1987; Diaz et al., 1993; Wiesler et al., combination of lower extremity features that 1996). include increased anteversion of the femoral Anatomical limb variation has been suggested head, external rotation of the tibia and a pronated as being responsible for the increased rate of non- foot. Other features can include an increased Q- contact ACL injury in women. There are few data angle, tibiofemoral valgus, tibial varus and a to support this. A single retrospective study hypermobile patella. These anatomical features, reviewing the experience of one sports medicine alone or in combination, have been blamed for a clinic concluded that there is no apparent variety of overuse syndromes in the lower legs of relationship between standing tibiofemoral active people, particularly women. This type of alignment, Q-angle (the angle formed by the limb alignment is seen more commonly in the intersection of a line parallel to the long axis of female population but is not limited to women. the femur and a line drawn through the centre of The exact prevalence of miserable malalignment the patella tendon) and knee injuries (particu- syndrome in population studies has not been larly ACL injury) in a series of female basketball elicited. However, limb alignment, particularly players (Gray et al., 1985). femoral anteversion, has been reviewed (Huid & Anatomical limb variation is perhaps most Anderson, 1982; Staheli, 1987, 1993). musculoskeletal injuries 219

A pronated flat foot, frequently associated analysis with regard to possible gender differ- with miserable malalignment syndrome, has ences. However, at least one study suggests that been implicated as a factor in non-contact ACL ankle sprains are more prevalent in women and injury (Canavan, 1996). Biomechanical studies girls (Harrer et al., 1996). Again, rigid analysis of have verified that internal rotation of the tibia risk factors needs to be undertaken to evaluate places greater force on the ACL ligament than whether this gender difference is real and external rotation of the tibia (Markolf et al., 1990). whether intrinsic and/or extrinsic factors are Therefore, one can theorize that the pronated responsible. foot, which obligates a linked system of tibial Although not classified in an injury category, internal rotation, may place more stress on the arthritic disorders (arthritis and arthralgias) ACL. In this theory shoe wear, with or without include more than 100 different illnesses and are the addition of a prefabricated orthotic, would the most frequent reason for decreasing physical obviously play a moderating role. activity in the ageing population. Most patients with arthritis are women. Arthritic disorders are 60–80% more common in women (Heiwick et al., Other gender-specific injury concerns 1995; Gabiel, 1996; Lawta, 1996). Osteoarthritis Dislocation of the patella is an acute injury of (typically referred to as age-related joint wear the knee in which the kneecap is forced out of and tear) is more prevalent among women than the trochlear groove of the femur by a strong men (1.5–4.0 times more common); this preva- valgus or external rotation force, creating an lence increases with age. A subcollection of injury in the medial patella and retinacular arthritides commonly known as connective restraints. A few studies (Larsen & Lauridsen, tissue diseases includes, but is not limited to, 1982; Halbrecht & Jackson, 1993), supported rheumatoid arthritis, systemic lupus erythe- by many physicians’ personal impressions, matosus (SLE) and fibromyalgia. Rheumatoid report that recurrent dislocations of the patella arthritis is two to three times more common occur more frequently in females. However, in women of all ages, while 90% of patients most studies on acute dislocations of the patella with SLE are women and it is three times continue to show a male preponderance (Cofield more common among African Americans. & Bryan, 1977; Hawkins et al., 1986; Vainiopaa Fibromyalgia is perhaps the most poorly defined et al., 1990). It is difficult to interpret these condition of this group. It is a chronic muscu- findings, as most studies reporting acute disloca- loskeletal syndrome characterized by diffuse tions of the patella in men are not prevalence pain at specific tender points; about 90% of all studies and date from a time when men identified cases of fibromyalgia are women. constituted the majority of athletes. However, Arthritis has been identified as a major women’s collective review of studies does suggest that health issue. Currently, most preventative and women have a higher incidence of recurrent palliative measures are aimed at patient educa- dislocation of the patella. Further analysis of tion, weight loss and appropriately directed this potential gender difference would need to exercise. address issues similar to those discussed previously under ACL injury. In addition, Overuse injuries of the outcome studies of dislocations of the patella lower extremities would need to examine morphology of the bony patella, degree of soft-tissue damage and treat- Overuse injuries are common in athletic and ment protocols after injury in order to assess active populations. The most common injuries whether gender is a risk factor for recurrent facing the female athlete are detailed below, dislocations. with strategies for diagnosis, treatment and Ankle sprains have not undergone much prevention. 220 medical issues

without contractions of the quadriceps muscle Patellofemoral pain syndrome and in a single arc of motion. PFPS without X-ray Patellofemoral pain syndrome (PFPS) is a global demonstration of malalignment may represent term used to describe anterior knee pain that subtle malalignment not detectable with current originates in the extensor mechanism. The exten- static imaging techniques. This subtle malalign- sor mechanism includes the bony patella and its ment may be a result of an imbalance of the femoral groove, quadriceps muscle, quadriceps quadriceps muscles, either in recruitment or and patella tendon, and retinacular structures strength. Alternatively, it may be an imbalance that surround the patella. PFPS is pain in the secondary to laxity or tightness in the peripatel- patellofemoral joint without documented lar structures, including laterally (iliotibial joint instability and can be further classified as muscle and lateral retinaculum) or medially occurring with or without malalignment. Mala- (vastus medialis muscle and medial retinacu- lignment refers to an abnormal relationship lum). Normal medial–lateral translation of the between the patella and the trochlear groove; this patella allows the examiner to move the patella can lead to asymmetry as the patella tracks in its medially about one-quarter the diameter of the groove. Malalignment syndromes are typically patella and laterally about one-half the diameter revealed on axial X-rays (Fig. 15.3) (Carson et al., of the patella (Arendt & Teitz, 1997). Normal tilt 1984; Fulkerson & Cautilli, 1993). The vast major- can be assessed on physical examination by the ity of cases of PFPS do not fall into a malalign- ability to bring the lateral border of the patella to ment category. This is perhaps because the the level of the horizontal plane or greater. This spectrum of malalignment is not clearly defined. examination is done in the supine position with Typically, X-rays are taken in a static view the knee in extension and muscle relaxed. Abnormal tightness or laxity, as demonstrated by translation and tilt tests, can lead to imbalance in motion of the patella during active use of the knee. This imbalance can lead to pain. Important features regarding the treatment of PFPS are listed below. • Central in the treatment of PFPS is balancing the movement of the patella as it tracks in the trochlear groove. Rehabilitation, particularly quadriceps strengthening, is widely recognized as useful for treating patellofemoral disorders (Bennett & Stauber, 1986; O’Neill et al., 1992; Molnar, 1993; Steinkamp et al., 1993). • The entire lower kinematic change in PFPS should be assessed for gait characteristics, flexi- bility and strength of the proximal and distal por- Fig. 15.3 A 20° axial view (Laurin’s view) of the knee of a patient who sustained an acute dislocation of the tions. Decreased rotation or weakness of external patella. Radiographic lines drawn along the lateral rotators of the hips, hamstring tightness, quadri- patella facet and across the highest point of the medial ceps tightness and Achilles tendon tightness are and lateral femoral condyles reveal converging lines frequently associated with PFPS. These should that represent continued tilt of this kneecap. A perpen- be assessed and treated with appropriately dicular line drawn from the highest point of the medial femoral condyle reveals more than 3 mm lateral dis- directed rehabilitation. placement of the patella from this perpendicular line, • Retinacular tightness of the patella should be indicating continued subluxation of this kneecap. examined by translation and tilt, with referral to musculoskeletal injuries 221

physical therapy for mobilization of the patella if specific fat stores. The period of time in which tight restraints are identified. these changes take place is shorter than the • A quadriceps strengthening programme growth period in adolescent boys (Tanner, 1962). should be started, emphasizing those activities This period of accelerated body changes can that do not irritate patellofemoral pain. Isometric produce changes in sports-specific performance exercises, advancing to closed-chain isotonic as girls accommodate to their new body shapes. exercises, are preferred as tolerated by the patient’s pain symptoms. Closed-chain kinetic Miserable malalignment syndrome exercises are more functional and result in lower contact stresses to the patella in mid-arc motion Miserable malalignment syndrome has been (Hungerford & Lennox, 1983; Steinkamp et al., blamed for a variety of overuse syndromes of the 1993). Eccentric quadriceps strengthening is lower extremity. An overpronated foot necessi- emphasized (Bennett & Stauber, 1986) as the tates more foot motion in the stance phase. quadriceps muscle is an important decelerator. Pronation of the foot necessitates internal rota- • Control of overpronation of the foot with a tion of the tibia, which forces a similar rotational semirigid orthosis is popular, although there are sequence up the lower extremity. Therefore, in few controlled studies that have demonstrated the person with an overpronated stance there is success using acceptable outcome measures (Tria greater rotation of the limb in accomplishing the et al., 1992). stance phase of gait. Running aggravates this • The McConnell tape technique (McConnell, problem because the stance phase occupies a 1986) is based on assessment and tape correction shorter period of time. One can think of this as a of patellar position, including glide, tilt and rota- ‘windscreen wiper’ effect, with a wider arc of tion. This may be useful for select patients but motion for the ‘windscreen wiper’ in the must be an adjunct to full treatment. The use of overpronated foot. Progression from walking patellar braces in patients with PFPS remains to running causes overpronation of the limb to controversial (Podesta & Sherman, 1988; Molnar, occur at a faster pace. This can lead to a variety of 1993). overuse syndromes, including plantar fasciitis, • Recognition of our incomplete knowledge of Achilles tendinitis, medial overload of the ankle the aetiology of PFPS is appropriate. Athletes (including posterior tibial tendinitis and shin need to be instructed to acknowledge painful splints), distal iliotibial band syndrome, activities and decrease or avoid them if possible. proximal iliotibial band syndrome and PFPS. Posture and exercise modification, including Treatment directed at reduction of pain and repetitive squatting and habitual hyperexten- inflammation in the painful area, along with sion of the limb in the standing position, may review of the entire alignment and function, as be employed with a positive effect on chronic outlined for PFPS, can be useful. patellofemoral pain. Distal and proximal iliotibial band tendinitis When planning a patellofemoral rehabilitation can also be seen when a tight iliotibial band and programme for women, particular attention lateral retinacular structures of the patella are needs to be paid to the woman’s typically shorter present. Relief of this syndrome should be stature and decreased strength. Strength- attempted with physical therapy modalities training equipment needs to be sized to an directed at the painful site and stretching of the individual to be effective and safe. iliotibial band and lateral retinacular structures PFPS is frequently seen in adolescent females. of the patella (patellar mobilization). At times, a During adolescence, the female body undergoes cortisone injection directed at the bursal site with significant changes, including increase in height, subsequent reduction of bent knee activities for widening of the pelvis and deposition of sex- 5–7 days following the injection can be useful. 222 medical issues

cycle. Stress is put on the posterior tibial tendon Stress fractures during the pronation phase of stance, stabilizing Stress fractures can be thought of as an overuse the foot in pronation. The posterior tibial muscle injury of bone. Historically, stress fractures have also fires during the push-off phase of walking been defined on the basis of the X-ray appear- and running. Tendinitis and rupture of this ance of a fracture line and/or the bone’s healing tendon are more prevalent in women, especially response as interpreted by traditional roentgeno- in those over age 40 (Frey & Shereff, 1988). graphic images (Savola, 1971). With the advent Whether this increased prevalence in women is of newer techniques for investigating stress secondary to an increased incidence of pronation phenomena of bone, particularly scintigraphic related to shoe wear or to the hormonal environ- analysis (Roub et al., 1979) and magnetic reso- ment remains speculative. nance imaging (Arendt & Clohisy, 1995), bone In more severe cases of posterior tibial tendini- stress is now regarded as a continuum from tis, particularly in the middle-aged athlete, normal remodelling to fatigue and bone exhaus- detailed attention to management is paramount tion. Bone can successfully accommodate stress due to the potential for rupture (Johnson, 1989). or undergo failure in response to increasing load. Typical features on physical examination include The ultimate result of increasing load would be a a flattened or pronated foot and inability to frank stress fracture on X-ray. perform a toe raise. In the younger female Special attention must be given to irregulari- athlete, posterior tibial tendinitis is frequently ties of the menstrual cycle when considering missed as a cause of medial ankle discomfort. stress fractures and stress phenomena of bone. Typically, the posterior tibial tendon is inflamed The effect of oestrogens on vertebral and cancel- but functionally intact. Typical examination lous bone is well documented (Cann et al., 1988; features include pain to direct palpation of the Drinkwater et al., 1990; Arendt, 1993). An associa- tendon and discomfort when single-leg toe tion between stress fractures and menstrual raising is attempted. Rest, ice and occasional irregularities has been observed (Warren et al., non-steroidal anti-inflammatory medications are 1986; Barrow et al., 1988). Stress injury to bone used in the early phase. Immobilization may be and stress fractures have been noted to occur required to reduce this inflammation. more commonly in females, especially in the After the acute inflammation has subsided, presence of disordered eating, amenorrhoea and attention is given to strengthening the posterior low bone density. There is probably a complex tibial muscle and stretching of the Achilles interaction between mechanical (limb alignment tendon complex if tight; use of a semirigid and training factors), nutritional and hormonal orthotic for control of overpronation is recom- factors on bone health. A careful menstrual mended. When performing Achilles tendon history is mandatory for the complete evaluation strengthening and closed-chain partial squats, of any stress fracture or stress phenomenon in the appropriate technique should be followed women. Any change in intensity, duration or fre- carefully. Often patients will perform an Achilles quency of the menstrual cycle associated with tendon stretch or a partial squat by placing increased training should be a cause of concern increased valgus on the knee in such a way that a (Shangold et al., 1990). plumb-line from the knee falls medial to the ankle (Fig. 15.4). This places increased stretch on the posterior tibial tendon. Posterior tibial tendinitis

The posterior tibial tendon contributes to the Flexor halluxus tendinitis maintenance of the longitudinal arch of the foot and functions to invert the hind foot during heel Flexor halluxus longus tendinitis is most strike and in initiating the stance phase of the gait common in the female ballerina who dances musculoskeletal injuries 223

(a) (b)

Fig. 15.4 Athlete performing squats and duck walks. Note full hip, knee and ankle flexion or any weakness: Fig. 15.5 A 44-year-old woman with bilateral hallux (a) normal; (b) asymmetrical hip, knee and ankle valgus. The patient also has arthritic changes at the first flexion. metatarsal phalangeal joints as well as medial subluxa- tion of the first phalanx bilaterally. enpointe (on the tips of her toes). In this position poorly fitting shoes, ligamentous laxity and the flexor halluxus acts as an accessory push-off overpronation (Hunter-Griffin, 1991; Frey et al., muscle. Athletes such as high jumpers or gym- 1993). Women’s shoes may aggravate bunions nasts who may use this muscle for accessory and other toe deformities. Frequently, women’s push-off can also suffer from this type of tendini- shoes, particularly sports shoes, are smaller tis. There is frequently pain in the muscle belly adaptations of men’s shoes. In general, the superior to the medial malleolus just medial to female foot has a different shape from that of the the Achilles tendon. This has been confused with male foot, being narrower relative to length with Achilles tendinitis but can be easily distin- a narrower heel compared with the forefoot. As guished by careful examination. Pain is aggra- foot length increases, forefoot width increases vated by maximum passive dorsiflexion of the somewhat but heel width rarely increases signifi- great toe or resisted plantar flexion of the great cantly. However, most shoe manufacturers typi- toe. Despite the fact that the pain is medial and cally scale their shoes by enlarging all key superior to the ankle, attention should be given internal dimensions in fixed proportions. This to limiting great toe motion with review of often results in shoes that are too loose in the sports-specific techniques for its treatment. hind foot, particularly for women with bigger feet (US size 8 or larger). Women who have a wide forefoot and a narrow hind foot may have a Foot concerns difficult time finding shoes that fit. If feet are A bunion is inflammation of the bursa over the forced into a bigger shoe to fit the forefoot but not medial prominence of the first metatarsal (Fig. the hind foot, this creates a sloppy shoe that 15.5). Bunions are nine times more common in allows the foot to move back and forth during women than in men. This is thought to be due activities. This can cause posterior heel pain and to a combination of hereditary predisposition, lesser toe deformities. If the shoe is a snug fit on 224 medical issues

the hind foot, it can create undue pressure on humeral head is held in its bony socket, the the forefoot, creating increased symptoms over a glenoid, by ligaments that reinforce the joint bunion (medial aspect of the first toe) or capsule and by the muscles of the rotator cuff bunionette (lateral aspect of the fifth toe). Care- that surround the joint. These muscles serve to ful attention to sports shoe selection will help a rotate the shoulder internally and externally. woman avoid injury and minimize the forces The tendons of four distinct muscles, the sub- that can complicate foot problems (Frey, 1997). scapularis (anteriorly), the supraspinatus (supe- Variable eyelet patterns exist in sports shoes that riorly), the infraspinatus and teres minor allow for adjustable lacing. This can create vari- (posteriorly), form a supportive cuff about the able width for a narrow foot or a wide foot, par- humeral head (Fig. 15.6). The scapular stabilizing ticularly in a high-arched foot. Current sports muscles, i.e. the trapezius, the rhomboids and the shoe design has variation in the type of last serratus anterior, are also important in gleno- (outline of the sole of a shoe), typically each shoe humeral stability since proper positioning of the company having a slightly different last. The scapula is needed for normal rotator cuff muscle type of last helps determine the stability of the function. shoe and the ‘fit’ of a shoe to a particular foot. Shoulder pain in women athletes may be a Motion control vs. shock absorbency is another result of: (i) laxity with secondary impingement; important consideration when selecting a sports (ii) laxity with recurrent subluxation; or (iii) shoe. impingement secondary to a compromised subacromial space. Contributing factors to the prevalence of these conditions in women include Overuse injuries of the poor upper body strength, shorter upper extrem- upper extremities ities and faulty technical skills. Whether ligamentous laxity is a contributing factor Shoulder pain in shoulder problems in women remains The shoulder is a joint of extreme mobility speculative. that sacrifices bony stability. Anatomically, the As previously discussed in this chapter, liga-

Clavicle Supraspinatus muscle Supraspinatus muscle Clavicle

Subscapularis muscle Infraspinatus muscle

Teres minor (a) (b) muscle

Fig. 15.6 The anterior ligaments of the shoulder that lend stability to the capsule include the superior glenohumeral ligament, the middle glenohumeral ligament and the inferior glenohumeral ligament. (a) Anterior aspect, and (b) posterior aspect. musculoskeletal injuries 225

mentous laxity is common in women. In the lifting or volleyball, may describe pain coupled majority of studies, this increased ligamentous with a sense of apprehension when raising their laxity has not been found to be directly related to arm overhead, especially in an abducted position an increase in sports injuries (Godshall, 1975; (Pink & Jobe, 1991). They may even experience Kalenak & Morehouse, 1975). However, in the an episode where the shoulder ‘slips out’ and shoulder, glenohumeral laxity has been directly stays out for a few seconds before being easily related to one type of shoulder problem, recur- reduced by the athlete or a friend (Jobe & Kvitne, rent atraumatic instability or AMBRI (atraumatic 1989). On physical examination, those with mul- multidirectional bilateral treated by rehabilita- tidirectional instability of the shoulder demon- tion instability). This type of shoulder instability strate laxity with anterior, posterior and inferior occurs atraumatically, i.e. with little or no abnor- translation of the humeral head in the glenoid. mal force on the joint. Typically, no damage to Inferior translation of the humeral head is noted tissue occurs. Ligaments and tissue are so lax that by a positive sulcus sign (Fig. 15.7) (Silliman & the shoulder can dislocate or sublux without Hawkins, 1994). trauma. AMBRI was so termed to differentiate it Treatment of athletes with multidirectional from traumatic shoulder dislocation. With trau- shoulder instability is aimed at strengthening the matic shoulder dislocation, injury to bone and rotator cuff, deltoid and scapular stabilizing soft tissue occurs, including damage to the humeral head that results in an impaction frac- ture (Hill–Sachs lesion) and/or damage to the glenoid by disruption of the labrum. This decreases the bony and ligamentous stability of the shoulder joint. This latter type of instability has been termed traumatic unilateral instability with a Bankart lesion (TUB) (Matsen et al., 1993). Treatment for these shoulder problems is very different. TUB responds favourably to operative treatment, i.e. repair of the bony glenoid and tightening of the stretched capsular restraints. The AMBRI type of instability implies a genetic predisposition for tissue laxity. Laxity in other joints (i.e. knees, fingers, elbows) is typically present in the athlete with AMBRI. This type of shoulder instability should initially be treated with a prolonged rehabilitation programme to strengthen the muscles about the shoulder and avoidance, if possible, of positions that could sublux or dislocate the shoulder. Surgical inter- vention is rarely advised, for failure is common secondary to poor quality tissue (Jobe et al., 1990d; Matsen et al., 1993). The presenting history of athletes with symptomatic multidirectional instability of the Fig. 15.7 A female athlete with multiple directional instability of the shoulder. Note the positive sulcus shoulder is variable. Some athletes, when partici- sign, which is produced by downward traction on the pating in sports requiring repetitive overhead arm pulling the humeral head inferiorly in its bony motion such as swimming, gymnastics, weight- socket. 226 medical issues

muscles. Initially, such exercises should be mial space that may be narrowed by degenera- performed below shoulder height. Anti- tive subacromial spurring. The subacromial inflammatory drugs may be useful at the begin- space may be genetically small secondary to ning of the exercise programme to decrease a hooked or beaked acromion (Hawkins & inflammation and its associated discomfort. Kennedy, 1980). On physical examination, ath- Sport-specific technique, e.g. swimming style, letes with impingement without instability have racquet strokes or throwing motions of the a positive impingement sign (pain when the athlete, needs to be examined and improper shoulder is abducted and internally rotated) and technical skills corrected. weakness of the rotator cuff. They may have The athlete with an unstable shoulder may not associated biceps tendon irritability, since this complain of instability but have shoulder pain tendon can also be traumatized from repeti- with overhead activities. Shoulder pain can tive impingement against the bony acromion result from a humeral head that is not firmly (Hawkins & Kennedy, 1980; Keirns, 1994). seated in the glenoid and therefore displaces Treatment for impingement without instabil- superiorly with overhead motion, causing ity is aimed at reducing inflammation of the impingement of the structures (tendons and tendons and bursa in the subacromial space. This bursa) in the subacromial space (Jobe et al., can involve anti-inflammatory drugs and reduc- 1990a). This leads to an impingement syndrome. tion of aggravating activities (typically overhead On examination, these athletes have a positive activities). Exercises to strengthen the cuff and impingement sign, as well as multidirectional the scapular stabilizing muscles are recom- shoulder laxity. Weakness of the rotator cuff is mended in order to improve shoulder mechanics typically present. Treatment is similar to that (Wilk et al., 1994). Intermittent judicious use of prescribed for multidirectional instability with injections of cortisone into the subacromial bursa symptomatic subluxation, centring on rehabilita- can be useful. Technical considerations, includ- tion of the rotator cuff and scapular stabilizing ing proper throwing mechanics, body rolling muscles. It is important to recognize this pain with breathing and stroking in swimming and syndrome as an instability problem, not as position of the shoulder in relationship to the impingement. Surgical treatment directed at body during the golf swing, need to be impingement alone, without recognizing the examined. The surgical approach is used when underlying instability, will fail. conservative treatment has failed. This involves The symptom of impingement with underly- arthroscopic or open débridement of the under- ing instability is also associated with unilateral surface of a beaked acromion or resection of anterior instability. Features on physical exami- degenerative spurs and débridement of a thick- nation include unilateral anterior shoulder laxity ened bursa. This may improve shoulder mechan- with a positive impingement sign. Internal rota- ics by increasing the size of the subacromial tion of the shoulder joint is frequently reduced, space (Hawkins & Kennedy, 1980). aggravating this symptom complex. In addition to rotator cuff strengthening exercises, stretching Frozen shoulder and strengthening of the soft tissues of the pos- terior shoulder are also important. Surgical stabi- Frozen shoulder syndrome (also termed adhe- lization of the unidirectional unstable shoulder sive capsulitis) is inflammation of the periarticu- can be considered after failure of conservative lar shoulder structures that results in marked treatment (Jobe et al., 1990b). limitation of forward and side elevation and Impingement without instability generally internal rotation of the shoulder (Parker et al., occurs in the older athlete and results from a 1989). A repetitive activity can be the precipitat- weak rotator cuff and a compromised subacro- ing event, although why the activity results in musculoskeletal injuries 227

such severe secondary inflammation and pain Lateral epicondylitis of the elbow with marked limitation of motion is not well understood. The frozen shoulder syndrome is Repetitive stress to the wrist extensor muscles most common in women between the ages of 40 can result in inflammation in the origins of these and 60 years (Ott et al., 1994). Some researchers muscles as they arise from their bony origin, feel that it represents a type of dystrophy. It is the lateral epicondyle of the elbow. Lateral often associated with medical conditions such epicondylitis is five times more common than as arteriosclerotic heart disease, epilepsy, pul- medial epicondylitis and generally occurs in monary disorders, thyroid disorders, diabetes those 21–65 years of age (Rettig & Patel, 1995). mellitus and gastrointestinal disorders (Ozaki et One might assume that the lower upper body al., 1989). The onset can be quite insidious. Even strength of women would predispose them to a though this condition has been termed ‘adhesive greater incidence of lateral epicondylitis. capsulitis’, adhesions have been found outside However, the incidence of lateral epicondylitis is and inside the joint and in the subacromial bursa. similar for both men and women, whereas Some subscapular bursal irritation may be medial epicondylitis (inflammation of the origin present, and increased vascularization around of the wrist flexors at the medial epicondyle) the cuff and biceps tendon has been described occurs more commonly in men (Rettig & Patel, (Duralde et al., 1993). 1995). The greater use of the two-handed Anti-inflammatory medication administered backhand by women playing racquet sports may orally and injected into the joint, combined with contribute to their lower incidence of lateral epi- exercises to increase flexibility and strength in condylitis. the muscles about the shoulder, comprise the rec- Figure 15.8 illustrates the origin of the wrist ommended treatment. Some physicians feel that extensors on the lateral epicondyle of the manipulation of the shoulder under anaesthesia humerus. The extensor brevis muscle has been is helpful to break up scar tissue and improve the muscle cited as the primary injury site. A shoulder function. Such manipulation must be rapid rise in repetitive wrist flexion–extension done with great care to avoid fracturing the prox- activities and/or poor mechanics in performing imal humerus (Duralde et al., 1993). This is a such activities has been implicated in the devel- greater risk in older individuals who have been opment of lateral epicondylitis. Although this restricting the use of their arm secondary to pain overuse syndrome was originally observed in and hence have weaker bones due to osteoporo- tennis players, frequently other activities are sis and disuse. Frozen shoulder syndrome typi- implicated in its development and include other cally improves with time, although its duration wrist-intensive sports, especially those that can last 6–12 months. emphasize wrist extensors. These include rac-

Fig. 15.8 The pain in lateral epicondylitis is thought to be due to chronic inflammation secondary to micro tears at the site of origin of the wrist extensor muscles on the lateral epicondyle. Extensor muscles 228 medical issues

quetball and volleyball, household tasks such as wallpapering or painting, or job-related activities such as paper thumbing, keyboarding, hammer- Posterior bundle ing and tightening screws. Diagnosis is made on the basis of the history of Anterior bundle pain with repetitive wrist extension, combined with a clinical examination revealing pain to pal- pation in the muscles originating on the lateral epicondyle. This pain will increase with resisted wrist extension. Treatment of lateral epicondylitis consists of the following strategies. • Increasing the strength and flexibility of the Transverse ligament wrist extensor muscles and balancing them with strong, flexible wrist flexors. Fig. 15.9 The stabilizing ligaments of the medial side of • Evaluating and correcting improper technique the elbow. used in performing the sport or work activity. For example in tennis, if the racquet handle size is inappropriate for a player’s palm size it should shot put) as well as in gymnastics, where the be changed, or if the racquet is strung too tightly gymnast uses her elbow as a weight-bearing post it should be adjusted. If a carpenter’s hammer is (Griffin, 1991). too long or if it is improperly weighted, this The elbow is stabilized medially by thickening needs to be corrected. In the case of the ticket of the elbow joint capsular (medial collateral counter’s repetitive thumbing of stubs during a ligament) (Fig. 15.9). Of these, the anterior work day, one needs to consider if this activity oblique bundle is the prime stabilizer of valgus could be changed or reduced (counting is done load (Jacobson, 1995). The lateral collateral liga- using a rubber-tipped knob). ment complex of the elbow is not as well defined, • Use of oral anti-inflammatory drugs and anal- although varus stress is far less common due to gesic creams. the normal valgus position of the elbow. In • Use of a brace reportedly can influence the throwing sports, the acceleration and cocking amount of tension created at the muscle origin phase places significant tensile stresses on the and hence minimize continued stress on the medial side of the elbow, as well as compressive irritated condyle. forces on the lateral structures. This can result in sprains of the medial collateral ligament and/or sprains of the flexor pronator muscles, which Medial tension/lateral compartment overload arise on the medial epicondyle; in the case of syndrome to the elbow growing bones, there is tension on the medial A woman’s increased valgus angle of the elbow, epicondylar physis as well as compressive combined with her naturally occurring ligamen- forces laterally on the radial capitellar joint. tous laxity and lower upper body strength, can Additionally, valgus overload can result in predispose her to compressive injuries around abnormal tracking of the olecranon process if, as the lateral side of the elbow, termed lateral com- it travels in its groove in the distal humerus, it pressive overload syndrome or traction injury to tracks ‘off centre’. The distal humerus olecranon the medial elbow structures (Kibler, 1995; ‘hits’ sideways in the fossa instead of centring Johnston et al., 1996). Since there are less women within it, resulting in spur formation (Wilson et participating in baseball than men, these injuries al., 1983; Rettig & Patel, 1995; Johnston et al., occur more commonly in field sports (javelin or 1996). These spurs can cause pain during the act musculoskeletal injuries 229

Table 15.7 Possible sites of involvement in lateral common in sports where the wrist is used as a compressive overload syndrome of the elbow weight-bearing joint (principally gymnastics) and in sports requiring repetitive flexion– Medial collateral ligament sprain Avulsion fracture of medial epicondyle (seen in extension of the wrist (fast-pitch softball, volley- youngsters with open physes) ball and weight-lifting). Other sports where the Sprain of flexor pronator muscles where they arise on wrist is used intensively include golf, basketball medial epicondyle and racquet sports. Osteochondritis dissecans of the lateral humeral Dorsal wrist pain from capsular impingement condyle or radial head secondary to high compressive loads is seen in the gymnast or tennis player who stabilizes her wrist by locking it in dorsiflexion instead of stabilizing the joint by tightening the muscles about it. Whether the pain of dorsal of throwing, as well as with activities of daily wrist impingement is due to bony impingement living that require elbow extension. Fractures or impinging synovium in the joint is not clearly through a spur may result in a loose body. understood. Treatment consists of initial rest This entity of lateral compressive overload combined with anti-inflammatory drugs and syndrome may simply present as a painful elbow modalities to decrease inflammation, followed after or during participation in sport. Therefore, by an exercise programme to strengthen the careful physical examination is needed to define muscles about the wrist (Griffin, 1991; Mattov et whether an athlete’s elbow pain is due to the al., 1996). A thorough evaluation of technique is tensile forces on the medial side of the elbow, the also warranted, so that modifications can be compressive forces laterally or abnormal forces made to prevent recurrent impingement. A within the trochlear groove (Table 15.7). thick wrist band or multiple layers of tape can Treatment involves not only strengthening the be used to block hyperextension of the wrist in muscles of the upper extremity, especially the the symptomatic athlete when she returns to wrist extensors and flexors, but also the elbow competition. power flexors (biceps and brachioradialis) and extensors (triceps). Sport techniques should be Stress injuries of the radial physis examined to correct inadequacies. For example, is the gymnast ‘locking her elbow’, i.e. jamming Stress reaction of the distal radius (radial stress it to make it carry her body weight rather than syndrome) is most common in gymnasts and is a carrying her weight through the muscles about source of wrist pain during the early teenage the elbow? Moreover, during her routine, is her years (Roy et al., 1985; Carek & Fumich, 1992; body centred over the elbow such that the load is DeSmet et al., 1994). Diagnosis is made on physi- distributed equally throughout her elbow joint cal examination. Symptomatic athletes have pain rather than merely concentrated laterally? to palpation over the physeal growth area. In more advanced cases the stress reaction can be confirmed radiographically, with widening and Wrist impingement syndrome haziness of the epiphyseal plate, fragmentation The wrist joint is a complex entity held together and cystic changes in the metaphyseal portion of by an elaborate network of ligaments that articu- the plate and a beaked defect of the distal aspect late with the distal radius and ulna proximally of the epiphysis (Carek & Fumich, 1992). In one and the metacarpals distally. Injuries to the hand study, 10% of the gymnasts studied had evidence and wrist are the most common types sustained of stress-related changes, either the acute during athletic competition (McCue et al., 1998). changes described above or chronic changes as The majority of these injuries are sprains and noted by a widened and shortened distal radius strains; however, overuse injuries to the wrist are (Fig. 15.10) (DeSmet et al., 1994). 230 medical issues

Fig. 15.10 (a) Anteroposterior and (b) lateral view of the wrist of a 14-year-old gymnast, demonstrating stress-related changes. (a) (b)

The dowel grip in both female and male gym- Overuse tendinitis of the hand and wrist nasts has been implicated in the development of radial stress syndrome because it transfers forces Tenosynovitis of the hand and wrist can com- from the hand to the wrist. Also thought to be monly occur from the repetitive microtrauma predisposing factors are weak upper body experienced during upper-extremity intensive strength, poor technique, jamming the wrist into sports, such as racquetball, golf, volleyball and the so-called fixed hand–wrist position to basketball. The left thumb of a right-handed improve stability, the use of very soft mats and golfer can develop de Quervain’s syndrome from multiple repetitions of manoeuvres involving being hyperabducted during the swing. In this single-arm weight-bearing (Carek & Fumich, overuse syndrome, there is pain and swelling in 1992). Others blame the rotational forces suffered the long abductor and short extensor tendons of on impact during performance of the vault as a the thumb, the two tendons that occupy a prime cause of this stress reaction (Roy et al., common sheath in the first dorsal wrist compart- 1985). ment (Fig. 15.11). This swelling leads to impinge- In most instances of symptomatic radial stress ment within the sheath. The smaller hand of the syndrome, rest relieves symptoms without woman may predispose her to this condition, sequelae if initiated prior to the development of especially if she uses clubs with grips that are too bony changes. Recovery generally takes 3–4 large. De Quervain’s syndrome may also be seen weeks. However, if treatment is delayed until in new mothers caused by the repetitive peeling after radiographic changes appear, symptoms and tightening of nappy tape closures. It has may be prolonged for up to 4–6 months (Roy et been conjectured that hormonal influences, par- al., 1985; DeSmet et al., 1994). ticularly during the early postpartum period, musculoskeletal injuries 231

incidence of carpal tunnel syndrome in athletes is slightly higher than the 1% reported in the general population. This condition is more fre- quent in women, particularly women greater than 50 years of age and especially those with predisposing factors, such as diabetes, alco- holism or inflammatory arthritis (Steyers & Schelkun, 1995). Treatment consists of rest from repetitive wrist activity (often a wrist splint is used) combined with oral anti-inflammatory Tendon sheath drugs. In severe cases, the injection of steroids Fig. 15.11 The first dorsal compartment of the wrist into the canal to decrease inflammation is houses the long abductor and short extensor tendons of required. The athlete should be screened for the thumb. medical conditions such as hypothyroidism or diabetes. In recalcitrant cases or cases with severe nerve impingement, surgical release of the carpal may result in increased joint laxity and hence canal is required. greater stress on the extensor tendons and stabi- lizing ligaments about the metacarpophalangeal Overuse injuries of the lumbar spine joint. However, this has not been proved. Initial treatment consists of the use of Muscle strains and ligament sprains anti-inflammatory creams, oral anti-inflamma- tory drugs and splinting of the thumb to decrease Back pain has been reported to occur in 75% of continued irritation of the tendons. This should high-performance athletes (Gerbino & Micheli, be followed by an exercise programme for the 1995). The back pain experienced by most chil- involved tendons, as well as activity modifica- dren and adults during or following sport activ- tion to decrease abduction forces on the metacar- ity is the result of inflammation of the vertebral pophalangeal joint and on the thumb extensor or sacral ligaments or of the paravertebral tendons (Sailer & Lewis, 1995). If such conserva- muscles, i.e. sprains and strains. For example, tive measures fail to relieve symptoms, the lightweight rowers have pain from the stress on careful injection of steroids into the tendon muscles and ligaments caused by the increased sheath is an appropriate and often successful flexion of their lower back that occurs with manoeuvre. In recalcitrant cases, operative sitting bent forward in the catch position. release of the sheath is recommended. Weight-lifters frequently strain paravertebral muscles due to improper lifting techniques. Low back strain has also been reported in what has Carpal tunnel syndrome been termed the ‘cosmetic’ athlete, i.e. those Carpal tunnel syndrome, which is characterized improving their physique through exercise by pain, numbness and/or tingling in the dis- (Goodman, 1987). Exercises implicated are bilat- tribution of the medial nerve, results from com- eral leg lifts, donkey kicks, sitting double toe pression of this nerve as it passes through the touches and the Yoga plough position. These wrist in the carpal canal. It has been reported in activities are particularly irritating to those with cyclists and weight-lifters, as well as in athletes poor posture, deficient muscle strength and participating in other sports requiring wrist inflexibility of the paravertebral and abdominal flexion with a strong grasp. Symptomatic ath- muscles; they should be done only by those with letes may have symptoms only after their sport strong and flexible paravertebral and abdominal or at night following a day of sport activity. The muscles. 232 medical issues

Generally in children, back pain caused by randomly selected adults, implying a congenital sprains and strains resolves in 4–6 weeks with aetiology to its development, in an athletic popu- conservative care, i.e. rest from the aggravating lation it is felt to occur also as a stress reaction activity, back strengthening exercises, oral anti- (Jackson et al., 1976; Gerbino & Micheli, 1995). inflammatory drugs and, if indicated, braces for Studies have documented its development in support. Pain that persists longer merits further symptomatic athletes who present with normal evaluation (Gerbino & Micheli, 1995). appearance on X-ray but who have increased bony uptake in the region of the pars on bone scan. Follow-up X-ray evaluation may show the Spondylolysis and spondylolisthesis defect, verifying that in these individuals the Gymnasts, skaters and dancers who repetitively defect is not a congenital variant but a true stress place their spine in hyperextension are prone to reaction of bone leading to a fracture. develop stress reactions of the pars interarticu- The recommended treatment of the athlete laris, the area of the posterior arch linking the with normal appearance on X-ray and a positive lamina to the superior articular facet (Fig. 15.12). bone scan is rest from sport with brace protection In fact, it has been reported that 20% of female using a lumbar orthosis for approximately 3 gymnasts have pars lesions (Jackson et al., 1976). months. It is felt that time is needed to diminish Unlike other stress fractures, this stress reaction inflammation and for the bone to repair itself of bone has not been directly related to low bone (Micheli et al., 1980; Gerbino & Micheli, 1995). mineral density in women. Its occurrence is This is followed by a rehabilitation programme almost equal in males and females participating to increase strength and flexibility of back and intensely in sports requiring repetitive hyperex- abdominal muscles prior to returning to sport. tension and/or flexion of the lumbar spine Though it is important to strengthen back exten- (Jackson et al., 1976). Football linemen seem to be sor muscles, the hyperextended position should as predisposed as female gymnasts if the hours be avoided. Extension exercises to the neutral of play and practice of these two sport partici- position only, if pain free, are encouraged. pants are equalized. In the symptomatic athlete with a radio- Although this defect is found in 5% of graphic defect already present, it is important to

Superior articular Pedicle process

Transverse Spinous process process and lamina

Isthmus

Opposite Interior inferior articular articular process Fig. 15.12 Spondylolysis is a defect process in the pars interarticularis and may occur as a stress fracture. musculoskeletal injuries 233

distinguish between a new and a chronic lesion. Long-standing lesions are treated symptomati- cally, i.e. a period of rest until acute symptoms subside. A brace may be useful in this time period for intermittent symptomatic treatment only, not continuous use. This is coupled with a rehabilitation programme and a paced return to sport as pain allows (Jackson et al., 1976; Johnson, 1993; Yu & Garfin, 1994). Bone sclerosis at the margin of the fracture indicates a chronic lesion. This can be seen on plain X-rays or, if necessary, thin-slice axial tomographic views of the lumbar region. Afracture is felt to be new if there is a pos- itive bone scan, no previous X-ray evidence of a fracture and no widening or sclerosis at fracture margins. There is debate on how aggressively new fractures should be treated, although these fractures do have the potential to heal. Aggressive conservative treatment includes 3–6 months away from a sport with use of a low-back orthosis for the first 3 months. Whether this lesion heals with bony or fibrous union, more aggressive treatment is often successful at reach- ing a pain-free state. If a pars defect is present on both sides of a ver- tebral body, the spine loses its posterior integrity Fig. 15.13 Radiograph demonstrating spondylolysis of L5 with a spondylolisthesis of L5 on S1. and can slip forward (ventral) on the vertebra below. This forward slipping is called spondy- lolisthesis (Fig. 15.13). There is a difference of opinion on continued sport participation with this problem. Most orthopaedic experts agree that if slippage is less than 25% of the width of the vertebrae, i.e. a grade 1 spondylolisthesis (Fig. 15.14), and the athlete is asymptomatic, she can participate in sports, including contact d sports. If the slippage progresses, activity must d1 d – = % of slip be stopped. This is most common during the d1 period of rapid growth in early teenage years. Some physicians recommend that an athlete with a slip of grade 2 or greater should not participate in contact sports. If the athlete with a slip of grade 2 or greater is symptomatic despite sport modification, surgical fusion of the involved vertebrae may need to be considered. Generally, Fig. 15.14 The amount of anterior displacement of L5 individuals with a significant spondylolisthesis on S1 is calculated by the ratio of the distance L5 has have decreased lumbar flexibility and marked moved on the sacrum (d) to the anterior–posterior hamstring tightness. This combination typically diameter of the sacrum (d1), i.e. d/d1. 234 medical issues

decreases their ability to be highly competitive athletes. Following fusion, return to competitive sports is reasonable as long as the athlete com- pletes an adequate rehabilitation programme to strengthen the muscles of the paravertebral and abdominal area and axial tomography of the spine does not reveal any compromise of the neural foramina or neural canal (Micheli, 1985). For the athlete with a slip, rehabilitation programmes involve not only developing strong and flexible paravertebral and abdominal muscles but also increasing hamstring flexibility.

Lumbar apophysitis

In the growing athlete, repetitive hyperextension or hyperflexion of the spine, such as occurs in gymnastics, dancing and skating, can result in irritation of the vertebral growth centres, i.e. the superior and inferior vertebral apophyses. It is theorized that a tight anterior longitudinal liga- ment, perhaps inadequately balanced by strong vertebral and abdominal muscles and further stressed by repetitive extension of the spine, causes irritation of the vertebral apophyses that Fig. 15.15 A13-year-old figure skater with apophysitis. can result in back pain. X-rays of these sympto- Note the irregular vertebral growth centres. matic youngsters demonstrate the irregular growth centres (Fig. 15.15). Lumbar apophysitis will generally improve in 4–6 weeks when treated with a programme of exercise and rest from strenuous activity. Some athletes progressive during the rapid growth of early also find that a back brace used during activity teenage years. provides additional support when they are Curves less than 20° are usually no obstacle to symptomatic. full athletic participation. It is a myth that athletic activity causes progression of the curve. In fact, participation in sports that develop lumbar and Idiopathic scoliosis thoracic spine strength is probably advantageous Adolescent idiopathic scoliosis is a structural to those with scoliosis. Bracing is often recom- curvature of the spine presenting at or about the mended for those with curves between 20 and onset of puberty. It accounts for about 8% of all 40°, although ‘brace-free’ time for athletic partici- cases of idiopathic scoliosis, the others being pation is usually permitted (Benson et al., 1977). juvenile and infantile. It has a prevalence of 2–3% Those with more severe curves, i.e. >50–60°, in the general population, with a female to male often require surgical intervention. Typically distribution of 3.6:1 for curves greater than 10° these patients do not have the spinal flexibility or (Weinstein & Buckwalter, 1994). Of athletes with balance required for competitive participation in scoliosis, 8% have a relative who suffered from sports such as basketball, volleyball, gymnastics, scoliosis. Like spondylolisthesis, curves are dance, skating and hockey. musculoskeletal injuries 235

Health, Education and Welfare, US Government References Printing Office, Washington, DC. Canavan, P.K. (1996) Pronation and ACL injuries: Anderson, A.E., Lipscomb, A.B., Liudahl, K.J. et al. what’s the link? Advance/Rehabilitation 5(9), 39–41. (1987) Analysis of the intercondylar notch by Cann, C.E., Cavanaugh, D.J. & Schurpfiel, K. (1988) computed tomography. American Journal of Sports Menstrual history is the primary determinant of Medicine 15(6), 547–552. trabecular bone density in women. Medicine and Arendt, E.A. (1993) Osteoporosis in the athletic female: Science in Sports and Exercise 20, 559. amenorrhea and amenorrheic osteoporosis. In A.J. Carek, P. & Fumich, R. (1992) Stress fracture of the Pearl (ed.) The Athletic Female, pp. 41–59. Human distal radius. Physician and Sportsmedicine 20, Kinetics Publishers, Champaign, Illinois. 115–118. Arendt, E.A. (1995) Assessment of the athlete with an Carson, W.G. Jr, James, S.L., Larson, R.L., Singer, K.M. acutely injured knee. In L.Y. Griffin (ed.) & Winternitz, W.W. (1984) Patellofemoral disorders: Rehabilitation of the Injured Knee, pp. 20–33. Mosby, St physical and radiographical evaluation. Part II: Louis. radiographic examination. Clinical Orthopaedics and Arendt, E.A. & Clohisy, D.R. (1995) Stress injuries of Related Research 185, 165–167. bone. In J.A. Nicholas & E.B. Hershman (eds) The Carter, C. & Wilkinson, J. (1964) Persistent joint laxity Lower Extremity and Spine, 2nd edn, pp. 65–79. Mosby, and congenital dislocation of the hip. Journal of Bone St Louis. and Joint Surgery 46B, 40–45. Arendt, E.A. & Dick, R. (1995) Knee injury patterns Clarke, K.S. & Buckley, W. (1980) Women’s injuries in among men and women in collegiate basketball and collegiate sports. American Journal of Sports Medicine soccer. American Journal of Sports Medicine 23, 8, 187–191. 694–701. Cofield, R.H. & Bryan, R.S. (1977) Acute dislocation of Arendt, E.A. & Teitz, C.C. (1997) The lower extremities. the patella: result of conservative treatment. Journal In C.C. Teitz (ed.) The Female Athlete, pp. 45–59. of Trauma 17, 526–531. American Academy of Orthopaedic Surgeons, Colosimo, A.J., Ireland, M.L. & Horn, T. (1991) Rosemont, Illinois. Isokinetic peak torque and knee joint laxity compari- Barrow, G.S. & Saba, S. (1988) Menstrual irregularities: son in female basketball and volleyball college stress fractures in collegiate distance runners. athletes (Abstract). Medicine and Science in Sports American Journal of Sports Medicine 16, 209–216. and Exercise 23, S135. Bell, D.G. & Jacobs, I. (1986) Electro-mechanical Daniel, D., Malcom, L. & Losse, G. (1983) Instrumented response times and rate of force development in measurement of ACL disruption (Abstract). Ortho- males and females. Medicine and Science in Sports and paedic Transactions 7, 585–586. Exercise 18, 31–36. de Loës, M. (1995) Epidemiology of sports injuries Bennett, J.G. & Stauber, W.T. (1986) Evaluation and in the Swiss organization ‘Youth and Sports’ treatment of anterior knee pain using eccentric exer- 1987–1989. International Journal of Sports Medicine 16, cise. Medicine and Science in Sports and Exercise 18, 134–138. 526–530. DeSmet, L., Claessens, A., Lefebre, J. & Beunen, G. Benson, D., Wolf, A. & Shoji, H. (1977) Can the (1994) Gymnast’s wrist: an epidemiology survey of Milwaukee brace patient participate in competitive ulnar variance and stress changes of the radial physis athletics. American Journal of Sports Medicine 5, 7–12. in elite female gymnasts. American Journal of Sports Bird, H.A. (1993) Joint hyperlaxity and its long-term Medicine 22, 846–850. effects on joints. Journal of the Royal Society of Health Diaz, M.A., Estevez, E.C. & Guijo, P.S. (1993) Joint 113(6), 327–329. hyperlaxity and musculoligamentous lesions: study Biro, F., Gewanter, H.L. & Baum, J. (1983) The hyper- of a population of homogeneous age, sex, and physi- mobility syndrome. Pediatrics 72, 701–706. cal exertion. British Journal of Rheumatology 32, Blair, S.N., Kohl, H.W. & Goodyear, N.N. (1987) Rates, 120–122. and risks for running and exercise injuries: studies in Drinkwater, B.L., Bruemner, B. & Chestnut, C.H. (1990) three populations. Research Quarterly for Exercise and Menstrual history as a determinant of current bone Sport 58, 221–228. density in young athletes. Journal of the American Breighton, P., Solomon, L. & Soskolne, C.L. (1973) Medical Association 263, 545–548. Articular mobility in an African population. Annals Duralde, X., Pollock, R., Flatow, E. & Bigliani, L. (1993) of the Rheumatic Diseases 32, 413–418. Frozen shoulder: prevention, diagnosis, and man- Calvert, R. (1975/1976) Athletic Injuries and Deaths in agement. Journal of Musculoskeletal Medicine 10, Secondary School and Colleges, 1975–1976. National 64–72. Center for Education Statistics, Department of Engebretsen, L. (1985) Soccer injuries in Norway. 236 medical issues

Journal of the Norwegian Medical Association 105, Grana, W.A. & Muse, G. (1988) The effect of exercise 1766–1769. on laxity in the anterior cruciate ligament defi- Engstrom, B., Johansson, C. & Tornkvist, H. (1991) cient knee. American Journal of Sports Medicine 16, Soccer injuries among elite female players. American 586–588. Journal of Sports Medicine 19, 372–375. Gray, J., Taunton, J.E., McKenzie, D.C., Clement, D.B., Ettinger, C.F., Johnson, R.J. & Shealy, J.E. (1995) A McConckey, J.P. & Davidson, R.G. (1985) A survey of method to help reduce the risk of serious knee injuries to the anterior cruciate ligament of the knee sprains incurred in alpine skiing. American Journal of in female basketball players. International Journal of Sports Medicine 23, 531–537. Sports Medicine 6, 314–316. Ferretti, A., Papandrea, P., Conteduca, F. & Mariani, P.P. Griffin, L. (1991) Upper extremity injuries. In A. Pearl (1992) Knee ligament injuries in volleyball players. (ed.) The Athletic Female, pp. 235–250. Human American Journal of Sports Medicine 20, 203–207. Kinetics Publishers, Champaign, Illinois. Frey, C. (1997) Shoes. In C.C. Teitz (ed.) The Female Griffin, L. (1994) Pathophysiology and healing of mus- Athlete, pp. 63–73. American Academy of Orthopedic culoskeletal tissues. In L.Y. Griffin (ed.) AAOS Surgeons, Rosemont, Illinois. Orthopedic Knowledge Update: Sports Medicine, pp. Frey, C.C. & Shereff, M.J. (1988) Tendon injuries about 17–33. American Academy of Orthopaedic Surgeons, the ankle in athletes. Clinics in Sports Medicine 7, Rosemont, Illinois. 103–118. Griffis, N.D., Vequist, S.W. & Yearout, K.M. (1989) Frey, C., Thompson, F., Smith, J., Sanders, M. & Injury prevention of the anterior cruciate ligament Horstman, H. (1993) American Orthopaedic Foot (Abstract). Paper presented at the 1989 AOSSM and Ankle Society women’s shoe survey. Foot and Annual Meeting, Traverse City, Michigan. Ankle 14, 78–81. Häkkinen, K. (1991) Force production characteristics of Fulkerson, J.P. & Cautilli, R.A. (1993) Chronic patellar leg extensor, trunk flexor and extensor muscles in instability, subluxation and dislocation. In J.M. Fox & male and female basketball players. Journal of Sports W. Del Pizzo (eds) The Patellofemoral Joint, pp. Medicine and Physical Fitness 31, 325–331. 135–148. McGraw-Hill, New York. Halbrecht, J.L. & Jackson, D.W. (1993) Acute disloca- Gabiel, S.E. (1996) Update on the epidemiology of the tion of the patella. In J.M. Fox. & W. Del Pizzo (eds). rheumatic diseases. Current Opinion in Rheumatology The Patellofemoral Joint, pp. 123–156. McGraw-Hill, 8, 96–100. New York. Gardner, L.I., Dzaidos, J.E., Jones, B.H. et al. (1988) Harrer, M.F., Berson, L., Hosea, T.M., Cody, R.P. & Prevention of lower extremity stress fractures: a con- Leddy, T.P. (1996) Lower extremity injuries: females trolled trial of a shock-absorbent insole. American vs. males in the sport of basketball (Abstract). Paper Journal of Public Health 78, 1563–1567. presented at the 1996 AOSSM Annual Meeting, Garrett, W.E. Jr (1990) Muscle strain injuries. Medicine Orlando, Florida. and Science in Sports and Exercise 22, 436–443. Hart, D.A., Roux, L., Frank, C. & Shrive, N. (1996) Sex Gedalia, A., Person, D.A., Brewer, E.J., Jr. & Giannini, hormone influences on rabbit ligaments in vivo and E.H. (1985) Hypermobility of the joints in juvenile in vitro. Transactions of the Orthopaedic Research Society episodic arthritis/arthralgia. Journal of Pediatrics 107, 21, 792. 873–876. Hawkins, R. & Kennedy, J. (1980) Impingement syn- Gerbino, P. & Micheli, L. (1995) Back injuries in the drome in athletes. American Journal of Sports Medicine young athlete. Clinics in Sports Medicine 14, 571–590. 8, 151–158. Godshall, R.W. (1975) The predictability of athletic Hawkins, R.J., Bell, R.H. & Anisette, G. (1986) Acute injuries: an eight-year study. Journal of Sports patella dislocations: the natural history. American Medicine 3, 50–54. Journal of Sports Medicine 14, 117–120. Good, L., Odensten, M. & Gillquist, J. (1991) Inter- Haycock, C.E. & Gillette, J.V. (1976) Susceptibility of condylar notch measurements with special reference women athletes to injury: myths vs. reality. Journal of to anterior cruciate ligament surgery. Clinical the American Medical Association 236, 163–165. Orthopaedics and Related Research 263, 185–189. Heidt, R.S. Jr, Dormer, S.G., Cawley, P.W., Scranton, Goodman, C. (1987) Low back pain in a cosmetic P.E., Losse, G. & Howard, M. (1996) Differences in athlete. Physician and Sportsmedicine 15, 97–103. friction and torsional resistance in athletic shoe–turf Grace, T.G., Sweetser, E.R., Nelson, M.A., Yedens, L.R. surface interfaces. American Journal of Sports Medicine & Skipper, B.J. (1984) Isokinetic muscle imbalance 24, 834–842. and knee-joint injuries. Journal of Bone and Joint Heiwick, C.G., Lawrence, R.C., Pollar, R.A., Lloyd, E. & Surgery 66A, 734–740. Heyses, S.P. (1995) Arthritis and other rheumatic Grana, W.A. & Moretz, J.A. (1978) Ligamentous laxity conditions: who is affected now, who will be affected in secondary school athletes. Journal of the American later. Arthritis Care Research 8, 203–211. Medical Association 240, 1975–1976. Hewett, T.E., Stoupe, A.L., Nance, T.A. & Noyes, F.R. musculoskeletal injuries 237

(1996) Plyometric training in female athletes. tion. In Surgery of the Foot and Ankle, pp. 221–244. American Journal of Sports Medicine 24, 765–773. Raven Press, New York. Hoffman, T., Stauffer, R.W. & Jackson, A.S. (1979) Sex Johnson, R. (1993) Low back pain in sports: managing difference in strength. American Journal of Sports spondylolysis in young patients. Physician and Medicine 7, 265–267. Sportsmedicine 21, 53–59. Houseworth, S.W., Mauro, V.J., Mellon, B.A. et al. (1987) Johnston, J., Plancher, K. & Hawkins, R. (1996) Elbow The intercondylar notch in acute tears of the anterior injuries to the throwing athlete. Clinics in Sports cruciate ligament: a computer graphic study. Medicine 15, 307–328. American Journal of Sports Medicine 15, 221–229. Jones, B.H., Bovee, M.W., Harris, J. III & Cowan, D.N. Huid, J. & Anderson, L. (1982) The quadriceps angle (1993) Intrinsic risk factors for exercise-related and its relation to femoral torsion. Acta Orthopaedica injuries among male and female army trainees. Scandinavica 53, 577–579. American Journal of Sports Medicine 21, 705–710. Hungerford, D.S. & Lennox, D.W. (1983) Rehabilitation Kalenak, A. & Morehouse, C.A. (1975) Knee stability of the knee in disorders of the patellofemoral joint: and knee ligament injuries. Journal of the American relevant biomechanics. Orthopedic Clinics of North Medical Association 234, 1143–1145. America 14, 397–402. Keirns, M. (1994) Conservative management of Hunter-Griffin, L.Y. (1991) Female athletes. In L.Y. shoulder impingement. In J. Andrew & K. Wilk Hunter-Griffin (ed.) Athletic Training and Sports (eds) The Athlete’s Shoulder, pp. 603–622. Churchill Medicine, 2nd edn, pp. 921–932. American Academy Livingstone, New York. of Orthopedic Surgeons, Rosemont, Illinois. Kibler, W.B. (1995) Pathophysiology of overload Huston, L.J. & Wojtys, E.M. (1996) Neuromuscular per- injuries around the elbow. Clinics in Sports Medicine formance characteristics in the elite female athletes. 14, 447–458. American Journal of Sports Medicine 24, 427–435. Klemp, P., Stevens, J.E. & Isaacs, S. (1984) A hypermo- Ireland, M.L. & Wall, C. (1990) Epidemiology and com- bility study in ballet dancers. Journal of Rheumatology parison of knee injuries in elite male and female 11, 692–696. United States basketball athletes (Abstract). Medicine Komi, P.V. & Karlsson, J. (1978) Skeletal muscle fibre and Science in Sports and Exercise 22, S82. types, enzyme activities and physical performance in Jackson, D., Wiltse, L. & Circione, R. (1976) young males and females. Acta Physiologica Spondylolysis in the female gymnast. Clinical Scandinavica 103, 210–218. Orthopaedics and Related Research 117, 68–73. Koplan, J.P., Powell, K.E. & Sikes, R.K. (1982) An Jackson, D.S., Furman, W.K. & Berson, B.L. (1980) epidemiologic study of the benefits and risks of Patterns of injuries in college athletes: a retrospective running. Journal of the American Medical Association study of injuries sustained in intercollegiate athletics 248, 3118–3121. in two colleges over a two-year period. Mount Sinai Koplan, J.P., Siscovick, D.S. & Goldbaum, G.M. (1985) Journal of Medicine 47, 423–426. The risks of exercise: a public health view of injuries Jacobson, K. (1995) Functional anatomy in biome- and hazards. Public Health Report 100, 189–195. chanics of the elbow. In C. Baker (ed.) Hughston Kowal, D.M. (1980) Nature and causes of injuries in Clinic Sports Medicine Book, pp. 299–305. Williams women resulting from an endurance training and Wilkins, Baltimore. program. American Journal of Sports Medicine 8, Jobe, F. & Kvitne, R. (1989) Shoulder pain in the over- 265–269. head or throwing athletes. Orthopaedic Review 28, LaPrade, R.F. & Burnett, Q.M. II (1994) Femoral inter- 963–975. condylar notch stenosis and correlation to anterior Jobe, F.W., Bradley, J.P. & Pink, M. (1990a) Impingement cruciate ligament injury. A prospective study. syndrome in overhand athletes, Part 1. Surgical American Journal of Sports Medicine 22, 198–203. Rounds For Orthopaedics August, 19–24. Larsen, E. & Lauridsen, F. (1982) Conservative treat- Jobe, F.W., Bradley, J.P. & Pink, M. (1990b) ment of patellar dislocations: influence of evident Impingement syndrome in overhand athletes, Part factors on the tendency to redislocation and the II. Surgical Rounds For Orthopaedics September, 39– therapeutic results. Clinical Orthopaedics and Related 41. Research 171, 131–136. Jobe, F.W., Bradley, J.P. & Pink, M. (1990c) Impingement Larsson, L.-G., Baum, J. & Mudholkar, S. (1987) syndrome in overhand athletes, Part III. Surgical Hypermobility: features and differential incidence Rounds For Orthopaedics October, 24–26. between the sexes. Arthritis and Rheumatism 30, Jobe, F., Tibone, J., Jobe, C. & Kvitne, R. (1990d) The 1426–1430. shoulder in sports. In C.A. Rockwood & F.A. Matsen Lawta, R.G. (1996) The connective tissue diseases and (eds) The Shoulder, pp. 961–990. W.B. Saunders, the overall influence of gender. International Journal of Philadelphia. Fertility and Menopausal Studies 41, 156–165. Johnson, K.A. (1989) Tibialis posterior tendon dysfunc- Leadbetter, W.B. (1990) Clinical staging concepts in 238 medical issues

sports trauma. In W.B. Leadbetter, J.A. Buckwalter & tive study among military recruits. Foot and Ankle 12, S.L. Gordon (eds) Sports-Induced Inflammation, 26–30. pp. 587–595. American Academy of Orthopaedic Molnar, T.J. (1993) Patellofemoral rehabilitation. In J.M. Surgeons, Rosemont, Illinois. Fox & W. Del Pizzo (eds) The Patellofemoral Joint, pp. Lenz, H.W. (1979) Women’s sports and fitness pro- 291–304. McGraw-Hill, New York. grams at the US Naval Academy. Physician and Moore, J.R. & Wade, G. (1989) Prevention of ACL Sportsmedicine 7, 41–50. injuries. National Strength Conditioning Society 6, Lindenfeld, T.N., Schmitt, D.J., Hendy, M.P., Mangine, 35–40. R.E. & Noyes, F.R. (1994) Incidence of injury in Moretz, J.A., Walters, R. & Smith, L. (1982) Flexibility as outdoor soccer. American Journal of Sports Medicine 22, a predictor of knee injuries in college football 364–371. players. Physician and Sportsmedicine 10, 93–97. Lund-Hassen, H., Gannon, J., Engebretsen, L. et al. Muneta, T., Takakuda, K. & Yamamoto, H. (1997) (1994) Intercondylar notch width and risk of ACL Intercondylar notch width and its relation to the con- rupture in female varsity team handball players. A figuration and cross-sectional area of the anterior case control study. Acta Orthopaedica Scandinavica cruciate ligament. American Journal of Sports Medicine 65(5), 529–532. 25, 69–72. Lysens, R., Steverlynck, A., van de Auweele, Y. et al. Myklebust, G., Maehlum, S., Engebretsen, L., Strand, T. (1984) The predictability of sports injuries. Sports & Solheim E. (1997) Registration of cruciate ligament Medicine 1, 6–10. injuries in Norwegian top level team handball. McConnell, J. (1986) The management of chondromala- A prospective study covering two sessions. cia patellae: a long term solution. Australian Journal of Scandianvian Journal of Medicine and Science in Sports Physiotherapy 33, 215. 7(5), 289–292. McCue, F.C., Dinsmore, H. & Kowalk, D. (1998) Nicholas, J.A. (1970) Injuries to knee ligaments: rela- Athletic injuries to the hand and wrist. In R.J. tionship to looseness and tightness in football Johnson & J. Lombardo (eds) Current Review of Sports players. Journal of the American Medical Association Medicine, 2nd edn, pp. 43–53. Current Medicine, 212, 2236–2239. Philadelphia. Noyes, F.R., Mooar, P.A., Matthews, D.S. & Grood, E.S. Macera, C.A., Jackson, K.L., Hagenmaier, G.W., (1983) The symptomatic ACL deficient knee. Part II: Kronenfeld, J.J., Kohl, H.W. & Blair, S.N. (1989a) Age, the results of rehabilitation activity modification and physical activity, physical fitness, body composition, counseling on functional disability. Journal of Bone and incidence of orthopaedic problems. Research and Joint Surgery 65A, 154–174. Quarterly for Exercise and Sport 60, 225–233. O’Neill, D.B., Micheli, L.J. & Warner, J.P. (1992) Macera, C.A., Pate, R.R. & Powell, F.P. (1989b) Patellofemoral stress: a prospective analysis of exer- Predicting lower extremity injuries among habitual cise treatment in adolescents and adults. American runners. Archives of Internal Medicine 149, 2565–2568. Journal of Sports Medicine 20, 151–156. Markolf, K.L., Gorek, J.F., Kabo, J.M. & Shapiro, J.S. Ott, J., Clancy, W. & Wilk, K. (1994) Soft tissue injuries (1990) Direct measurement of resultant forces in the of the shoulder. In J. Andrew & K. Wilk (eds) anterior cruciate ligament. Journal of Bone and Joint The Athlete’s Shoulder, pp. 241–259. Churchill Surgery 72A, 557–567. Livingstone, New York. Matsen, F.A., Fu, F.H. & Hawkins, R.J. (eds) (1993) Ozaki, J., Nakagawa, Y., Sakurai, G. & Tanai, F. (1989) The Shoulder: a Balance of Mobility and Stability. Recalcitrant chronic adhesive capsulitis of the shoul- Proceedings of a workshop, Vail, Colorado, der. Journal of Bone and Joint Surgery 71A, 1511–1522. September 1992. American Academy of Orthopedic Parker, R., Froimson, A., Winsberg, D. & Arsham, N. Surgeons, Rosemont, Illinois. (1989) Frozen shoulder. Part I: chronology, pathogen- Mattov, A., Arendt, E. & Riehl, R. (1996) The female esis and clinical picture and treatment. Orthopedics athlete. In J. Zachazewski, D. Magee & W. Quillen 12, 869–873. (eds) Athletic Injuries and Rehabilitation, pp. 841–851. Pink, M. & Jobe, F. (1991) Shoulder injuries in the W.B. Saunders, Philadelphia. athlete. Clinical Management 11, 39–47. Micheli, L. (1985) Sports following spinal surgery in the Podesta, L. & Sherman, M.F. (1988) Knee bracing. young athlete. Clinical Orthopaedics and Related Orthopedic Clinics of North America 19, 737–745. Research 196, 152–157. Protzman, R. (1979) Physiologic performance of Micheli, L., Hall, J. & Miller, M. (1980) Use of the modi- women compared to men. American Journal of Sports fied Boston brace for back injuries in athletes. Medicine 7, 191–194. American Journal of Sports Medicine 8, 351–356. Rettig, A. & Patel, D. (1995) Epidemiology of the elbow, Milgrom, C., Shlamkovitch, N., Finestone, A. et al. forearm, and wrist injuries in the athlete. Clinics in (1991) Risk factors for lateral ankle sprain: a prospec- Sports Medicine 14, 289–297. musculoskeletal injuries 239

Roub, L.W., Gumerman, L.W. & Hanley, E.N. (1979) Staheli, L.T. (1987) Rotational problems of the lower Bone stress: a radionuclide imaging prospective. extremities. Orthopedic Clinics of North America 18, Radiology 132, 431–438. 503–512. Roy, S., Caine, D. & Singer, K. (1985) Stress changes of Staheli, L.T. (1993) Rotational problems in children. the distal radial epiphysis in young gymnasts. Journal of Bone and Joint Surgery 75A, 939–948. American Journal of Sports Medicine 13, 301–308. Steiner, M.E., Grana, W.A., Chillag, K. & Schelberg- Ryan, J. & Pearl, A. (1994) Pathophysiology and healing Karnes, E. (1986) The effect of exercise on of musculoskeletal tissues. In L. Griffin (ed.) anterior–posterior knee laxity. American Journal of Orthopedic Knowledge Update: Sports Medicine, p. 21. Sports Medicine 14, 24–29. American Academy of Orthopedic Surgeons, Steinkamp, L.A., Dillingham, M.F., Markel, M.D., Hill, Rosemont, Illinois. J.A. & Kaufman, K.R. (1993) Biomechanical consider- Sailer, S. & Lewis, S. (1995) Rehabilitation and splinting ations in patellofemoral joint rehabilitation. American of common upper extremity injuries in athletes. Journal of Sports Medicine 21, 438–444. Clinics in Sports Medicine 14, 411–446. Steyers, C. & Schelkun, P. (1995) Practical management Savola, C.J. (1971) Stress fracture: a classification of of carpal tunnel syndrome. Physician and Sports- earliest radiographic signs. Radiology 100, 519–524. medicine 23, 83–87. Schickdatz, M.S. & Weiker, G.G. (1993) The predictive Strand, T., Wisnes, A.R. & Tvedte, R. (1990) ACL value of radiographs in the evaluation of unilateral injuries in team handball. Journal of the Norwegian and bilateral anterior cruciate ligament injuries. Medical Association 110, 45–48. American Journal of Sports Medicine 21(1), 110–113. Tanner, J.M. (ed.) (1962) Growth at Adolescence, with a Sciore, P., Smith, S., Frank, C.B. & Hart, D.A. (1997) General Consideration of the Effects of Hereditary and Detection of receptors for estrogen and progesterone Environmental Factors upon Growth and Maturation in human ligaments and rabbit ligaments and from Birth to Maturity, 2nd edn. Blackwell Scientific tendons by RT-PCR. Transactions of the Orthopaedic Publications, Oxford. Research Society 22, 51. Tomasi, L.F., Peterson, J.A. & Pettit, G.P. (1977) Shangold, M., Rebor, R.W. & Wentz, A.C. (1990) Women’s response to army training. Physician and Evaluation and management of menstrual dysfunc- Sportsmedicine 5, 32–37. tion in athletes. Journal of the American Medical Tria, A.J. Jr, Palumbo, R.C. & Alicea, J.A. (1992) Association 263, 1665–1669. Conservative care for patellofemoral pain. Ortho- Shelbourne, K.D., Davis, T.J. & Klootwyk, T.E. (1998) pedic Clinics of North America 23, 545–554. The relationship between intercondylar notch width Vainiopaa, S., Laasonen, E., Silvennoinen, T., Vasenius, of the femur and the incidence of anterior cruciate J. & Rokkanen, P. (1990) Acute dislocation of the ligament tears. A prospective study. American Journal patella: a prospective review of operative treatment. of Sports Medicine 26(3), 402–408. Journal of Bone and Joint Surgery 72B, 365–369. Shively, R.A., Grana, W.A. & Ellis, D. (1981) High Warren, M.P., Brooks-Gunn, J. & Hamilton, L.H. (1986) school sports injuries. Physician and Sportsmedicine 8, Scoliosis and fractures in young ballet dancers. New 46–50. England Journal of Medicine 314, 1348–1353. Silliman, J. & Hawkins, R. (1994) Clinical examination Weesner, C.L., Albohm, M.J. & Ritter, M.A. (1986) of the shoulder complex. In J. Andrews & K. Wilk A comparison of anterior and posterior cruciate (eds) The Athlete’s Shoulder, pp. 45–58. Churchill ligament laxity between female and male basket- Livingstone, New York. ball players. Physician and Sportsmedicine 14, 149– Skinner, H.B., Wyatt, M.P., Stone, M.L., Hogdon, J.A. & 154. Barrack, R.L. (1986) Exercise related knee joint laxity. Weinstein, S. & Buckwalter, J. (1994) Turek’s American Journal of Sports Medicine 14, 30–34. Orthopaedics, 5th edn, pp. 447–485. J.B. Lippincott, Slaughterbeck, J.R., Narayan, R.S., Clevenger, C. et al. Philadelphia. (1997) Effects of estrogen level on the tensile proper- Whiteside, P. (1980) Men’s & women’s injuries in com- ties of the rabbit anterior cruciate ligament (ACL). parable sports. Physician and Sportsmedicine 8, Transactions of the Orthopaedic Research Society 22, 76. 130–140. Souryal, T.O. & Freeman, T.R. (1993) Intercondylar Wiesler, E.R., Hunter, D.M., Martin, D.F., Curl, W.W. & notch size and anterior cruciate ligament injuries in Hoen, H. (1996) Ankle flexibility and injury patterns athletes. A prospective study. American Journal of in dancers. American Journal of Sports Medicine 24, Sports Medicine 21, 535–539. 754–757. Souryal, T.O., Moore, H.A. & Evans, J.P. (1998) Wilk, K., Arrigo, C. & Andrews, J. (1994) Current con- Bilaterality in anterior cruciate ligament injuries: cepts in the rehabilitation of the athlete’s shoulder. associated intercondylar notch stenosis. American Journal of the Southern Orthopedic Association 3, Journal of Sports Medicine 16, 449–454. 205–215. 240 medical issues

Wilson, F., Andrews, J., Balckburn, T. & McCaulskey, G. Yu, C. & Garfin, S. (1994) Recognizing and managing (1983) Valgus extension overload in the pitching lumbar spondylolisthesis. Journal of Musculoskeletal elbow. American Journal of Sports Medicine 11, 83–87. Medicine 11, 55–64. Winter, E.M. & Brookes, F.B. (1991) Electromechanical Zelisko, J.A., Noble, H.B. & Porter, M. (1982) A com- response times and muscle elasticity in men and parison of men’s and women’s professional basket- women. European Journal of Applied Physiology 63, ball injuries. American Journal of Sports Medicine 10, 124–128. 297–299. Wojtys, E.M. & Huston, L.J. (1994) Neuromuscular per- Zillmer, D.A., Powell, J.W. & Albright, J.P. (1991) formance in normal and anterior cruciate ligament- Gender-specific injury patterns in high school deficient lower extremities. American Journal of Sports varsity basketball. Journal of Women’s Health 1, 69–76. Medicine 22, 89–104. Chapter 16

Cardiovascular Issues

PATRICIA SANGENIS

Introduction Cardiovascular system For many years young girls and women in The cardiovascular system comprises the heart, general were discouraged from participating in blood vessels and blood. The heart serves as a sports, exhaustive training and competition. The muscular pump that circulates the blood, oxygen underlying idea was that physical activity could and nutrients to all the tissues and organs of the harm the reproductive system, diminishing fer- body through the blood vessels. The heart has tility; another interesting concept was that a two atria that act as receiving chambers and two woman had a weaker heart. However, time ventricles that serve as pumping chambers. The passed and the evolution of female performance heart is a muscular pump and its walls are com- in sports, some amazing records and mothers posed of three layers: the inner layer, the endo- who became world champions persuaded sports cardium; the middle layer of muscle, the scientists to question these concepts. myocardium; and the outer layer, the epi- Do the differences in performance between cardium. The heart is encased in a protective female and male reflect biological differences or membrane, the pericardium. are they the result of education and social and The heart is a double-system pump, the right cultural restrictions placed on young girls? Do a and left sides being completely separated by smaller heart and smaller blood volume play an a thick muscle wall called the septum. The important role in performance? In the past, very systemic circuit is the left side of the heart and few of the large epidemiological studies exam- the pulmonary circuit the right side of the ined the female cardiovascular system, coronary heart. The left atrium receives the oxygenated heart disease not being considered a major issue. blood from the lungs through the pulmonary Today we know that cardiovascular disease is the veins. From the left atrium the blood passes leading cause of death in women, in many coun- through the mitral valve into the left ventricle, tries claiming more lives than all forms of cancer, which pumps blood through the aortic semi- accidents and diabetes combined. Exercise is one lunar valve into the aorta. This blood supplies of the most effective tools for maintaining a every cell with oxygen and nutrients and also healthy heart via modification of such risk transports carbon dioxide and other waste prod- factors as hypertension, elevated lipids and ucts. The deoxygenated blood returns via the lipoproteins, obesity and diabetes. Exercise is superior and inferior venae cavae to the right also considered an independent factor in the pre- atrium and then passes through the tricuspid vention of coronary heart disease. valve into the right ventricle. This chamber pumps the blood through the pulmonary semi- lunar valve into the pulmonary artery, which 241 242 medical issues

carries the deoxygenated blood to the lungs for vision. The cardiac evaluation should emphasize reoxygenation. pulse, auscultation and blood pressure. Cardiac muscle has the ability to generate its • Radial and femoral pulses should be palpated. own electrical signal, the conduction system • Resting heart rate indicates cardiovascular allowing the heart muscle to contract rhythmi- fitness and may be abnormal in anaemia, cardiac cally. The intrinsic heart rate averages 60–80 disorders and anorexia nervosa. beats·min–1. Disturbances of heart rhythm are • To confirm elevated blood pressure, abnormal called dysrhythmias, the degree of seriousness measurements should be found on at least three varying widely: bradycardia is a resting heart occasions. The upper limits of normal for athletes rate < 60beats·min–1; tachycardia is a resting aged 11 years or younger are 130/75mmHg heart rate > 100beats·min–1. Complex dysrhyth- (17.3/10kPa) and for those aged 12 years or older mias may cause symptoms such as dizziness, 140/85mmHg (18.6/11.3kPa). fatigue, lightheadedness and fainting. • Heart murmurs are the most common abnor- mality found during the examination. Most murmurs in young, healthy athletes fall into the Preparticipation cardiovascular II/VI systolic ejection group that usually sug- physical examination gests ‘flow’ murmurs or well-conditioned ath- Although exercise is the best way to maintain a letic hearts. Any murmurs with a grade greater healthy heart, it is important to identify the pres- than II/VI, any diastolic murmur or any murmur ence of heart disease in an athlete before partici- that increases during the Valsalva manoeuvre or pation in sport. The traditional established goals other methods that increase intra-abdominal of the preparticipation physical examination are pressure deserves special consideration before to prepare the athlete for safe participation in the athlete is allowed to participate in sport activ- sports, to uncover any life-threatening condi- ity. An abnormal sound can indicate the turbu- tions the athlete may have and to satisfy legal lent flow of blood through a narrowed or leaky requirements set forth by various governing valve. It could also indicate errant blood flow bodies. through a hole in the septum that separates the right and left sides of the heart (septal defect). Most murmurs in athletes are benign, although Medical history they can indicate diseased valves or septal • A history of sudden cardiac death or cardiac defects. problems in family members < 50 years of age might need further evaluation. Evaluation techniques • Has the athlete been told that she has an extra heart beat, high blood pressure, a heart murmur, The examiner should be ready to refer the athlete a click or any other heart abnormality? for further testing or to order more tests if any of • Has she ever stopped exercising because of the above findings are noted. The following is a dizziness, chest pain or palpitations? list of evaluation techniques that may be helpful: • Has she ever passed out during exercise? • 12-lead ECG; • chest X-ray; • blood lipid profile; Medical examination • stress test; The medical examination should be mainly • echocardiography; screening in nature. Any chest wall or other • Holter monitoring; skeletal abnormality seen with Marfan’s syn- • angiography. drome should be noted, including pectus excava- If the athlete is over 40 or is a high-risk individ- tum, long arms, arachnodactyly and abnormal ual, a very thorough cardiac examination should cardiovascular issues 243

be given before athletic clearance is granted. A result of decreased ventricular filling and stroke high-risk individual may be defined as one with volume. two or more major risk factors for coronary heart disease and symptoms suggestive of cardiac, Common physical findings in athletes pulmonary or metabolic disease. Major risk factors include cigarette smoking, hypertension • Carotid upstroke: normal or hyperdynamic, [> 160/90mmHg (21.3/12kPa)], serum choles- reflecting increased stroke volume. terol > 240mg·dl–1, diabetes or a family history of • Jugular venous pulse: normal unless pattern cardiac disease prior to age 65. The American associated with conduction abnormalities. College of Sports Medicine (1994) suggests that • Enlarged heart on percussion. graded exercise testing of all such individuals be • Prominent apical impulse and right ventricu- included in any preparticipation screening lar lift. process. If congenital or other anatomical defects • S1 and S2 normal. are present, echocardiographic evaluation of the • Third heart sound. anatomy should be done, perhaps supplemented • Fourth heart sound. by angiography. • Mid-systolic flow murmur. • Diastolic flow murmur: rare. • Peripheral pulses: normal or hyperdynamic, Clinical manifestations of the reflecting increased stroke volume. athlete’s heart Many athletes, particularly those who have Electrocardiogram undergone endurance training, will have various manifestations of exercise training that are The ECG alterations found in well-trained ath- occasionally misinterpreted as organic cardiac letes may mimic those observed in patients with disease. Most of these findings are related to the organic heart disease. Alterations may be noted physiological adaptations that occur as a result of in all the waves of the ECG. These alterations are exercise training and do not represent true generally thought to represent manifestations of organic heart disease. the physiological adaptations that occur within Cardiac enlargement in athletes may be the heart and cardiovascular system as a result of detected during palpation of the chest as a dis- exercise training. Changes in the waveforms are placed apical impulse or a right ventricular lift. due to cardiomegaly and an increased myocar- Third and fourth heart sounds are frequently dial mass. The disturbances of rhythm are largely heard in athletes. The third heart sound is related related to alterations in the autonomic nervous to a prominent rapid filling phase of the left ven- system, specifically increased parasympathetic tricle during early diastole and has no clinical activity. The ECG findings in athletes are summa- significance. The mechanism of production of rized below. the fourth heart sound is related to heart rate, 1 Rhythm: PR interval or changes in the intrinsic diastolic (a) sinus bradycardia; properties of the left ventricle. The combination (b) first-degree atrioventricular (AV) block; of a long PR interval and a thin chest wall (c) second-degree AV block, Wenckebach type; may result in an audible fourth heart sound. The (d) high-grade AV block. large stroke volumes seen in well-trained ath- 2 Axis: normal or slightly rightward. letes may result in mid-systolic murmurs. These 3 P wave: murmurs are due to a large stroke volume being (a) notched; ejected through normal semilunar valves. The (b) left atrial enlargement; murmurs related to large volumes decrease in (c) right atrial enlargement. intensity or disappear in the upright position as a 4 QRS complex: 244 medical issues

(a) left ventricular hypertrophy voltage; also be present. Other symptoms include chest (b) right ventricular hypertrophy voltage; pain, palpitations, dizziness, abnormal ECG, (c) intraventricular conduction defects; atrial or ventricular dysrhythmia, systemic (d) incomplete right bundle branch block; emboli, mitral regurgitation, syncope and even (e) pseudoanteroseptal myocardial infarction sudden death. with QS in leads V1–V3. Mitral valve prolapse is generally a benign 5 ST segment: syndrome and most patients can exercise (a) early repolarization; without restrictions. The American College of (b) ST segment elevation. Cardiology (Maron et al., 1985) recommends lim- 6 T wave: iting competitive participation in those patients (a) increased amplitude; whose chest pain is worsened by exercise and in (b) biphasic or inverted T waves in anterior those with a history of syncope, supraventricular precordial leads. tachycardia, ventricular dysrhythmias, moder- 7 QT interval: normal or variable. ate or severe mitral regurgitation, or a family 8 U wave: normal or increased amplitude. history of sudden death due to mitral valve pro- Sinus bradycardia at rest is a well-recognized lapse. Exercise should be restricted, especially if hallmark of a cardiovascular training effect. The the dysrhythmias are worsened during physical resting heart rate tends to be lower in endurance- activity. Mitral valve prolapse may also be associ- trained athletes. In general the heart rate at rest ated with Marfan’s syndrome. Other valvular · varies inversely with VO2max or exercise capacity. heart diseases affect male and female athletes Heart rates of < 40beats·min–1 may be seen fre- equally. quently in well-trained athletes, with even lower Recommendations regarding eligibility for rates during sleep. Differentiating athlete’s heart competition and limitations for physical activity from an underlying true organic heart disease and sports have been published by the American can be difficult, although lack of symptoms, a College of Cardiology and the American College history of exercise training and participation in of Sports Medicine. athletic events without symptoms are helpful signs. Nevertheless, if the physical examination Hypertrophic cardiomyopathy reveals evidence suggestive of valvular or myocardial disease, other evaluation techniques This syndrome, characterized by a thickened left might be useful. ventricle, is idiopathic, genetically transmitted and the most common cause of sudden death in young people during exercise. Any athlete with a Cardiovascular diseases in women history of dizziness or exercise-related syncope must be suspected of having hypertrophic car- Mitral valve prolapse diomyopathy and should be evaluated by an This condition occurs with greater frequency in experienced cardiologist. women than men (Levy & Savage, 1987). It is This cardiomyopathy may or may not have an characterized by a variety of cardiac symptoms, outflow tract gradient. Some of the findings some patients reporting chest pain and ventricu- include ECG abnormalities, a family history of lar dysrhythmias but most not having any sudden death or cardiomyopathy, systolic ante- symptoms. Signs are those associated with aus- rior motion of the mitral valve in the echo- cultatory features (mid-systolic non-ejection cardiogram, asymmetric septal hypertrophy and click and late systolic murmur). Echocardio- diastolic filling abnormalities. Those women graphic or cineangiographic evidence of with significant left ventricular outflow tract systolic billowing of the mitral valve leaflets in obstruction, a personal history of syncope, or the left atrium and a thickened mitral valve may complex dysrhythmias should not participate in cardiovascular issues 245

any form of athletic competition. Regardless cells, which are the principal constituent of the of disease severity, no participation in high- early lipid-filled plaque. Macrophages and intensity competitive sports is recommended by platelets release a variety of growth factors and the American College of Cardiology (Maron et chemoattractants that result in the proliferation al., 1985). of smooth muscle cells. The rate at which coronary atherosclerosis pro- gresses will be mainly determined by genetics Coronary heart disease and lifestyle factors such as diet, smoking, physi- While there is still a general misconception cal activity and stress. Although the prevalence among the lay public that coronary heart disease of coronary heart disease is lower among the is a man’s disease, there is increasing awareness active population, the risk factors and symptoms of the problem in women. Although it has a later such as chest pain are equally important for both onset in life among women, it has a worse prog- women and men (Hubbard et al., 1992) (Table nosis. Even the rate of early death after myocar- 16.1). Misperception of angina pectoris in dial infarction is higher for women (Lerner & women may delay the evaluation, increasing the Kannel, 1986). The frequency of silent or unrec- risk. Exercise ECG testing is recommended for ognized myocardial infarction is higher in women who have a history typical of angina pec- women than in men, and women are referred for toris even if the resting ECG is normal (Hlatky revascularization at a later stage of illness et al., 1984). Among young and middle-aged (Gardner et al., 1985) and have higher operative women, coronary heart disease has a low preva- mortality rates and periprocedural complica- lence (Wenger et al., 1993), so a normal exercise tions with coronary bypass surgery (Loop et al., ECG has high specificity for excluding the illness 1983). Since women participate in competitive (Weiner et al., 1979). When indicated, perfusion sports well past their sixties, it is important to imaging with thallium improves the specificity realize that they are not immune to heart disease. of exercise testing in women (Friedman et al., Atherosclerosis begins in infancy, with lipid 1982). being deposited in the endothelium of the artery. Atherosclerotic plaques develop in coronary Hypertension arteries when the amount of low-density lipoprotein cholesterol (LDL-C) entering the The pathophysiology of hypertension is not well subintimal space exceeds removal, resulting in understood. Of hypertensive adults, 90% are the accumulation of LDL-C in the form of choles- classified as having idiopathic hypertension. terol esters. The trigger may be an injury to, or Idiopathic hypertension is also referred to as disruption of, the endothelial cells lining the essential hypertension and its origin is unknown. intima. The injury to the endothelium increases Some of the factors that may contribute to or its permeability and exposes the subintimal and cause essential hypertension include obesity, medial layers of the artery wall to infiltration by insulin resistance, physical inactivity, high monocytes, platelets, LDL-C and other vasoac- sodium intake, stress and genetic factors. tive substances. Another hypothesis about the development of the plaque assumes that lipid fil- Role of exercise in the prevention of tration occurs through the endothelium when cardiovascular heart disease the concentration of LDL-C in the blood is ele- vated. LDL-C is filtered into the subintimal space The representation of women in prospective and followed by monocytes that assimilate the studies relating exercise to cardiovascular extracellular lipid and become macrophages. disease has been inadequate. Therefore it is diffi- The progressive accumulation of lipid by cult to determine possible gender differences in macrophages leads to their conversion to foam the effect of exercise on the risk of heart disease. 246 medical issues

Table 16.1 Risk of developing coronary artery disease on the basis of specific values for the various risk factors. (From Wilmore & Costill, 1994 with permission)

Relative level of risk

Risk factor Very low Low Moderate High Very high

Blood pressure (mmHg) Systolic < 110 120 130–140 150–160 > 170 Diastolic < 70 76 82–88 94–100 > 106 Cigarettes (per day) Never or 5 10–20 30–40 > 50 none in 1 year Cholesterol (mg·dl-1) < 180 < 200 220–240 260–280 > 300 Cholesterol:HDL* < 3.0 < 4.0 < 4.5 > 5.2 > 7.0 Triglycerides (mg·dl-1) < 50 < 100 130 200 > 300 Glucose (mg·dl-1) < 80 90 100–110 120–130 > 140 Body fat (%) Men 12 16 25 30 > 35 Women 16 20 30 35 > 40 Body mass index† < 25 25–30 30–40 > 40 Stress tension Never Almost never Occasional Frequent Nearly constant Physical activity 240 180–120 100 80–60 < 30 (min·week-1) > 25kJ·min-1 (5 MET)‡ > 60% Maximal heart rate 120 90 30 0 0 reserve ECG abnormality 0 0 0.05 0.10 0.20 (ST depression in mV)§ Family history of premature 0 0 1 2 + 3 heart attack (blood relative)¶ Age (years) < 30 40 50 60 > 70

*HDL, high-density lipoprotein. †Body mass index = weight (kg)/height (m2). ‡1 MET is equal to the oxygen cost at rest. §Other ECG abnormalities are also potentially dangerous and are not listed here. ¶Premature heart attack refers to persons younger than 60 years of age.

Most risk factors are shared equally by women more physically active women (Magnus et al., and men. However, there are two factors under 1979; Salonen et al., 1982) and for fit older and study that may uniquely affect the female cardio- younger women (Ekelund et al., 1988; Blair et al., vascular system: the use of oral contraceptives 1989). Studies also support an inverse relation and postmenopausal hormone replacement. between blood pressure and fitness or physical Physical activity might play an important role activity status (Gibbons et al., 1983; Reaven et al., in preventing or delaying the onset of coronary 1991). Exercise has little or no effect in severe artery disease in women. Possible mechanisms hypertension. Powell et al. (1987), in an extensive involve a reduction in risk factors as a result of review of epidemiological studies on physical physical activity and/or physiological adapta- inactivity and coronary artery disease, found tions with training. Some studies do show lower that the relative risk from physical inactivity is all-cause and cardiovascular mortality rates for similar to the risk associated with the three other cardiovascular issues 247

major risk factors. In 1992 the American Heart The causes of sudden death in athletes are Association declared that physical inactivity is a summarized below. primary risk factor for coronary artery disease. 1 Myocardial: Physical activity, especially endurance train- (a) hypertrophic cardiomyopathy (asymmetric ing, exerts a beneficial effect on blood lipid levels: septal hypertrophy); there is an increase in high-density lipoprotein (b) idiopathic cardiomyopathy; cholesterol (HDL-C), a decrease in triglycerides, (c) myocarditis; a decrease in LDL-C and total cholesterol, and (d) myocardial infarction. almost all studies show benefits in the LDL-C: 2 Conduction system disorders: HDL-C and total cholesterol:HDL-C ratios (a) primary conduction system disease; (Haskell, 1984; Goldberg & Elliot, 1985). Exercise (b) accessory bypass tracts (Wolff–Parkinson– has also been reported to be effective in weight White syndrome); reduction, in the control of diabetes and for (c) congenital long QT interval syndrome. reducing anxiety (Kirkcaldy, 1989). No evidence 3 Coronary artery disorders: is yet available to indicate that exercise leads to (a) coronary atherosclerosis; cessation of smoking. (b) coronary artery anomalies; (c) coronary artery hypoplasia; (d) myocardial bridging, intramural coronary Sudden death artery. Sudden cardiovascular deaths in athletes during 4 Valvular: training or competitive events are rare but have (a) aortic stenosis; attracted a great deal of attention. The instanta- (b) mitral valve prolapse. neous nature of the deaths suggests that cardiac 5 Vascular: arrhythmias are probably the immediate cause of (a) aortic dissection (Marfan’s syndrome or death in most instances. In children and adults atherosclerosis); under the age of 30, atherosclerotic heart disease (b) subarachnoid haemorrhage. is an unusual cause of exercise-related deaths. Hypertrophic cardiomyopathy is well recog- Conclusion and recommendations nized as a high risk factor for exercise-induced for future research sudden death (McManus et al., 1982). It is unknown which of several factors present in this Research should be directed towards under- disease is the initiating cause of sudden death. standing the basic mechanisms of the cardiovas- These athletes present with marked septal hyper- cular system and should focus on aspects unique trophy, disarray of ventricular myocardial fibres, to women, especially in areas in which compari- and predisposition to ventricular arrhythmias sons between women and men are inadequate or and sudden death. The resting ECG is usually data are unavailable. The aspects of cardiovascu- abnormal. A massive screening effort to identify lar disease that need to be clarified are summa- competitive athletes at high risk for sudden rized below. death appears impractical. • Investigations need to address why there is a Congenital anomalies of the coronary arteries later onset of coronary heart disease in women are also reported as a cause of sudden death. compared with men, as well as a later onset of When the left coronary artery has its origin from other cardiovascular disorders such as aortic the right sinus of Valsalva and passes between stenosis, hypertension, stroke, heart failure and the aorta and pulmonary artery, the blood flow peripheral vascular disease (Wenger et al., 1993). through the artery is compromised during exer- • Research should determine why women cise as a result of its anatomical position (Levin et undergo intensive or invasive evaluations less al., 1978). frequently or later than men who have symp- 248 medical issues

toms of similar or lesser severity, particularly in Gilchrist, L.D., Schinke, S.P. & Nurius, P. (1989) Reduc- the evaluation of chest pain. ing onset of habitual smoking among women. Pre- vention Medicine 18, 235–248. • Educational messages focusing on cardiovas- Goldberg, L. & Elliot, D.L. (1985) The effect of physical cular disease in women should be increased to activity on lipid and lipoprotein levels. Medical promote the objective of enhancing cardiovascu- Clinics of North America 69, 41–55. lar health. Haskell, W.L. (1984) The influence of exercise on the • A vigorous antismoking campaign is needed concentrations of triglyceride and cholesterol in human plasma. Exercise and Sport Sciences Reviews 12, to enhance awareness about the relation between 205–244. cigarette smoking and cardiovascular disease. Hlatky, M.A., Pryor, D.B., Harrell, F.E. Jr, Califf, R.M., The prevalence of smoking among adolescent Mark, D.B. & Rosati, R.A. (1984) Factors affecting girls has exceeded that among boys for the past sensitivity and specificity of exercise electrocardiog- decade (Gilchrist et al., 1989). raphy: multivariable analysis. American Journal of Medicine 77, 64–71. • More women should be encouraged to adopt Hubbard, B.L., Gibbons, R.J., Lapeyre, A.C. III, Zins- an active lifestyle. Also, as more female athletes meister, A.R. & Clements, I.P. (1992) Identification of challenge the limits of endurance and resistance severe coronary artery disease using simple clinical performance, scientists will have more opportu- parameters. Archives of Internal Medicine 152, nities to collect information on the respiratory 309–312. Kirkcaldy, B. (1989) Exercise as a therapeutic modality. and cardiovascular responses to exercise. Medicine and Sports Science 29, 166–187. • A gender-specific pattern of cardiovascular Lerner, D.J. & Kannel, W.B. (1986) Patterns of coronary regulation during exercise may exist. It is impor- heart disease morbidity and mortality in the sexes: a tant to understand the health and performance 26-year follow-up of the Framingham population. implications of these gender-related differences. American Heart Journal 111, 383–390. Levin, D.C., Fellows, K.E. & Abrams, H.L. (1978) Hemodynamically significant primary abnormali- References ties of the coronary arteries: angiographic aspects. Circulation 58, 25–34. American College of Sports Medicine (1994) Recom- Levy, D. & Savage, D. (1987) Prevalence and clinical mendations for determining eligibility for features of mitral valve prolapse. American Heart competition in athetes with cardiovascular Journal 113, 1281–1290. abnormalities. Medicine and Science in Sports and Exer- Loop, F.D., Golding, L.R., MacMillan, J.P., Cosgrove, cise 26, S223–283. D.M., Lytle, B.W. & Sheldon, W.C. (1983) Coronary Blair, S.N., Khol, H.W., Paffenbarger, R.S., Clark, D.G., artery surgery in women compared with men: analy- Cooper, K.H. & Gibbons, L.W. (1989) Physical fitness ses of risk and long-term results. Journal of the Ameri- and all-cause mortality: a prospective study of can College of Cardiology 1, 383–390. healthy men and women. Journal of the American McManus, B.M., Waller, B.F., Graboys, T.B. et al. (1982) Medical Association 262, 2395–2401. Exercise and sudden death. Part 1. Current Problems Ekelund, L., Haskell, W.L., Troung, Y.L., Gordon, E.H. in Cardiology 6, 1–89. & Shepps, D.S. (1988). Physical fitness as predictor of Magnus, K., Matroos, A. & Strackee, J. (1979) Walking, cardiovascular (CVD) mortality in asymptomatic cycling, or gardening, with or without seasonal females. Circulation 78 (Suppl. 11), Abstract 110. interruptions, in relation to acute coronary events. Friedman, T.D., Greene, A.C., Iskandrian, A.S., Hakki, American Journal of Epidemiology 110, 724–733. A.H., Kane, S.A. & Segal, B.L. (1982) Exercise Maron, B.J., Gaffney, F.A., Jeresaty, R.M., McKenna, thallium-201 myocardial scintigraphy in women: W.J. & Miller, W.W. (1985) Cardiovascular abnormal- correlation with coronary arteriography. American ities in the athlete: recommendations regarding eligi- Journal of Cardiology 49, 1632–1637. bility for competition. Task force III: Hypertrophic Gardner, T.J., Horneffer, P.J., Gott, V.L. et al. (1985) Coro- cardiomyopathy, other myopericardial diseases and nary artery bypass grafting in women: a ten-year mitral valve prolapse. Journal of the American College perspective. Annals of Surgery 201, 780–784. of Cardiology 6, 1215–1217. Gibbons, L.W., Blair, S.N., Cooper, K.H. & Smith, M. Powell, K.E., Thompson, P.D. & Caspersen, C.J. (1987) (1983) Association between coronary heart disease Physical activity and the incidence of coronary risk factors and physical fitness in healthy adult heart disease. Annual Reviews in Public Health 8, women. Circulation 67, 977–983. 253–287. cardiovascular issues 249

Reaven, P.D., Barrett-Connor, E. & Edelstein, S. (1991). angina, ST-segment response and prevalence of Relation between leisure-time physical activity and coronary-artery disease in the Coronary Artery blood pressure in older women. Circulation 83, Surgery Study (CASS). New England Journal of Medi- 559–565. cine 301, 230–235. Salonen, J., Puska, P. & Tuomilehto, J. (1982) Physical Wenger, N.K., Speroff, L. & Packard, B. (1993) Cardio- activity and risk of myocardial infarction, cerebral vascular health and disease in women. New England stroke and death. American Journal of Epidemiology Journal of Medicine 329, 247–256. 115, 526–537. Wilmore, J.H. & Costill, D.L. (1994) Physiology of Weiner, D.A., Ryan, T.J., McCabe, C.H. et al. (1979) Exer- Sports and Exercise. Human Kinetics Publishers, cise stress testing: correlations among history of Champaign, Illinois. Chapter 17

Physical Activity and Risk for Breast Cancer

PATTY S. FREEDSON, CHUCK E. MATTHEWS AND PHILIP C. NASCA

Introduction rates for white and black women were 26.8 and 31.9 per 100000 respectively. Although the mor- Interest in the relationship between physical tality rate has remained relatively constant since activity and breast cancer began with an observa- 1950, the incidence of breast cancer has been tional study of former college athletes (Frisch et increasing in the USA, particularly since 1980 al., 1985). This study was the first to suggest that (Fig. 17.1). A significant portion of this increase physical activity confers a protective effect can be attributed to changes in the diagnostic against the development of breast cancer. criteria for the disease and increased detection ‘Athlete’ was defined as a woman who had been by screening programmes since the early 1980s on one varsity, house or intramural team for at (Kelsey & Horn-Ross, 1993). However, some least 1 year and/or who had been recognized for studies have reported that the incidence of the athletic distinction. Training had to be regular disease is increasing independent of enhanced and occur at least two times per week during the screening and diagnostic changes (White et al., season. The relative risk for breast cancer among 1990; Kelsey & Horn-Ross, 1993; Hankey et al., non-athletes was 1.86 [95% confidence interval 1994). Given the relatively stable mortality rates (CI) 1.0–3.47] compared with former athletes and increased incidence rates for breast cancer, after controlling for age, family history of breast primary prevention of the disease is an impor- cancer, age at menarche, number of pregnancies, tant public health concern. This chapter reviews oral contraceptive use, oestrogen use during the existing epidemiological literature, evaluat- menopause, smoking and body composition. ing the association between regular physical Since 1985, a number of epidemiological studies activity and breast cancer and potential biologi- have examined this issue using several different cal mechanisms through which physical activity approaches and experimental designs. The may mediate the relationship. notion that physical activity may provide protec- tion from breast cancer is appealing, as this Physical activity and breast disease is a major public health concern for cancer risk women. Breast cancer is the most common cancer Since 1994, several epidemiological studies have among women in the USA. In 1994, it was esti- examined the association between physical mated that there were 182000 new cases and activity and risk of breast cancer (Bernstein et al., 46000 deaths from the disease. Nearly one-third 1994; Dorgan et al., 1994; Friedenreich & Rohan, of all new cancer cases among women were 1995; Mittendorf et al., 1995; Taioli et al., 1995; cancers of the breast (Gloeckler et al., 1994). In D’Avanzo et al., 1996; McTiernan et al., 1996; Tretli 1991, the age-adjusted breast cancer mortality & Gaard, 1996; Chen et al., 1997; Coogan et al., 250 physical activity and risk for breast cancer 251

120

110

100

90

80 Incidence per 100 000

70 Fig. 17.1 Age-adjusted breast cancer incidence rates per 100 000 60 white () and black () women 1970 1975 1980 1985 1990 1995 in the USA, 1973–91. Year

1997; Hu et al., 1997; Thune et al., 1997). These Influence of physical activity reports have provided conflicting results, with assessment methods Bernstein et al. (1994), Mittendorf et al. (1995) and Thune et al. (1997) providing the most com- A common observation emerges from the group pelling evidence of a protective effect. Bernstein of published retrospective studies that found a et al. (1994) reported that lifelong participation in reduced risk of breast cancer in more active physical activity was associated with a protective women, i.e. quantifying lifelong participation in effect, while Mittendorf et al. (1995) concluded physical activity, rather than at a single point in that activity every day of the year between the time, may be important in observing a reduced ages of 14 and 22 years was related to a reduced risk for the disease. Among the five retrospective risk of breast cancer. In the study by Thune et al. cohort studies that reported a protective effect, (1997), adult physical activity conferred the pro- each either directly quantified or had a reason- tective effect. In contrast, Dorgan et al. (1994) able proxy measure of lifetime activity levels, e.g. reported a small increased risk of breast cancer usual occupational activity or reported exercise among physically active women and Chen et al. habits throughout life (Frisch et al., 1985; Vena et (1997) reported a minimal protective effect of al., 1987; Vihko et al., 1992; Zheng et al., 1993; either lifelong or adult leisure-time physical Bernstein et al., 1994). activity. A single measure of physical activity in retro- Tables 17.1 and 17.2 summarize study design, spective cohort studies may not reflect the life- subject characteristics, outcome measures, physi- long participation of women in physical activity. cal activity assessment techniques and results Indeed, Dorgan et al. (1994) present evidence that from all epidemiological studies conducted activity scores on the physical activity index in since 1985. It should be noted that even though 1954–56 were only weakly correlated (r=0.18 the association between regular physical activ- and 0.25) to the physical activity index scores ity and breast cancer risk remains equivocal, measured 14 and 16 years later. In the investiga- several lines of evidence point to potential tions of Albanes et al. (1989) and Paffenbarger et mechanisms through which physical activity al. (1992), no data were presented on the changes may possibly modify the risk of developing the in physical activity in the interval between base- disease. line and follow-up. 252 medical issues

There are no longitudinal data on the trends Summary of observational studies for physical activity behaviour in the USA that date back to the baseline of these investigations; Of the 18 published studies presented in Tables however, survey data have been available for the 17.1 and 17.2, only three suggest a moderate to USA and Canada since the early and mid 1980s. strong protective effect of physical activity where In both countries there has been a trend towards the 95% relative risk CI does not include 1.0 increasing participation in physical activities, (Bernstein et al., 1994; Mittendorf et al., 1995; predominantly in moderate intensity activities Thune et al., 1997). Investigations that have (e.g. walking, gardening, social dancing) observed a protective effect for high levels of (Stephens & Casperson, 1994). Trend data from activity on the risk of breast cancer appear to the Minnesota Heart Survey between 1980–82 have better information for physical activity over and 1985–87 suggest that women increased their much of the individual’s lifetime or to have a total activity [+55kJ·day–1 (+13kcal·day–1)] in proxy lifetime measure (e.g. occupational physi- leisure time over this time period (Jacobs et al. cal activity). Based on these findings, physical 1991). Therefore, it is likely that a single assess- activity accumulated over a lifetime appears to ment of physical activity is a poor indicator of attenuate breast cancer risk in women. The lifelong activity behaviour, particularly when remainder of this review examines the experi- trends for activity appear to be changing. mental evidence supporting the notion that

Table 17.1 Selected features of studies examining the association between physical activity and breast cancer

Breast cancer Physical activity Reference Design Sample cases assessment

Frisch et al. (1985) Retrospective 5398 US college Self-reported Classified as cohort alumnae breast cancer in athletes or non- graduating 1981; 69 cases athletes based on between 1925 college and 1981; aged participation in 21–81 years in sport or physical 1981 training Vena et al. (1987) Retrospective 25000 residents Death certificate Occupational job cohort of Washington diagnosis of breast classification dying between cancer; 791 cases 1974 and 1979 Albanes et al. Prospective cohort 7407 from Review of hospital Recreational and (1989) NHANES I and admission, death non-recreational NHEFS records and self- activity self- report; classified into one histologically of three categories: confirmed in all low, moderate or but one case; 122 high cases Paffenbarger et al. Prospective cohort 4706 University Incident cases of College sport (1992) of Pennsylvania breast cancer; 46 participation: alumnae cases £ 5h·week-1 or graduating > 5h·week-1 between 1916 and 1950

Continued Table 17.1 (Continued)

Breast cancer Physical activity Reference Design Sample cases assessment

Vihko et al. (1992) Retrospective 8619 language Incident cases of Job classification cohort teachers and breast cancer 1499 physical verified by education Finnish Cancer teachers Registry; 128 cases Dosemeci et al. Hospital-based Hospital Histologically Occupation titles (1993) case control patients from confirmed cases of and years in Turkey; 244 breast cancer; 241 occupation used controls cases to estimate energy expenditure and sitting time at work Zheng et al. Record linkage 3783 incident 2736 verified by Occupational (1993) cancer cases in Chinese Cancer physical activity, Shanghai, Registry sitting time and China energy diagnosed expenditure; three between 1980 levels of activity and 1984 Bernstein et al. Population case- University of 545 cases matched Lifetime (since (1994) control Southern on birth date, race menarche) California parity, physical activity Cancer neighbourhood (≥ 2h·week-1); Surveillance residence interviewer Program, administered 1983–89; < 40 years of age; 545 controls Dorgan et al. Prospective cohort 2298 from Incident cases Usual h·day-1 in (1994) Framingham based on hospital sedentary, light, Heart Study admission, death moderate and records and self- heavy activities; report; all but one index weighted case histologically for energy confirmed; 117 expenditure; low cases vs. high quartile Friedenreich & Population case- Cancer registry 444 cases Recreational Rohan (1995) control in Adelaide and physical activity controls from converted to electoral roll kcal·week-1; low vs. high quartile Mittendorf et al. Population case- Cancer 6888 cases Strenuous (1995) control registries in recreational Massachusetts, physical activity at Maine, New 14–18 and 18–22 Hampshire, years of age Wisconsin and controls from drivers’ licenses or Medicare lists

Continued p. 254 254 medical issues

Table 17.1 (Continued)

Breast cancer Physical activity Reference Design Sample cases assessment

Taioli et al. (1995) Hospital case- One hospital 617 cases Strenuous control source for cases recreational and controls physical activity at ages 15–21, 22–44 and 45 +; < 3 vs. ≥ 3h·week-1 Tretli & Gaard Ecological Norwegian 20111 cases Increased physical (1996) Cancer Registry activity during the Second World War D’Avanzo et al. Multicentre Hospitals in 2569 cases Occupational and (1996) population case- Italy were leisure-time control sources for physical activity at cases and 2588 ages 15–19, 30–39 controls and 50–59 years; lowest vs. highest quartile McTiernan et al. Population case- Washington 537 cases Recreational (1996) control State Cancer activity at ages Registry and 12–21 years and 2 RDD controls years before interview Hu et al. (1997) Hospital case- Hospital in 157 cases Recreational control Japan for cases activity in and breast adolescence and cancer in twenties screening programme for 369 controls Thune et al. Prospective cohort 25624 from 351 cases Occupational and (1997) three counties recreational in Norway in activity in years 1974–78 and preceding survey; 1977–83 health sedentary vs. survey regularly active Chen et al. (1997) Population case- Seattle–Puget 747 cases Recreational control Sound SEER activity 2 years Registry and before survey and 961 RDD from 12 to 21 controls years; no activity vs. ≥ 4h·week-1

NHANES, National Health and Nutrition Examination Survey; NHEFS, NHANES I Epidemiologic Follow-up Study; RDD, random digit telephone dialling; SEER, surveillance, epidemiology and end results. Table 17.2 Results of studies examining the association between physical activity and breast cancer

Variables controlled in Reference analyses Contrasts Results

Frisch et al. (1985) Age Non-athletes vs. athletes 54% increased risk for non-athletes Age, number of Non-athletes vs. athletes 86% increased risk for pregnancies, family non-athletes history of cancer, body composition, age at menarche, smoking, oral contraceptive or oestrogen use Vena et al. (1987) Age Job activity level: 1 (low active) 15% increased mortality 2 17% reduced mortality 3, 4 and 5 15% reduced mortality Albanes et al. Age at menarche and Premenopausal (1989) menopause, parity, Recreational (low vs. 40% reduced risk for low age at first birth, high) family history of Non-recreational (low 60% reduced risk for low breast cancer, body vs. high) mass index, dietary Postmenopausal fat intake Recreational (low vs. 50% reduced risk for low high) Non-recreational (low 70% increased risk for vs. high) low All, P > 0.05 Paffenbarger et al. Age £ 5 vs. > 5h·week-1 in No association (1992) college sports Age, BMI, maternal ≥ 4600 vs. < 4600 12% reduced risk for history of cancer kJ·week-1 (1095 more active (P > 0.05) kcal·week-1) Vihko et al. (1992) Age Language vs. physical 20% increased risk for education teachers language teachers (NS) Age, observation Language vs. physical 30% increased risk for period, age at first education teachers language teachers (NS) birth, number of children Dosemeci et al. Age, smoking, Energy expenditure [< 8 30% increased risk for (1993) socioeconomic status vs. > 12kJ·min-1 (<1.9 vs. low energy expenditure > 2.8 kcal·min-1)] (P > 0.05) Zheng et al. Age Sitting time (1993) Long (> 80% of work) 27% increased incidence Moderate (20–80% of 10% increased incidence work Short (< 20% of work) 7% lower incidence Energy expenditure Low [< 8kJ·min-1 31% increased incidence (1.9 kcal·min-1)] Moderate 5% increased incidence [8–12kJ·min-1 (P > 0.05) (1.9–2.8 kcal·min-1)] High [> 12kJ·min-1 21% reduced incidence (>2.8 kcal·min-1)]

Continued p. 256 256 medical issues

Table 17.2 (Continued)

Variables controlled in Reference analyses Contrasts Results

Bernstein et al. Age at menarche, first Lowest vs. highest 58% reduced risk for (1994) full-term pregnancy, weekly activity high (95% relative risk number of full-term quintile CI 0.27–0.64) pregnancies, lactation, family history of breast cancer, Quetelet’s index, oral contraceptive use Dorgan et al. Age at first pregnancy, Lowest vs. highest 60% greater risk for high (1994) education, occupation, physical activity (95% relative risk CI alcohol consumption quartile 0.9–2.9) Friedenreich & Quetelet’s index, Lowest vs. highest 27% greater risk for low Rohan (1995) energy intake quartile (95% relative risk CI 0.50–1.05) Mittendorf et al. Age, age at menarche, No strenuous activity 50% reduced risk for (1995) age at menopause, vs. activity every day active (95% relative risk menopausal status, of the year CI 0.4–0.7 first full-term pregnancy, parity, family history of breast cancer, history of benign breast disease, type of menopause, alcohol consumption, BMI, BMI/ menopausal status Taioli et al. (1995) Age, education, BMI, < 3 vs. ≥ 3h·week-1 of 1.0 relative risk (95% age at menarche, exercise relative risk CI 0.6–1.8) parity Tretli & Gaard None Increased physical Decreased incidence of (1996) activity during breast cancer among Second World War women in puberty during Second World War D’Avanzo et al. Age, centre, menarche Lowest vs. highest 15–19 years: 6% (1996) age, first full-term quartile decreased risk for low pregnancy, parity, (95% relative risk CI menopausal status, 0.77–1.16) age at menopause, 30–39 years: 27% caloric intake, decreased risk for low previous BBD, breast (95% relative risk CI cancer family history 0.56–1.06) 50–59 years: 32% decreased risk for low (95% relative risk CI 0.4–1.09)

Continued physical activity and risk for breast cancer 257

Table 17.2 (Continued)

Variables controlled in Reference analyses Contrasts Results

McTiernan et al. Age, education No exercise vs. ≥ 3 40% reduced risk (1996) h·week-1 of high- (95% relative risk CI intensity exercise 0.4–1.0) Hu et al. (1997) None No exercise vs. highest Premenopausal breast tertile of energy cancer expenditure Activity in adolescence: 28% reduced risk (95% relative risk CI 0.38–1.38) Activity during twenties: 1.01 (95% relative risk CI 0.54–1.87) Postmenopausal breast cancer Activity in adolescence: 1.39 (95% relative risk CI 0.61–3.13) Activity in twenties: 0.53 (95% relative risk CI 0.19–1.52) Thune et al. Age at study entry, Sedentary vs. 33% reduced risk (95% (1997) BMI, height, consistently active relative risk CI 0.40–1.1) residence, number of children Chen et al. (1997) Age No activity vs. ≥ 8% reduced risk (95% 4h·week-1 relative risk CI 0.71–1.22)

BMI, body mass index; CI, confidence interval; NS, not significant.

regular participation in physical activity reduces posed a model which suggests that combined the risk of breast cancer before and after exposure to oestrogens and progesterone is menopause. important to an increased risk for breast cancer. Reviewing several studies that examined the proliferative activity of breast tissue during the Biological mechanisms: menstrual cycle, these authors provide evidence hormonal effects suggesting that higher rates of breast cell prolif- Although the aetiology of breast cancer is not erative activity are associated with increased completely understood, several factors have levels of both oestradiol and progesterone been clearly associated with increased risk of the during the luteal phase of the cycle. This mecha- disease. The most striking observation is that nism appears to be the direct link between circu- many of the risk factors are related to exposure to lating hormones and risk of breast cancer endogenous or exogenous hormones (Kelsey, (Preston-Martin et al., 1990). An increased level of 1993; Pike et al., 1993). Pike et al. (1993) have pro- cell proliferation in breast tissue may lead to a 258 medical issues

greater number of genetic errors, which in turn resulting in primary amenorrhoea (menarche at increases the risk of cell mutations and the devel- >16 years), secondary amenorrhoea (lack of opment of cancer. menstruation for three to four consecutive Pike et al. (1993) suggest that their model pro- months) or ‘unobtrusive’ but hormonally impor- vides a mechanism to explain the following epi- tant alterations in menstrual function (Bullen et demiological findings: (i) lower risk for women al., 1985; Bernstein et al., 1987; Bonen, 1994). In after the menopause (naturally occurring or fol- the two latter situations, circulating levels of lowing ovarian removal); (ii) increased risk oestrogen and/or progesterone are reduced from among women exposed to oestrogen replace- those observed in a regular menstrual cycle and ment therapy or oral contraceptives; and (iii) this could be a mechanism whereby exposure to lower risk for obese women before, but not after, these hormones is reduced. In each of these the menopause. The latter paradoxical finding of instances, the cessation of exercise results in a reduced risk for premenopausal obesity and return to normal menstrual functioning (Bonen, increased risk for postmenopausal obesity may 1994). The fluctuations of oestradiol and proges- be explained by this model. Pike et al. (1993) terone over the course of a typical menstrual present evidence which suggests that pre- cycle are presented in Fig. 17.2. This illustration menopausal obesity is associated with a greater clearly shows the sharp peak of oestradiol at the number of anovulatory cycles and lower levels of end of the follicular phase and the abrupt rise in circulating progesterone levels; thus this group progesterone accompanied by a mild elevation of of women have a favourable hormonal profile oestradiol during the luteal phase of the cycle. (Hartz et al., 1979). Postmenopausal obese Female athletes training at very high volumes women have increased levels of circulating have often reported secondary amenorrhoea oestrogen, thus elevating their breast cancer risk (Bonen, 1994). In experimental studies, female (Simpson & Mendelson, 1987; Barbosa et al., athletes have low levels of oestradiol and proges- 1990). The recent Women Nurses Study findings terone and have greatly reduced peak hormone by Huang et al. (1997) support this hypothesis. concentrations over the course of a menstrual They reported that a higher body mass index and cycle (Loucks et al., 1989; Bonen, 1994). Similar weight gain after 18 years of age was unrelated hormonal changes have been observed in groups to breast cancer risk before menopause, but of inactive women following the initiation of vig- was associated with breast cancer risk after orous high-volume (>20h·week–1) exercise pro- menopause. Finally, the model of Pike et al. (1993) grammes (Bullen et al., 1985). In experimental fits several other epidemiological findings studies of lower exercise volume (1–2h·week–1), related to reduced exposure to ovarian hormones unobtrusive changes, lower progesterone levels and lower breast cancer risk, including later or a shortened luteal phase have been observed menarche, a greater number of pregnancies and in some but not all investigations (Bernstein et al., more years of breast-feeding (Kelsey, 1993). The 1987; Bonen, 1992). epidemiological findings which suggest that Data from Loucks et al. (1989) provide a vivid high levels of regular physical activity confer a example of secondary amenorrhoea and the protective effect on breast cancer risk may also be ‘unobtrusive’ alterations in hormonal profile explained in terms of the model suggested by associated with high levels of athletic training. Pike et al. (1993). These investigators examined urinary markers for oestrogen and progesterone, oestrone glu- curonide (E G) and pregnanediol glucuronide Impact of physical activity on 1 (PdG), over 30 days in three groups of women endogenous hormones who differed in their menstrual and exercise Regular vigorous exercise has been associated status. The athletic women were competitive with an alteration of normal menstrual function, runners, cyclists, swimmers or triathletes physical activity and risk for breast cancer 259

400 20

300 15 ) ) –1 –1 ml . ml .

Ovulation 200 10 Oestradiol (pg Progesterone (ng 100 5

0 0 1 3 5 79111315171921232527 Day of menstrual cycle

Fig. 17.2 Serum concentrations of oestradiol () and progesterone () by day of the menstrual cycle. Day 1 is the first day of menses and a 28-day cycle is assumed, with ovulation occurring on day 14. (From Pike et al., 1993 with permission.)

who had been training for more than 8 years. 1980; Bonen, 1994). Under conditions of low

Comparisons of urinary excretion of E1G and caloric availability or deficit the body limits PdG were made between regularly cycling energy expenditure to systems within the body sedentary, regularly cycling athletic and amenor- that are of lesser importance. For instance, the rhoeic athletic groups (Fig. 17.3). Amenorrhoeic luteal phase of the menstrual cycle is marked by athletes appeared to have very low levels of an increase in resting metabolic rate of 10–15%. oestradiol and progesterone, with little fluctua- Therefore, shortening its length during times of tion over the cycle. Among the regularly cycling moderate caloric deficit will conserve energy athletes, although a normal oestrogen profile (Bonen, 1994; Heymsfield et al., 1994). A conse- was observed, luteal-phase progesterone levels quence of this adaptation may be to lower a were significantly reduced (P <0.05) and the woman’s exposure to endogenous progesterone. length of the luteal phase was significantly short- Warren (1980) hypothesized that the ‘energy ened (by 2 days, P <0.05) compared with seden- drain’ associated with exercise may be related to tary women (Fig. 17.3). Thus, it appears that the many of the observed reproductive disorders hormonal profile associated with lower risk of among exercising women. This hypothesis is breast cancer may be achieved via physical activ- consistent with observations that energy avail- ity. However, the exercise volume needed to ability is directly related to reproductive function attain this profile is quite large. Moderate levels in many species of mammals (Bronson, 1988). of exercise may not always provide the hypothe- Loucks and Callister (1993) have also speculated sized hormonal profile. that energy availability is an important factor in Alterations in hormonal function among human reproductive function and have pre- women who undertake regular vigorous exercise sented evidence that the low-T3 (triiodothyro- appear to be related to an energy conservation nine) syndrome, which is associated with adaptation within the human organism (Warren, secondary amenorrhoea, can be prevented in 260 medical issues

45 CR) 1 – 30 mg . G (ng

1 15 E

0 –16 –12 –8 –40 481216 (a) Day from significant increase in PdG 5

4 CR) 1

– 3 mg . g

µ 2

PdG ( 1

0 –16 –12 –8 –40 481216 (b) Day from significant increase in PdG

Fig. 17.3 Mean (± SE) daily urinary excretion of (a) oestrone glucuronide (E1G) and (b) pregnanediol glucuronide (PdG) in different groups of women. Days are orientated from a significant increase in urinary PdG excretion, with day 1 being the day of first significant increase. , cycling sedentary; , cycling athletic; , amenorrhoeic athletic. CR, creatinine. (From Loucks et al., 1989 with permission.) exercising women who balance their energy standable. Since physical activity and caloric expenditure with intake. To our knowledge no intake can each be independently manipulated studies have directly examined the influence of to achieve a reduced energy availability and the energy availability on progesterone levels during attendant protective hormonal profile, the classi- the luteal phase or on the length of the luteal fication of exposure to breast cancer risk by eval- phase. Interestingly, Bonen (1992) provide indi- uating only one side of the energy balance rect evidence that length of the luteal phase and equation (e.g. physical activity) may be limited. progesterone levels are not altered in exercising It is possible that the inconsistencies in the exist- women who maintain their energy balance (e.g. ing literature on physical activity and breast maintain body mass and percentage body fat). cancer are related to the inability to classify this Their results provide indirect evidence that ‘low-risk’ hormonal profile accurately by exam- length of the luteal phase and progesterone ining only one side of the energy balance equa- levels may be influenced by energy availability tion. No studies of the association between in the physiological system rather than by physi- physical activity and breast cancer have exam- cal activity only. ined the interaction of energy expenditure and If energy availability rather than physical energy intake on breast cancer risk. The greater activity is the key to a ‘low-risk’ hormonal profile protective effect of physical activity in lean for breast cancer, the variability of the women observed by Thune et al. (1997) indirectly epidemiological studies may be more under- supports this energy balance theory. physical activity and risk for breast cancer 261

Alternative biological mechanisms: concentrations of free oestrone (Siiteri, 1987; obesity attenuation and enhanced Barbosa et al., 1990). immunosurveillance It is generally understood that higher levels of physical activity aid in the maintenance of fat- In addition to the potential impact of physical free mass and attenuate gains in fat mass over the activity on endogenous hormones, high levels of lifespan. Studies of the age-related changes in activity may influence the risk of breast cancer body composition suggest that following the beneficially via an influence on the development menopause there is an acceleration in both accu- of obesity and on immunosurveillance of early mulation of fat mass and loss of fat-free mass. tumour growth. Obesity has been associated Moreover, the accumulation of fat mass tends to with increased risk of breast cancer in post- increase on the trunk and intra-abdominally menopausal women and decreased risk in pre- (Heymsfield et al., 1994). Regular participation in menopausal women (Kelsey, 1993; Pike et al., physical activity appears to attenuate these 1993; Huang et al., 1997). The protective effect of changes. Interestingly, a recent study observed obesity before the menopause is transient that abdominal fat was lost preferentially in because an increase in body mass after the response to exercise training and that loss of menopause has been associated with an overall fat mass was highly correlated with loss approximately 2.5-fold increased risk of the of visceral fat (r=0.70) in obese women (Despres disease (Lubin et al., 1985; Ballard-Barbash et al., et al., 1991). These findings strongly support the 1990). role of regular physical activity in blunting the The recent study by Huang et al. (1997) age-related gain in fat mass and in reducing fat reported that weight gain after age 18 was mass after it has been accumulated. strongly associated with an increased risk of Our understanding of the interrelations postmenopausal breast cancer in women who between the immune system and physical activ- had never used hormone replacement therapy. ity is only beginning to emerge. The published The relative risk was 1.99 (95% CI 1.43–2.76) for a data provide some support for the hypothesis ≥20-kg weight gain compared with women who that moderate levels of activity can improve host were weight stable. Thus it appears that weight defence against tumour growth by enhancing gain is a potent stimulus for the development of macrophage and monocyte function (Hoffman- breast cancer after the menopause for women Goetz, 1994; Woods & Davis, 1994). Additionally, who have not used hormone replacement it has been hypothesized that physical activity therapy. may buffer the neuroendocrine stress response, Accumulation of fat mass in central locations which is known negatively to affect immune on the body appears to be a particularly strong function, and therefore exercise may enhance risk factor for the disease. Schapira et al. (1990) immune function indirectly (LaPierre et al., 1994). found that higher levels of centrally located fat Unfortunately, our current understanding of the conferred a five- to six-fold increased risk for relationship of physical activity to the immune developing breast cancer. These findings are con- system is in its infancy. The field is only begin- sistent with the hypothesis that after menopause ning to derive preliminary findings, which are obesity creates a high-risk hormonal environ- exceedingly complex and often interrelated to ment. In postmenopausal women, the predomi- many systems in the body. nant circulating oestrogen is oestrone, which is produced in an aromatization reaction from Conclusion circulating androgens within adipose tissue (Simpson & Mendelson, 1987). Increased levels The mechanisms presented to explain some of of adiposity have been associated with increased the epidemiological findings of a reduced risk of serum concentrations of oestrone and greater breast cancer in more physically active women 262 medical issues

are plausible. The concept that high levels of increased risk for obese women in this group, physical activity reduce exposure to oestrogen recommendations for physical activity aimed at and progesterone before the menopause and attenuating excessive weight gain in adulthood influence oestrone levels indirectly by attenuat- could be made (Hankey et al., 1994). Such recom- ing fat-mass gains after the menopause are gen- mendations should focus on reducing the gain in erally supported in the literature. Presently, the adult body mass often seen with ageing rather data supporting the proposed mechanisms are than promoting high levels of exercise training, stronger than the current epidemiological find- which may produce secondary amenorrhoea. ings. Studies that report a protective effect of Currently in the USA, participation rates of physical activity on breast cancer have shown women in regular vigorous or moderate- that lifelong exposure to activity is important. intensity physical activity are relatively low for Studies that did not demonstrate consistent both the adolescent and adult populations. patterns of activity over the lifespan did not Among 9th to 12th grade girls, participation in generally report this effect. There is no clear vigorous activity three or more times weekly was explanation why some studies have observed an only 27.5% for whites, 17.4% for blacks and adverse effect of higher levels of physical activity 20.9% for Hispanics. During high school, partici- on risk of breast cancer, although these findings pation rates dropped in each successive grade: may be related to: (i) the assessment of activity at 30.6, 27.1, 23.4 and 17.3% for 9th through 12th only a single point in time; (ii) the lack of control grades, respectively (Centers for Disease Control for factors that increased breast cancer risk in and Prevention, 1991). By middle age, only about more active women; or (iii) incomplete assess- 10% of women in the USA report participation in ment of energy availability. regular vigorous activity and only 40% partici- If the findings of Bernstein et al. (1994) and pate in regular activity of any kind (Stephens & Thune et al. (1997) are reproduced, showing that Casperson, 1994). If the association between very high levels of physical activity reduce breast regular physical activity and breast cancer is cancer risk by appoximately 50% and that the eventually confirmed, significant population- proposed hormonal changes are responsible, wide effects on the development of breast cancer then consideration would have to be given to may be possible by increasing activity levels in a public health recommendations for physical large proportion of the population. activity in this group of women. Such high levels of physical activity may lead to reduced risk of References breast cancer. However, if the hypothesized hor- monal changes do take place, they may lead to Albanes, D., Blair, A. & Taylor, P.R. (1989) Physical adverse outcomes for bone health. Secondary activity and risk of cancer in the NHANES I pop- amenorrhoea has been associated with lower ulation. American Journal of Public Health 79, 744– 750. bone density (lower peak bone mass and/or Ballard-Barbash, R., Schatzkin, A., Taylor, P. & Kahle, L. enhanced bone resorption) in young women con- (1990) Association of change in body mass with sequent to reduced exposure to endogenous breast cancer. Cancer Research 50, 2152–2155. oestrogens (Constantini, 1994). Barbosa, J.C., Schulz, T.D., Filley, S.J. & Nieman, D.C. If public health recommendations are to be (1990) The relationship among adiposity, diet, and hormone concentrations in vegetarian and non- made specifically for women, then these recom- vegetarian post menopausal women. American mendations should be formulated so that the risk Journal of Clinical Nutrition 51, 798–803. of breast cancer and cardiovascular disease is Bernstein, L., Ross, R.K., Lobo, R.A., Hanisch, R., reduced optimally and the risk of osteoporosis is Krailo, M.D. & Henderson, B.E. (1987) The effects not increased. Since most cases of breast cancer in of moderate physical activity on menstrual cycle patterns in adolescence: implications for breast the USA are detected in postmenopausal women cancer prevention. British Journal of Cancer 55, (88% after age 50 years) and there is a clear 681–698. physical activity and risk for breast cancer 263

Bernstein, L., Henderson, B.E., Hanisch, R., Sullivan- reproductive system among former college athletes Halley, J. & Ross, R.K. (1994) Physical exercise and compared to non-athletes. British Journal of Cancer 52, reduced risk of breast cancer in young women. 885–891. Journal of the National Cancer Institute 86, 1403–1408. Gloeckler, L.A., Miller, B.A., Hankey, B.F., Kosary, C.L., Bonen, A. (1992) Recreational exercise does not impair Harras, A. & Edwards, B.K. (eds) (1994) Cancer Statis- menstrual cycles: a prospective study. International tics Review, 1973–1991. NIH pub. no. 94-2789. Journal of Sports Medicine 13, 110–120. National Cancer Institute, Bethesda, Maryland. Bonen, A. (1994) Exercise induced menstrual cycle Hankey, B.F., Miller, B., Curtis, R. & Kosary, C. (1994) changes: a functional temporary adaptation to meta- Trends in breast cancer in younger women in con- bolic stress. Sports Medicine 17, 373–392. trast to older women. Monographs of the National Bronson, F.H. (1988) Seasonal regulation of reproduc- Cancer Institute 16, 7–16. tion in mammals. In E. Knobil & J.D. Neill (eds) The Hartz, A.J., Barboriak, P.N., Wong, A., Katayama, K.P. & Physiology of Reproduction, Vol. 2, pp. 1831–1871. Rimm, A.A. (1979) The association of obesity with Raven Press, New York. infertility and related menstrual abnormalities in Bullen, B.A., Skrinar, G.S., Beitins, I.Z., von Mering, G., women. International Journal of Obesity 3, 57–73. Turnbull, B.A. & McArthur, J.W. (1985) Induction of Heymsfield, S.B., Gallagher, D., Poehlman, E.T. et al. menstrual disorders by strenuous exercise in (1994) Menopausal changes in body composition untrained women. New England Journal of Medicine and energy expenditure. Experimental Gerontology 29, 312, 1349–1353. 377–389. Centers for Disease Control and Prevention. (1991) Hoffman-Goetz, L. (1994) Exercise, natural immunity, Chronic disease and health promotion. Reprints and tumor metastasis. Medicine and Science in Sports from Morbidity and Mortality Weekly Reports: and Exercise 26, 157–164. 1990–1991. Youth Risk Behavior Surveillance Hu, Y.-H., Nagata, C., Shimizu, H., Kaneda, N. & System, US Department of Health and Human Ser- Kashiki, Y. (1997) Association of body mass index, vices, Atlanta. physical activity, and reproductive histories with Chen, C.-L., White, E., Malone, K.E. & Daling, J.R. breast cancer: a case-control study in Gifu, Japan. (1997) Leisure-time physical activity in relation to Breast Cancer Research and Treatment 43, 65–72. breast cancer among young women (Washington, Huang, Z., Hankinson, S.E., Colditz, G.A. et al. (1997) United States). Cancer Causes and Control 8, 77–84. Dual effects of weight and weight gain on breast Constantini, N.W. (1994) Clinical consequences of ath- cancer risk. Journal of the American Medical Association letic amenorrhea. Sports Medicine 17, 213–223. 278, 1407–1411. Coogan, P.F., Newcomb, P.A., Clapp, R.W., Trentham- Jacobs, D.R., Hahn, L.P., Folsom, A.R., Hannan, P.J., Dietz, A., Baron, J.A. & Longnecker, M.P. (1997) Sparfka, J.M. & Burke, G.L. (1991) Time trends in Physical activity in usual occupation and risk of leisure-time physical activity in the upper midwest breast cancer (United States). Cancer Causes and 1957–1987: University of Minnesota studies. Epidemi- Control 8, 626–631. ology 2, 8–15. D’Avanzo, B., Nanni, O., La Vecchia, C. et al. (1996) Kelsey, J.L. (1993) Breast cancer epidemiology: Physical activity and breast cancer risk. Cancer Epi- summary and future directions. Epidemiologic demiology 5, 155–160. Reviews 15, 1256–1263. Despres, J.P., Pouliot, M.C., Mooranji, S. et al. (1991) Kelsey, J.L. & Horn-Ross, P.L. (1993) Breast cancer: Loss of abdominal fat and metabolic response to Magnitude of the problem and descriptive epidemi- exercise training in obese women. American Journal of ology. Epidemiologic Reviews 15, 7–16. Physiology 261, E159–E167. LaPierre, A., Ironson, G., Antoni, M.H., Schneideman, Dorgan, J.F., Brown, C., Barrett, M. et al. (1994) Physical N., Klimas, N. & Fletcher, M.A. (1994) Exercise and activity and risk of breast cancer in the Framingham psychoneuroimmunology. Medicine and Science in Heart Study. American Journal of Epidemiology 139, Sports and Exercise 26, 182–191. 622–669. Loucks, A.B. & Callister, R. (1993) Induction and pre- Dosemeci, M., Hayes, R.B., Vetter, R. et al. (1993) Occu- vention of low-T3 syndrome in exercising women. pational physical activity, socioeconomic status and American Journal of Physiology 264, R924–R930. risks of 15 cancer sites in Turkey. Cancer Causes and Loucks, A.B., Mortola, J.F., Girton, L. & Yen, S.C. (1989) Control 4, 313–321. Alterations in the hypothalamic–pituitary–ovarian Friedenreich, C.M. & Rohan, T.E. (1995) Physical and hypothalamic–pituitary–adrenal axes in athletic activity and risk of breast cancer. European Journal women. Journal of Clinical Endocrinology and Metabo- of Cancer Prevention 4, 145–151. lism 68, 402–411. Frisch, R.E., Wyshak, G., Albright, N.L. et al. (1985) Lubin, F., Ruder, A.M., Wax, Y. & Modan, B. (1985) Lower prevalence of breast cancer and cancers of the Overweight and changes in weight throughout adult 264 medical issues

life in breast cancer etiology. American Journal of Epi- T. Stephens (eds) Physical Activity, Fitness, and demiology 122, 579–588. Health, pp. 204–213. Human Kinetics Publishers, McTiernan, A., Stanford, J.L., Weiss, N.S., Daling, J.R. & Champaign, Illinois. Voigt, L.F. (1996) Occurrence of breast cancer in rela- Taioli, E., Barone, J. & Wynder, E.L. (1995) A case- tion to recreational exercise in women age 50–64. Epi- control study on breast cancer and body mass. demiology 7, 598–604. European Journal of Cancer 31A, 723–728. Mittendorf, R., Longnecker, M.P., Newcomb, P.A. et al. Thune, I., Brenn, T., Lund, E. & Gaard, M. (1997) Physi- (1995) Strenuous physical activity in young adult- cal activity and the risk of breast cancer. New England hood and risk of breast cancer (United States). Cancer Journal of Medicine 336, 1269–1275. Causes and Control 6, 347–353. Tretli, S. & Gaard, M. (1996) Lifestyle changes during Paffenbarger, R.S., Lee, I.M. & Wing, A.L. (1992) The adolescence and risk of breast cancer: an ecological influence of physical activity on the influence of site- study of the effect of World War II in Norway. Cancer specific cancers in college alumni. In M.M. Jacobs Causes and Control 7, 507–512. (ed.) Exercise, Calories, Fat, and Cancer, pp. 7–15. Vena, J.E., Graham, S. & Zielezny, M. (1987) Occupa- Plenum Press, New York. tional exercise and risk of cancer. American Journal of Pike, M.C., Spicer, D.V., Dahmoush, L. & Press, M.F. Clinical Nutrition 45, 18–27. (1993) Estrogens, progestogens, normal breast cell Vihko, V.J., Apter, D.L. & Pukkala, E.A. (1992) Risk of proliferation, and breast cancer risk. Epidemiologic breast cancer among female teachers of physical edu- Reviews 15, 17–35. cation and languages. Acta Oncologica 31, 201–204. Preston-Martin, S., Pike, M.C. & Ross, R.K. (1990) Warren, M.P. (1980) The effects of exercise on pubertal Increased cell division as a cause of human cancer. progression and reproductive function in girls. Cancer Research 50, 7415–7421. Journal of Clinical Endocrinology and Metabolism 51, Schapira, D.V., Kumar, N.B., Lyman, G.H. & Cox, C.E. 1150–1157. (1990) Abdominal obesity and breast cancer risk. White, E., Lee, C.Y. & Kristal, A.R. (1990) Evaluation of Annals of Internal Medicine 112, 182–186. the increase in breast cancer incidence in relation to Siiteri, P.K. (1987) Adipose tissue as a source of hor- mammography use. Journal of the National Cancer mones. American Journal of Clinical Nutrition 45, Institute 82, 1546–1552. 277–282. Woods, J.A. & Davis, J.M. (1994) Exercise, mono- Simpson, E.R. & Mendelson, C.R. (1987) Effect of aging cyte/macrophage function, and cancer. Medicine and and obesity on aromatase activity of human adipose Science in Sports and Exercise 26, 147–157. cells. American Journal of Clinical Nutrition 45, Zheng, W., Shu, X.O., McLaughlin, J.K., Chow, W., Gao, 290–295. Y.T. & Blott, W.J. (1993) Occupational physical activ- Stephens, T. & Casperson, C.J. (1994) The demography ity and the incidence of cancer of the breast, corpus of physical activity. In C. Bouchard, R.J. Shepard & uteri, and ovary in Shanghai. Cancer 71, 3620–3624. Chapter 18

Diabetes and Sport

BARBARA N. CAMPAIGNE

Introduction betes are diagnosed as either type I (IDDM) or type II (NIDDM). NIDDM is the most common Exercise is well known as an adjunct therapy in form and frequently is undiagnosed until the the management of diabetes. One of the earliest later stages of the disease. NIDDM is an inherited indications that exercise was effective in dimin- disorder revealed by environmental factors, par- ishing the sweetness of urine was made in 600 BC ticularly obesity. NIDDM is evident as hyperin- by the Indian physician Shushruta (1938). After sulinaemia and diminished insulin sensitivity. the discovery of insulin in the early 1920s, the IDDM has a strong hereditary component, which three cornerstones of diabetes care became may be triggered by an environmental factor insulin, diet and exercise. Exercise has been such as a viral infection. IDDM, previously shown to be beneficial in controlling blood known as juvenile diabetes, primarily occurs in glucose in non-insulin-dependent diabetes melli- children or young adults. At the onset of IDDM, tus (NIDDM) (Horton, 1991a) and gestational unusual weight loss may occur in conjunction diabetes mellitus (GDM) (Bung et al., 1991) for with excessive thirst, urination and tiredness. reasons that are discussed in the specific sections Another form of diabetes specific to women is below. Exercise can be safe and effective in main- GDM, which manifests itself during pregnancy. taining cardiovascular health in individuals with The origin of GDM may be multifactorial and is insulin-dependent diabetes mellitus (IDDM) probably related to ineffective glucose clearance. (Campaigne & Gunnarsson, 1988; Campaigne & The primary clinical manifestation of GDM is Lampman, 1994). This chapter covers exercise hyperinsulinaemia (Summary and Recommen- in women with diabetes, focusing on athletes. dations of the Second International Workshop- Issues that are specific to women throughout Conference on Gestational Diabetes Mellitus, the lifespan are discussed. Because very little 1991). The effects of exercise on each of these research has been conducted on women only, types of diabetes are discussed. Because NIDDM studies on men with diabetes have been occurs primarily in overweight individuals, included. Since athletes affected by diabetes are most athletes with diabetes will have IDDM. primarily those with IDDM, this is the focus of Therefore, managing the athlete or physically the chapter and not NIDDM. active individual with IDDM is covered in depth in the following section. Overview of diabetes Diabetes mellitus is a chronic illness that is recog- nized as two major diseases with several other minor or less prevalent types. Most cases of dia- 265 266 medical issues

quately stimulated by exercise. This, in con- Exercise and managing the athlete junction with an increase in hepatic glucose pro- with IDDM duction produced by exercise, may result in hyperglycaemia. Acute exercise 3 If insulin absorption is enhanced by insulin Acute exercise brings about an increase in being administered subcutaneously prior to glucose utilization; thus an increase in glucose exercise (overadministration of insulin), inhibi- production is necessary in order to maintain tion of glucose production may result. This, near-normal glucose levels. Depending on its along with the increased glucose utilization duration and intensity, exercise is characterized induced by exercise, may lead to hypoglycaemia. by individual endocrine and neural responses. Hormonal changes that affect glucose utiliza- The control of the availability and utilization of tion take place during the menstrual cycle, pos- metabolic fuel is influenced principally by a sibly making the response to exercise variable. balance of insulin, glucagon and the cate- Hormones play a role in insulin sensitivity and cholamines adrenaline and noradrenaline. Other thus glucose utilization; changes in insulin sensi- factors that may have a significant influence on tivity that occur during the menstrual cycle metabolic fuel during exercise in type I diabetes possibly influence circulating glucose levels. include the central nervous system (Kjaer et al., Because of the many considerations indicated, 1987), state of glucose control (Jenkins et al., 1986) careful glucose monitoring and appropriate and the overall metabolic profile (Wasserman & adjustments including diet and\or insulin are Vranic, 1985; Cooper et al., 1986; Katz et al., 1986). necessary to make exercise safe and prevent Diabetes may alter all or some of these factors hypoglycaemia or hyperglycaemia in women and thus the individual with IDDM may be with IDDM. The following points have been unable to respond properly to the increased shown to be helpful when considering insulin glucose usage brought about by exercise. treatment in relation to exercise. Figure 18.1 illustrates the importance of • Consider timing of insulin action in relation to insulin in influencing blood glucose levels in exercise (e.g. rapid acting vs. long acting). physically active individuals with type I dia- • Inject insulin away from exercising muscle. betes. Three possible consequences need to be • Decrease insulin dose, especially for those considered. receiving insulin subcutaneously (see Table 18.2). 1 If treatment with intravenous insulin infusion • Individualize insulin treatment. generates normal portal insulin levels, glucose • Consider dietary intake. production will equal glucose utilization and cir- Other possible ways to prevent exercise-induced culating glucose homeostasis will be maintained. hypoglycaemia, though less effective than alter- 2 If circulating insulin levels are low (insulin ing insulin treatment and dietary carbohydrate deficiency), glucose utilization may not be ade- intake, include the following.

Status of Hepatic glucose Muscle glucose Blood plasma insulin production utilization glucose Fig. 18.1 The influence of plasma Normal or slightly insulin on blood glucose levels of diminished individuals with type I diabetes. The size of arrow pointing up or down indicates a varying rate of Markedly diminished increase or decrease; horizontal arrow shows no change. (From Increased Campaigne & Lampman, 1994 with permission.) diabetes and sport 267

• Inject insulin in non-exercising muscle group. 1984). Wallberg-Henriksson et al. (1982, 1984) • Prevent intramuscular injection by avoiding found no change in blood glucose control, as perpendicular injection, injecting into the skin- determined by home-monitored blood glucose fold and using needles < 8 mm long for thigh levels, HbA1c or urinary glucose, in men after injection. 8–16 weeks of physical training. Zinman et al. (1984) studied adult men and women over 12 weeks of training compared with a non-diabetic Physical training · control group. Maximal oxygen uptake (VO2max) Physical training is defined as the effects of increased significantly and similarly in the two repeated bouts of exercise performed on a groups. In those with diabetes, exercise sessions regular basis over a period of weeks. The effects resulted in a significant decrease in blood of physical training in IDDM are well docu- glucose, while HbA1 was unchanged after the 12 mented (Horton, 1991a; Campaigne & weeks. There was no change in insulin dose or in Lampman, 1994; Ruderman & Devlin, 1995). the number of reported hypoglycaemic episodes Exercise has been shown to have beneficial during the study period. According to self- effects on insulin sensitivity, glucose transport, report, caloric intake increased on exercise days. blood lipids and lipoproteins, and skeletal In well-controlled patients on insulin-pump muscle enzymes in individuals with IDDM. treatment, Yki-Jarvinen et al. (1984) were unable Regular exercise can be beneficial when consci- to demonstrate any further improvement in entious screening and close monitoring of the blood glucose by exercise, beyond the improve- individual’s progress are applied. Table 18.1 lists ments noted at the start of pump treatment. the benefits of regular exercise for individuals with IDDM. Very little information is available Insulin sensitivity specifically on women; however, several of the studies cited in these findings included groups of It has been suggested that people with diabetes men and women. become more sensitive to insulin after physical training. Some studies cite no decrease in insulin need or a slight fall during physical training, Glucose control although Costill et al. (1979) noted a significant Most studies in adults with IDDM have not decrease in insulin dose during training and Bak shown improvements in haemoglobin (Hb)A1c et al. (1989) found a 12% decrease in insulin dose with training (Wallberg-Henriksson et al., 1982, after 6 weeks of physical training. 1984; Yki-Jarvinen et al., 1984; Zinman et al., Whole-body insulin sensitivity as assessed by the glucose clamp technique is accepted as a measure of skeletal muscle insulin sensitivity Table 18.1 Benefits of exercise on insulin-dependent (DeFronzo et al., 1979). Wallberg-Henriksson et diabetes mellitus al. (1982), Yki-Jarvinen et al. (1984) and Landt et Improved insulin sensitivity al. (1985) have all documented significant Improved blood lipids and lipoproteins increases in insulin sensitivity in adults and ado- Increased caloric expenditure, resulting in reduction or lescents with IDDM. These studies reported maintenance of body weight, reduction in body fat about a 20% increase in insulin sensitivity with and preservation of lean body mass Improved physical fitness physical training. Because well-trained, non- Improved flexibility and strength diabetic individuals have been found to have a Decreased blood pressure in hypertension higher insulin sensitivity compared with their Reduced risk of cardiovascular disease sedentary counterparts, the increase in insulin Improved psychological well-being, including sensitivity brought about by physical training enhanced quality of life, improved self-esteem appears to be a normal physiological adaptation 268 medical issues

that is due, in part, to an increase in insulin rently available regarding the long-term effects action. of exercise in patients with IDDM. Moy et al. The precise mechanism behind increases in (1993) followed 548 patients with IDDM over 7 insulin sensitivity with physical training is cur- years. Baseline physical activity was inversely rently unknown. The nature of this change in related to risk of mortality during the 7-year insulin sensitivity is probably related to glucose period. Males expending < 4200 kJ·week–1 (1000 transport, which has been indicated by recent kcal·week–1) had a threefold greater risk of death findings. Clarification of the mechanism respon- than those expending > 8400 kJ·week–1 (2000 sible for increased insulin sensitivity with exer- kcal·week–1). In females, the findings were cise in diabetes is an important area of research. similar but not as apparent. Data from the Joslin Clinic on 48 patients at 25-year follow-up indi- cate that men who developed complications Blood lipids associated with diabetes reported a lower fre- Most studies have been done in men or in quency of physical activity throughout life com- gender-diverse groups. In a cross-sectional pared with those who had no complications study, Gunnarson et al. (1987) examined the rela- (Chazan et al., 1970). A lower incidence of tionship between serum lipoprotein levels, gly- macrovascular disease has been observed in caemic control and physical fitness in female individuals with IDDM who engaged in team type I diabetic patients. Subjects were divided sports in high school and college compared with into three groups based on glycaemic control: their sedentary counterparts (LaPorte et al., good (HbA1, 9.5%), acceptable (HbA1, 9.6–10.9%) 1986). These investigators also reported a lower and poor (HbA1, 11.0%). Those in good control incidence of mortality after 25 years in the physi- were found to have the lowest triglyceride con- cally active group. These results agree with find- centrations, mainly attributable to lower levels of ings in non-diabetic individuals (Paffenbarger et very low-density lipoprotein (VLDL) triglyc- al., 1978). These findings further support evi- eride. The patients in good control also had dence that even moderate levels of activity per- higher concentrations of high-density lipopro- formed regularly are beneficial in improving tein (HDL) cholesterol and HDL-2 cholesterol, longevity in individuals with diabetes. while HDL-3 cholesterol was similar in all The above findings show that in individuals groups. When patients were grouped by a who begin an exercise programme in good · measure of aerobic capacity (VO2max), triglyc- glucose control, regular exercise may have little erides were also lower in those with higher or no effect on long-term blood glucose control. aerobic capacity, consistent with a lower low- There are known atherogenic effects of insulin density lipoprotein (LDL) fraction. HDL-2 cho- and some individuals can decrease their insulin lesterol and the HDL-2 : HDL-3 ratio were found dose after beginning a regular exercise pro- to be significantly elevated in subjects with high gramme. Exercise does improve insulin sensitiv- aerobic capacity. Adding HbA to the multiple ity and may be beneficial in improving blood · 1 regression analysis with VO2max and the lipid and lipids in patients with IDDM. These findings lipoprotein parameters did not further explain indicate that regular physical activity may the variability of the lipid fraction under study. decrease the overall risk of the development of These authors concluded that both good gly- coronary heart disease in those with diabetes. caemic control and high aerobic capacity may be Though clinical correlates of glucose control may important for favourable lipid status in patients not be improved by regular exercise, research on with type I diabetes. These findings support the subcellular increases in glucose transport and use of physical training for women with type I glucose metabolism may be beneficial. In addi- diabetes. tion, there is some epidemiological evidence to Favourable but limited information is cur- suggest that individuals with IDDM who exer- diabetes and sport 269

cise regularly throughout life may develop fewer their blood glucose levels on a regular basis complications and live longer than those who (several times each day), including before and have not exercised. after exercise. A readily absorbable form of car- bohydrate should be available at all times (some- thing small, convenient and concentrated), such Dietary intake as glucose tablets, hard candy, fruit juice or some Diabetes can be effectively controlled by diet, sports nutrition bars. In order to achieve stable exercise and insulin, with consistency of man- glucose levels a balance between insulin dose agement and lifestyle being key to good control. and dietary intake is essential. As with non- Dietary intake is an essential component of any diabetic athletes, the focus on extra carbohydrate athlete’s training programme; in the case of the consumed before activity should be shifted to athlete with diabetes it may be a life-saving extra carbohydrate during activity. factor. The athlete should be monitored carefully Coaches, professional staff and individuals to maintain ideal body weight, blood glucose training with athletes who have diabetes need to levels and normal growth (Peterson & Peterson, be aware of the signs of hypoglycaemia, such as 1988). Regular dietary histories may be required confusion, weakness, tiredness and unusual irri- if problems arise in maintaining normal weight, tability. If these symptoms are not recognized growth and glucose levels. Clinical screening on and treated, hypoglycaemia could potentially a regular basis (every 3–6 months) should lead to unconsciousness or convulsions. In most include a blood lipid profile, electrolyte values, cases, activities done alone (e.g. scuba diving,

HbAlc (a measure of long-term glucose control) sky diving and independent mountain climbing and dietary factors. The athlete should receive or hiking) should be avoided. careful instruction by a trained nutritionist on An area of extreme importance to the athlete the use of dietary exchange lists and on maintain- with diabetes is the long-lasting effect of pro- ing a dietary history. Nutritional counselling longed exercise. Insulin adjustments are neces- should be a part of the initial screening and man- sary and specific dietary changes need to be agement of individuals with diabetes. In the case made. Low blood glucose reactions often occur of those beginning an exercise programme, it nocturnally with little warning, are inconsistent may be necessary to design meal plans for exer- and are difficult to prevent or correct. Several cise days and non-exercise days as a part of the new products exist that are specifically designed training programme. In planning the diet of the to prevent hypoglycaemia over a prolonged time athlete with diabetes, the type of insulin needs to period or during the night (e.g. Z-bar, Nite-bite). be considered as does the means of insulin These ‘bars’ are a slow-release carbohydrate administration and the type, intensity and dura- source that are designed to have a ‘timed-release’ tion of exercise. Regular meals and snacks should effect and prevent hypoglycaemia hours after be emphasized, as should the importance of they are consumed. Athletes may need to keep emergency feeds and self-care. In general, the careful records and report any adverse blood well-balanced diet and sound nutrition advo- glucose reactions to the healthcare team so that a cated for the individual with diabetes is recom- specific programme can be designed to alter the mended for everyone. timing and amount of exercise, diet and insulin During intense exercise (heavy training or to achieve optimal blood glucose levels. competition) it may be necessary to replace glucose through supplemental carbohydrate Timing and mode of insulin treatment feeding. Athletes performing sustained exercise (e.g. tennis players, swimmers and distance The majority of individuals with IDDM are runners) need to receive snacks during training. treated with multiple subcutaneous insulin injec- All individuals with diabetes need to monitor tions throughout the day. Most insulin treatment 270 medical issues

plans consist of a mixed split dose of insulin. This rapid-acting insulin. It is best to develop an exer- includes a combination of short-acting and cise routine so that caloric intake and insulin longer-acting (sustained-release) insulin admin- dose can be adjusted to optimize blood glucose istered in the morning and afternoon in order to control. Table 18.2 lists effective ways to prevent optimize blood glucose control. Carbohydrate hypoglycaemia in relation to exercise in IDDM. and total caloric intake need to be matched with Table 18.3 provides information on the action of the amount and timing of insulin given. There various insulin preparations to be considered in are several times of day that are optimal for exer- relation to exercise timing. It is important to note cise in relation to glucose control. General recom- that the optimal level of blood glucose before mendations include not exercising at the time of beginning exercise or an athletic event should be peak insulin action. If an individual is required to individualized based on the length and intensity exercise at a specific time, insulin dose can be of the activity and the individual’s metabolic reduced to prevent its peak effect during exer- profile in relation to exercise. A general guideline cise. This strategy would include decreasing is that blood glucose should be > 120 but < 220 long-acting insulin in order to prevent hypogly- mg·dl–1 immediately prior to exercise. caemia during exercise occurring in the late after- noon. Exercise should be recommended when Specific sports the effects of insulin are lowest and blood glucose is rising. When exercise is unplanned, a Because of their unique requirements, which quickly absorbed carbohydrate snack can be con- may affect the individual with diabetes, certain sumed before exercise to prevent hypogly- sports have specific guidelines and recommen- caemia. Exercising before insulin administration dations (e.g. scuba diving, mountain climbing). and breakfast may decrease the need for short- or The American Diabetes Association provides

Table 18.2 General guidelines for preventing hypoglycaemia in relation to exercise

Blood glucose monitoring Monitor blood glucose immediately before, during (approximately every 30min) and after exercise Delay exercise if blood glucose is ≥ 250mg·dl-1 or ketosis is present, or if blood glucose level is ≥ 300mg·dl-1 whether or not ketosis is present Consume carbohydrates if blood glucose is £ 100mg·dl-1 Learn individual glucose response to different types of exercise Avoid exercising late at night

Diet When exercise is unplanned extra carbohydrate should be consumed (e.g. 20–30g for every 30min of exercise) During exercise consume easily absorbable carbohydrate when necessary After exercise a carbohydrate snack may be required

Insulin Indications for reductions in insulin dose may occur before and after exercise, depending on the intensity and duration of exercise and the individual’s experience Suggestions for altering insulin dose: (a) Intermediate-acting insulin: decrease by 30–35% on the day of exercise (b) Intermediate- and short-acting insulin: omit dose of short-acting insulin that precedes exercise (c) Multiple doses of short-acting insulin: reduce the dose prior to exercise by 30–35% and supplement carbohydrates (d) Continuous subcutaneous infusion: eliminate meal-time bolus or increment that precedes or immediately follows exercise Do not exercise at the time of peak insulin action diabetes and sport 271

Table 18.3 Activity characteristics of insulin. (From Table 18.4 Benefits of exercise on non-insulin- Roitman, 1998 with permission.) dependent diabetes mellitus

Onset Peak Duration Reduced blood glucose and glycosylated haemoglobin (hours) (hours) (hours) levels Improved glucose tolerance Rapid-acting: 0.5–1 2–4 6–8 Improved insulin response to oral glucose stimulus regular Improved peripheral and hepatic insulin sensitivity Improved blood lipid and lipoprotein levels Intermediate-acting: 1–3 6–12 18–26 Decreased blood pressure in hypertension lente or NPH Reduced risk of cardiovascular disease Long-acting: 4–8 12–18 24–28 Improved physical fitness ultralente Increased caloric expenditure, resulting in reduction or or human maintenance of body weight, reduction in body fat and preservation of lean body mass Onset, peak and duration of action vary considerably Improved flexibility and strength and may depend upon the individual patient, injection Improved psychological well-being, including site, vascularity and temperature. enhanced quality of life, increased self-esteem guidelines on these sports in relation to diabetes management (Ruderman & Devlin, 1995). A few complications that may be particularly haz- of the key points that need attention with regard ardous (i.e. retinopathy, peripheral and auto- to these activities are listed below. nomic neuropathy). scuba diving Exercise, NIDDM and the recreational athlete • The diabetic diver should perform frequent self-monitoring of blood glucose, particularly The benefits of regular exercise for individuals before exercise. with NIDDM have been clearly documented • Before exercise, determine the expected physi- (Horton, 1991b; Campaigne & Lampman, 1994) cal exertion. (Table 18.4). Regular physical activity as part of • Fast-acting glucose gel should be carried by the treatment plan for NIDDM is a current the diving partner. recommendation of the American Diabetes Asso- • Divers affected by hypoglycaemia should ciation (1990). Regular exercise results in leave the water. improved blood glucose control on a daily basis

• Diving is a high-risk activity for those with and a decrease in HbA1c levels as a result of cardiovascular disease or cardiac autonomic improved long-term blood glucose control neuropathy. (Schneider et al., 1984). The mechanism of improved glucose control during regular exer- mountain climbing cise in NIDDM has been studied. Individuals with NIDDM have improved insulin sensitivity • The individual with diabetes should hike or with physical training (Bjorntorp et al., 1972, climb with a partner. 1983). Regular exercise lowers the risk of cardio- • Blood glucose levels should be self-monitored vascular disease by reducing blood pressure in frequently. individuals with hypertension and improving • Insulin should be stored so that it does not blood lipid profiles (Huttunen et al., 1979; freeze and is not exposed to direct sunlight and Haskell, 1986). Specific lipid and lipoprotein extremes in temperature. changes include decreased triglycerides and • The diabetic climber should be screened for VLDLs and increased HDLs. Decreases in both 272 medical issues

systolic and diastolic blood pressure have been Table 18.5 Recommended screening procedures for shown to occur in mild to moderate hyperten- diabetes sion (Boyer & Kasch, 1970; Choquette & Fergu- History and physical examination (for newly diagnosed son, 1973) and may be associated with the effects patients or without current records) of lowering insulin levels on renal sodium reten- Review all systems tion (Horton, l991b). An important effect of Identification of medical conditions (e.g. asthma, regular exercise for NIDDM can be weight reduc- arthritis) tion in conjunction with dietary intervention, Diabetes evaluation with the combination resulting in the preserva- Glycosylated haemoglobin tion of lean tissue (Pavlou et al., 1985; Hill et al., Ophthalmoscopic examination (retinopathy) 1987; Lampman et al., 1987; Lucas et al., 1987). Neurological examination (neuropathy) Data comparing rural and urban cultures Nephrological evaluation (micro-albumin or protein in urine) provide evidence of a lower prevalence of Nutritional status evaluation NIDDM among active rural populations (underweight/overweight, eating disorders) (Zimmet et al., 1981, 1990). Some data from cross- sectional studies show that glucose tolerance and Cardiovascular evaluation diabetes occur more frequently in sedentary Blood pressure with orthostatic measurements Peripheral pulses individuals compared with individuals who are Bruits more active (King et al., 1984; Taylor et al., 1984; 12-lead electrocardiogram Dowse et al., 1991), independent of body mass Serum lipid profile (total cholesterol, triglycerides, and age. Physical activity has been indicated as a HDL and LDL cholesterol) significant approach to preventing NIDDM in Graded exercise test (those > 30 years of age with IDDM, those > 35 years of age with NIDDM, those men (Helmrich et al., 1991) and women (Manson with suspected history of or documented et al., 1991). In a prospective cohort study of cardiovascular disease, those with multiple 87 253 women aged 34–59 years, Manson et al. cardiovascular disease risk factors present, or those (1991) found that women who exercised vigor- with diabetes of > 10 years) ously at least once per week had a significantly lower risk of NIDDM compared with women HDL, high-density lipoprotein; IDDM, insulin- dependent diabetes mellitus; LDL, low-density who did not exercise weekly. Of importance is lipoprotein; NIDDM, non-insulin-dependent diabetes that the beneficial effect of exercise was not mod- mellitus. ified by a family history of diabetes. Statistical adjustment for age, family history of diabetes, body mass index and other variables did not therefore the feet should be examined regularly alter the beneficial effects of exercise on diabetes by the individual and the physician. Helpful tips risk. Table 18.5 provides guidelines for screening for those who are physically active include: (i) the individual with IDDM or NIDDM prior wear proper fitting, well-cushioned shoes (e.g. to designing and beginning an exercise gel or air soles); (ii) have clean dry socks avail- programme. able after activity; (iii) check for blisters regu- larly; and (iv) wear special water footwear when walking on rough surfaces near the water (pool Foot care or ocean). Of particular importance for anyone with dia- betes is the need to care for the feet. Individuals Complications of diabetes who have developed peripheral neuropathy need special attention in this area, as insensitivity Detailed information on determining the appro- in the feet may cause a callus or blister to go priate types and levels of physical activity for unnoticed. Infections can develop quickly and individuals with complications of diabetes is diabetes and sport 273

available (Campaigne & Lampman, 1994; Ruder- et al., 1990). These types of exercise result in less man & Devlin, 1995). After an initial screening is chance of fetal distress than activities utilizing completed, the existence of complications can be the lower body, while still achieving a cardiovas- established and recommendations for exercise or cular workout. Pregnant women with IDDM physical activity can be made. need to adhere to strict glucose control in order to Absolute contraindications for strenuous exer- ensure the optimal health of the fetus. The cise include: danger of exercise for the woman with diabetes is • poor glycaemic control; a possible deleterious effect on blood glucose • proliferative retinopathy; control. Therefore, very careful counselling and • microangiopathy; close monitoring of glucose control and insulin • neuropathy; dose need to be emphasized for the pregnant • nephropathy; woman with IDDM. Since the primary goal is to • evidence of cardiovascular disease. achieve near-normal blood glucose levels (Jovanovic et al., 1981), beginning a vigorous exer- cise programme before or during gestation is not Exercise and diabetic pregnancy recommended for women with diabetes. Very little research has been done on the effects of exercise during pregnancy in women with Exercise and gestational diabetes IDDM. Artal et al. (1985) found low-level exercise to be safe for women with IDDM and not to affect There are three significant factors that influence plasma glucose or glucagon concentrations. the development of GDM: genetic predisposi- Others have found no improvement in postpran- tion, decrease in insulin action and impaired dial glucose levels following the evening meal in pancreatic b-cell function (Horton, 1991b). pregnant women with IDDM (Hollingsworth & During pregnancy the development of insulin Moore, 1987). During diabetic pregnancy, a blood resistance depends on a host of factors, including glucose level greater than four standard devia- the hormonal environment, hereditary predispo- tions from the mean increases the risk of sponta- sition, age, excess body weight and the level of neous abortion, with the risk rising markedly as physical activity (Horton, 1991b). It is docu- hyperglycaemia increases (Mills et al., 1988). If mented that glucose tolerance deteriorates complications of diabetes are present (retinopa- during the course of gestation (Ruderman & thy, neuropathy, etc.) precautions should be Devlin, 1995). Because of the effects of exercise on taken, including the restriction of certain types of insulin secretion, insulin sensitivity and glucose exercise (Graham & Lasko-McCarthey, 1990). metabolism, it seems reasonable to infer that Any conditions that require bed rest during regular exercise may be effective in preventing or pregnancy would be clear contraindications treating GDM. However, very few data are avail- to exercise. able that illustrate this possibility (Jovanovic- Certain types of exercise have been shown to Peterson et al., 1989). Improvements in glucose be safe during normal pregnancy. The American tolerance with exercise training in women with College of Obstetricians and Gynecologists GDM have been demonstrated (Jovanovic- (1994) has established guidelines for exercise Peterson & Peterson, 1990). These authors found during pregnancy. The safest form of exercise that the hyperglycaemia occurring with GDM during pregnancy should not bring about: (i) can be managed by arm ergometry. In the sixth uterine contraction; (ii) low birth weight infants; week of training, women achieved near-normal or (iii) fetal distress (Ruderman & Devlin, 1995). glucose levels, HbAlc and response to glucose Exercises that primarily use the upper body and challenge. In contrast, women who had been avoid mechanical stress to the trunk have been managed by diet alone showed no significant shown to be the safest during pregnancy (Durak improvement in glucose control. These results 274 medical issues

indicate that insulin administration may be ized, the growth spurt is initiated and menarche avoided in some women with GDM by the safe follows (Drash et al., 1980). In adolescents with application of regular exercise (Jovanovic- diabetes, if blood glucose is normalized rapidly Peterson & Peterson, 1991). The use of exercise in there is a risk of diabetic retinopathy in some pre- the healthcare management of GDM has great disposed individuals (Drash et al., 1980). Thus potential. Further study needs to be done in this during adolescence blood glucose levels need to area. be carefully monitored in order to ensure optimal growth and normal development as well as to prevent the long-term complications of diabetes. Special considerations Menarche has been found to occur later in ath- Women have specific health needs that change letes (non-diabetic) compared with non-athletes during the lifespan. These need to be considered (Marcus et al., 1985; Ding et al., 1988; Loucks et al., when working with the athlete with diabetes. 1989). However, there is no evidence document- Women with diabetes have special health needs ing delayed menarche in athletes. Certain types and physiological conditions that predispose of athletes appear to have the highest occurrence them to certain health problems, such as delayed of amenorrhoea, such as long-distance runners pubertal development, osteoporosis, coronary and gymnasts (Brownell et al., 1992). Exercise heart disease and obesity. The sections below combined with other conditions, such as a describe specific areas of concern that need to be calorie-deficient diet and low body weight, considered in women with diabetes. increases the risk of amenorrhoea, particularly among competitive athletes (Tanner & Davies, 1985; Loucks et al., 1992). In light of the previ- Adolescence ously mentioned concerns that chronic hypergly- The adolescent girl with diabetes has certain caemia is associated with delayed menarche, physiological and psychological considerations adolescent girls with diabetes who exercise regu- specific to her disease. Fluctuations in blood larly need careful dietary monitoring in order to glucose are frequently seen in relation to emo- prevent or reverse exercise-associated amenor- tional swings, hormonal changes and specific rhoea and maintain near-normal blood glucose dietary patterns that occur during the adolescent levels (Jovanovic-Peterson, 1995). All girls, dia- years. It becomes increasingly necessary to con- betic and non-diabetic, who exercise regularly sider these factors when making participation need careful evaluation and regular monitoring in sports safe for the diabetic adolescent. In for the occurrence of amenorrhoea. If amenor- most circumstances, undertaking regular physi- rhoea is present, the athlete should be evaluated cal activity and sports can be recommended for for other associated factors such as possible children and adolescents with diabetes, as it may osteoporosis and eating disorders (Yeager et al., be effective in preventing complications later in 1993). Disordered eating behaviour among life, promote optimal bone density, increase young women with IDDM is common (Rydall et socialization and improve self-esteem. Before al., 1997) and is associated with non-compliance participation in regular exercise, careful clinical with the diabetes treatment plan and poor blood evaluation should be carried out by the diabetes glucose control. Anyone exhibiting the signs of management team to ensure optimal health and eating disorders should be evaluated and safety of the individual. managed appropriately in a timely fashion (see Chapter 25). Amenorrhoea Menopause Long-term hyperglycaemia is associated with short stature and delayed puberty ( Jovanovic- The onset of the menopause brings about several Peterson, 1995). When blood glucose is normal- health implications, including an increased risk diabetes and sport 275

of developing osteoporosis and cardiovascular individuals with these problems, brought on by disease. Both these health risks are associated muscle disuse and the resulting muscle atrophy. with decreasing oestrogen levels at menopause. Good glucose control decreases the prevalence The postmenopausal loss of endogenous oestro- of these problems (Jovanovic-Peterson, 1995). gen influences the woman with diabetes Glucose control, calcium intake, oestrogen status in several ways. Oestrogen alters glucose and physical activity should be assessed, as each metabolism by affecting gluconeogenesis and contributes to the promotion of optimal bone glycogenolysis; oestrogen also has a beneficial health and prevention of osteoporosis in women influence on lipid metabolism (van der Mooren with diabetes. Regular exercise should be recom- et al., 1994). Menopause changes the diabetes mended for adolescent girls and may be particu- management plan in women with NIDDM larly beneficial for those with an increased risk of because of the associated decrease in metabolism osteoporosis later in life. and associated weight gain. Caloric intake needs to be reduced by 20% in order to prevent weight Cardiovascular disease gain; thus the insulin dose needs to be decreased equally (Reilly et al., 1993). If exercise is added to Women with diabetes have a markedly increased the management programme, caloric intake may risk of developing cardiovascular disease com- not need marked alteration, insulin sensitivity pared with non-diabetic women (Solomon, may be improved along with the prevention of 1996). This risk has been documented to be as weight gain and menopause-associated hyper- much as five to seven times higher in diabetic glycaemia may be diminished. women compared with non-diabetic women (Manson et al., 1991). In fact, the risk of develop- ing cardiovascular disease in diabetic women is Osteoporosis equal to that in non-diabetic men. Insulin is an Osteoporosis and risk of fracture are major indirect risk factor for cardiovascular disease, health problems, especially for postmenopausal possibly because of its secondary effects on women. The relationship between regular physiological parameters such as blood pressure weight-bearing exercise and bone density has and lipid metabolism. The protective effects of been documented (Smith & Gilligan, 1991; oestrogen are lost after the menopause, unless Marcus et al., 1992; Suominen, 1993; Alekel et al., hormone replacement therapy is used (Freed- 1995; Drinkwater et al., 1995). Regular exercise man, 1996). As in women without diabetes, increases peak bone mass in adolescents, slows the risk of cardiovascular disease increases at the decline in bone mass in middle age and may menopause possibly because of the loss of the increase bone density in women with osteoporo- protective effects of oestrogen. Exercise is impor- sis (Marcus et al., 1992). A greater muscle mass tant in the prevention of cardiovascular disease appears to enhance bone mass by imposing a and in the management of the risk factors for car- greater mechanical stress on bone (Sandler, 1988; diovascular disease both before and after the Marcus et al., 1992). Active individuals are menopause (Blair, 1996). Active, physically fit stronger and have a greater muscle mass than women without diabetes have been shown to their inactive counterparts, which reduces the receive comparable benefits from regular physi- risk of falls in the former (Pocock et al., 1989). cal activity as men (Blair, 1996). In addition, indi- When counselling individuals with diabetes it viduals with diabetes appear to reap similar should be emphasized that women with poor benefits from physical activity as those without glycaemic control are at increased risk of osteo- diabetes (Berlin & Colditz, 1990; Ford & DeSte- porosis (Jovanovic-Peterson, 1995). Bone dem- fano, 1991). It has been noted that women with ineralization and fractures are complications of diabetes who engage in regular vigorous physi- diabetes, as are osteoarthritis and Charcot’s cal activity have reduced rates of coronary heart joints. In addition, there is a higher risk of falls in disease compared with those who are not as 276 medical issues

physically active (Solomon, 1996). As indicated bone mineral density in premenopausal women. in previous sections, regular exercise can Medicine and Science in Sports and Exercise 27, 1477–1485. decrease the risk of cardiovascular disease via American College of Obstetricians and Gynecologists several beneficial effects, such as decreasing (1994) Exercise During Pregnancy and the Postpartum blood pressure in those with elevated blood pres- Period. ACOG, Washington, DC. sure, increasing insulin sensitivity, decreasing American Diabetes Association (1990) Diabetes melli- insulin need, increasing the HDL : total choles- tus and exercise. Diabetes Care 13, 804–805. Artal, R., Wiswell, R. & Romem, Y. (1985) Hormonal terol ratio and decreasing LDL and triglyceride responses to exercise in diabetic and nondiabetic levels, as well as improving cardiovascular pregnant patients. Diabetes 34 (Suppl. 2), 78–80. fitness. It should be noted that women are Bak, J.F., Jacobsen, U.K., Jorgensen, F.S. & Pedersen, O. likely to have non-specific electrocardiographic (1989) Insulin receptor function and glycogen syn- changes in response to exercise; thus alternative thase activity in skeletal muscle biopsies from patients with insulin dependent diabetes mellitus: methods, such as radionuclide stress testing, effects of physical training. Journal of Clinical may be required for those considered at risk of Endocrinology and Metabolism 69, 158–164. cardiovascular disease. Berlin, J.A. & Colditz, G.A. (1990) A meta-analysis of physical activity in the prevention of coronary heart disease. American Journal of Epidemiology 132, 612–628. Conclusion and recommendations Bjorntorp, P., Fahlen, M., Grimby, G. et al. (1972) Carbo- for future research hydrate and lipid metabolism in middle-aged physi- cally well-trained men. Metabolism 21, 1037–1044. Regular physical activity can be an important Bjorntorp, P., de Jounge, D., Sjostrom, L. & Sullivan, L. part of the management plan for the woman with (1983) The effect of physical training on insulin pro- diabetes and particularly for those with NIDDM. duction in obesity. Metabolism 19, 631–637. Blair, S.N. (1996) Physical inactivity and cardiovascular Girls and women with IDDM can exercise and disease risk in women. Medicine and Science in Sports participate in sports with careful management and Exercise 28, 9–10. specific to their needs. Regular physical activity Boyer, J. & Kasch, F. (1970) Exercise therapy in hyper- reduces the risk of many diseases to which tensive men. Journal of the American Medical Associa- women with diabetes are predisposed, including tion 211(10), 1668–1671. Brownell, K.D., Rodin, J. & Wilmore, J.H. (1992) Eating, hypertension, coronary heart disease, obesity Body Weight and Performance in Athletes. Lea and and osteoporosis. The woman with diabetes Febiger, Philadelphia. needs comprehensive healthcare management, Bung, P., Atral, R., Khodiguian, N. & Kjos, S. (1991) taking into account diet, insulin dose, hormone Exercise in gestational diabetes: an optional thera- replacement therapy and exercise, in order to peutic approach? Diabetes 40 (Suppl. 2), 182–185. Campaigne, B.N. & Gunnarsson, R. (1988) The effects ensure optimal blood glucose and lipid levels, to of physical training in people with insulin- assist in weight management and to prevent dependent diabetes. Diabetic Medicine 5, 429–433. accelerated bone loss. Because very little research Campaigne, B.N. & Lampman, R.L. (1994) Exercise in has been undertaken on women, areas for future the Clinical Management of Diabetes Mellitus. Human research include: (i) the effects of exercise on the Kinetics Publishers, Champaign, Illinois. Chazan, B.I., Balodimos, M.C., Ryan, J.R. & Marble, A. risk of osteoporosis in women with IDDM; (ii) (1970) Twenty-five to forty-five years of diabetes exercise, glucose control and menarche in girls with and without vascular complications. Diabetolo- with diabetes; (iii) evaluation of strength training gia 6, 565–569. in women with diabetes; and (iv) further investi- Choquette, G. & Ferguson, R. (1973) Blood pressure gations on exercise and diabetic pregnancy. reduction in borderline hypertensives following physical training. Canadian Medical Association Journal 108, 699–703. References Cooper, D.M., Wasserman, D.H., Vranic, M. & Wasser- man, K. (1986) Glucose turnover in response to exer- Alekel, L., Clasey, J.L., Fehling, P.C. et al. (1995) Contri- cise during high- and low-flow breathing in humans. butions of exercise, body composition, and age to American Journal of Physiology 14, E209–E214. diabetes and sport 277

Costill, D.L., Cleary, P., Find, W., Foster, C., Ivy, J.L. & walking exercise in pregnant insulin-dependent Witzmann, F. (1979) Training adaptations in skeletal (type I) diabetic women: reduction of plasma lipid muscles of juvenile diabetics. Diabetes 28, 818–822. levels but absence of a significant effect on glycemic DeFronzo, A., Tobin, J.D. & Andres, R. (1979) Glucose control. American Journal of Obstetrics and Gynecology clamp technique: a method for quantifying insulin 157, 1359–1363. secretion and resistance. American Journal of Physiol- Horton, E.S. (1991a) Exercise. In H.E. Leovitz (ed.) ogy 237, E214–E223. Therapy for Diabetes Mellitus and Related Disorders, pp. Ding, J.H., Sheckter, C.B., Drinkwater, B.L. et al. (1988) 103–111. American Diabetes Association, Alexandria, High cortisol levels in exercise-associated amenor- Virginia. rhea. Annals of Internal Medicine 108, 530–534. Horton, E.S. (1991b) Exercise in the treatment of Dowse, G.K., Zimmet, P.Z., Gareeboo, H. et al. (1991) NIDDM: applications for GDM? Diabetes 40 (Suppl. Abdominal obesity and physical inactivity as risk 2), 175–178. factors for NIDDM and impaired glucose tolerance Huttunen, J.K., Lansimies, E., Voutilainen, E. et al. in Indians, Creole, and Chinese Mauritians. Diabetes (1979) Effect of moderate physical exercise on serum Care 14, 271–282. lipoproteins. Circulation 60, 1220–1229. Drash, A.L., Daneman, D. & Travis, L. (1980) Progres- Jenkins, A.B., Furler, S.M., Chisholm, D.J. & Kraegen, sive retinopathy with improved metabolic control in E.W. (1986) Regulation of hepatic glucose output diabetic dwarfism (Mauriac’s syndrome). Diabetes 29 during exercise by circulating glucose and insulin in (Suppl. 2), 1A. humans. American Journal of Physiology 250, Drinkwater, B.D., Grimston, S.K., Raab-Cullen, D.M. & R411–R417. Snow-Harter, C.M. (1995) Osteoporosis and exercise. Jovanovic, L., Druzin, M. & Peterson, C.M. (1981) The Medicine and Science in Sports and Exercise 27, i–vii. effect of euglycemia on the outcome of pregnancy in Durak, E.P., Jovanovic-Peterson, L. & Peterson, C.M. insulin-dependent diabetics as compared to normal (1990) Comparative evaluation of uterine response controls. American Journal of Medicine 71, 92–97. to exercise on five aerobic machines. American Journal Jovanovic-Peterson, L. (1995) Women and exercise: In of Obstetrics and Gynecology 162, 754–756. N. Ruderman & J.T. Devlin (eds) The Health Profes- Ford, E.S. & DeStafano, F. (1991) Risk factors for mortal- sionals Guide to Diabetes and Exercise, p. 211. American ity from all causes and from coronary heart disease Diabetes Association, Alexandria, Virginia. among persons with diabetes. Findings from the Jovanovic-Peterson, L. & Peterson, C.M. (1990) Dietary National Health and Nutrition Examination Survey I manipulation as a primary treatment strategy for Epidemiologic Follow-up Study. American Journal of pregnancies complicated by diabetes. Journal of the Epidemiology 133, 1220–1230. American College of Nutrition 9, 320–325. Freedman, M. (1996) Postmenopausal hormone Jovanovic-Peterson, L. & Peterson, C.M. (1991) Is exer- replacement therapy and cardiovascular disease cise safe or useful for gestational diabetic women? risk. Medicine and Science in Sports and Exercise 28, Diabetes 40 (Suppl. 2), 179–181. 17–18. Jovanovic-Peterson, L., Durak, E.P. & Peterson, C.M. Graham, C. & Lasko-McCarthey, P. (1990) Exercise (1989) Randomized trial of diet vs. diet plus cardio- options for persons with diabetic complications. Dia- vascular conditioning on glucose levels in gesta- betes Educator 16, 212–220. tional diabetes. American Journal of Obstetrics and Gunnarsson, R., Wallberg-Henriksson, H., Rossner, S. Gynecology 161, 415–419. & Wahren, J. (1987) Serum lipid and lipoprotein Katz, A., Broberg, S., Sahlin, K. & Wahren, J. (1986) Leg levels in female Type I diabetics: relationships to glucose uptake during maximal dynamic exercise in aerobic capacity and glycaemic control. Diabetes and humans. American Journal of Physiology 251, E65–E70. Metabolism 13, 417–421. King, H., Zimmet, P., Raper, L.R. & Balkau, B. (1984) Haskell, W.L. (1986) The influence of exercise training Risk factors for diabetes in three Pacific populations. on plasma lipids and lipoproteins in health and American Journal of Epidemiology 119, 396–409. disease. Acta Medica Scandinavica Suppl. 711, 25–37. Kjaer, M., Secher, N.H., Bach, F.W. & Galbo, H. (1987) Helmrich, S.P., Raglund, D.R., Leung, R.W. & Paffen- Role of motor center activity for hormonal changes barger, R.S. (1991) Physical activity and reduced and substrate mobilization in humans. American occurrence of non-insulin dependent diabetes melli- Journal of Physiology 253, R687–R695. tus. New England Journal of Medicine 325, 147–152. Lampman, R.M., Schteingart, D.E., Santinga, J.T. et al. Hill, J.O., Sparling, P.B., Shields, T.W. & Heller, P.A. (1987) The influence of physical training on glucose (1987) Effects of exercise and food restriction on body tolerance, insulin sensitivity, and lipid and lipopro- composition and metabolic rate in obese women. tein concentrations in middle aged hypertriglyceri- American Journal of Clinical Nutrition 46, 622–630. demic and carbohydrate intolerant men. Diabetologia Hollingsworth, D.R. & Moore, T.R. (1987) Postprandial 30, 380–385. 278 medical issues

Landt, K.W., Campaigne, B.N., James, F.W. & Sperling, strength, physical fitness and weight but not age M.A. (1985) Effects of exercise training on insulin predict fermoral neck bone mass. Journal of Bone and sensitivity in adolescents with type 1 diabetes. Dia- Mineral Research 4, 441–447. betes Care 8, 461–465. Reilly, J.J., Lord, A., Bunker, V.W. et al. (1993) Energy LaPorte, R.E., Dorman, J.S. & Taiima, N. (1986) Pitts- balance in healthy elderly women. British Journal of burgh insulin-dependent diabetes mellitus morbid- Nutrition 69, 21–27. ity and mortality study: physical activity and Roitman, J.L. (ed.) (1998) American College of Sports diabetic complications. Pediatrics 78, 1027–1033. Medicine Resource Manual for Guidelines for Exercise Loucks, A.B., Mortola, J.F., Girton, L. & Yen, S.C.C. Testing and Prescription, 3rd edn. Baltimore, Williams (1989) Alterations in hypothalamic–pituitary– and Wilkins. ovarian and the hypothalamic–pituitary–adrenal Ruderman, N. & Devlin, J.T. (eds) (1995) The Health Pro- axes in athletic women. Journal of Clinical Endo- fessionals Guide to Diabetes and Exercise. American crinology and Metabolism 68, 402–411. Diabetes Association, Alexandria, Virginia. Loucks, A.B., Vaitukaitis, J., Cameron, J.L. et al. (1992) Rydall, A.C., Rodin, G.M., Olmsted, M.P., Devenyi, The reproductive system and exrcise in women. R.G. & Daneman, D. (1997) Disordered eating behav- Medicine and Science in Sports and Exercise 24, S288– ior and microvascular complications in young S293. women with insulin-dependent diabetes mellitus. Lucas, C.P., Patton, S., Stepke, T. et al. (1987) Achieving New England Journal of Medicine 336, 1849–1854. therapeutic goals in insulin-using diabetic patients Sandler, R.B. (1988) Muscle strength and skeletal com- with non-insulin-dependent diabetes mellitus. A petence: implications for early prophylaxis. Calcified weight reduction-exercise–oral agent approach. Tissue International 42, 281–283. American Journal of Medicine 83(3A), 3–9. Schneider, S.H., Amorosa, L.F., Khachadurian, A.K. & Manson, J.E., Rimm, E.B., Stampfer, M.J. et al. (1991) Ruderman, N.B. (1984) Studies on the mechanism of Physical activity and incidence of non-insulin- improved glucose control during regular exercise in dependent diabetes mellitus in women. Lancet 338, type 2 (non-insulin dependent) diabetes. Diabetologia 774–778. 26(5), 355–360. Marcus, R., Cann, C. & Madvig, P. (1985) Menstrual Shushruta, S.C.S. (1938) Vaidya Jayayaii Trikamji Acharia. function and bone mass in elite women distance Nimyar Sagar Press, Bombay. runners: endocrine and metabolic features. Annals of Smith, E.L. & Gilligan, C. (1991) Physical activity effects Internal Medicine 102, 158–163. on bone metabolism. Calcified Tissue International 49 Marcus, R., Drinkwater, B., Dalsky, G. et al. (1992) (Suppl.), S50–S54. Osteoporosis and exercise in women. Medicine and Solomon, C.G. (1996) Diabetes mellitus and risk of car- Science in Sports and Exercise 24, S301–S307. diovascular disease in women. Medicine and Science Mills, J.L., Simpson, J.L., Driscoll, S.G. et al. (1988) The in Sports and Exercise 28, 15–16. National Institutes of Childhealth and Family Devel- Summary and Recommendations of the Second Inter- opment Diabetes in Early Pregnancy Study: inci- national Workshop-Conference on Gestational Dia- dence of spontaneous abortion among normal betes Mellitus (1991) Diabetes 34 (Suppl. 2), 179–181. women and insulin-dependent diabetic women Suominen, H. (1993) Bone mineral density and long whose pregnancies were identified within 21 days of term exercise. Sports Medicine 16, 316–330. conception. New England Journal of Medicine 319, Tanner, J.M. & Davies, S.W.D. (1985) Clinical longitudi- 1617–1623. nal standards for height and height velocity for Moy, C.S., Songer, T.J., LaPorte, R.E. et al. (1993) Insulin- North American children. Journal of Paediatrics 107, dependent diabetes mellitus, physical activity, and 317–329. death. American Journal of Epidemiology 137, 74–81. Taylor, R., Ram, P., Zimmet, P., Raper, L.R. & Ringrose, Paffenbarger, R.S. Jr, Wing, A.L. & Hyde, R.T. (1978) H. (1984) Physical activity and prevalence of diabetes Physical activity as an index of heart attack risk in in Melanesian and Indian men in Fiji. Diabetologia 27, college alumni. American Journal of Epidemiology 108, 578–582. 161–175. Van der Mooren, M.J., de Graaf, J., Demacker, P.N., de Pavlou, K.N., Steffee, W.P., Lerman, R.H. & Burrows, Haan, A.F. & Rolland, R. (1994) Changes in low- B.S. (1985) Effects of dieting and exercise on lean density lipoprotein profile during 17 beta-estradiol- body mass, oxygen uptake and strength. Medicine hydrogesterone therapy in post-menopausal and Science in Sports and Exercise 17, 466–471. women. Metabolism: Clinical and Experimental 43, Peterson, M.S. & Peterson, K. (1988) Eat to Compete: 799–802. A Guide to Sports Nutrition. Medical Year Book Wallberg-Henriksson, H., Gunnarsson, R. & Henriks- Publishers, Chicago. son, J. (1982) Increased peripheral insulin sensitivity Pocock, N.J., Eisman, J. & Gwinn, T. (1989) Muscle and muscle mitochondrial enzymes but unchanged diabetes and sport 279

blood glucose control in type I diabetics after physi- Yki-Jarvinen, H., DeFronzo, P. & Koivisto, V.A. (1984) cal training. Diabetes 31(12), 1044–1050. Normalization of insulin sensitivity in Type I dia- Wallberg-Henriksson, H., Gunnarsson, R., Henriksson, betic subjects by physical training during insulin J., Ostman, J. & Wahren, J. (1984) Influence of physi- pump therapy. Diabetes Care 7, 520–527. cal training on formation of muscle capillaries in Zimmet, P., Faaiuso, S., Ainuu, S., Whitehouse, S., type I diabetes. Diabetes 33, 851–857. Milne, B. & DeBoer, W. (1981) The prevalence of dia- Wasserman, D.R. & Vranic, M. (1985) Interaction betes in the rural and urban Polynesian population between insulin, glucagon, and catecholamines in of Western Samoa. Diabetes 30, 45–51. the regulation of glucose production and uptake Zimmet, P., Dowse, G., Finch, C., Serjeantson, S. & during exercise: physiology and diabetes. In B. Saltin King, H. (1990) The epidemiology and natural (ed.) Biochemistry of Exercise, Vol. VI, pp. 167–179. history of NIDDM: lessons from the South Pacific. International Series on Sports Sciences, Copenhagen. Diabetes Metabolism Reviews 6, 91–124. Yeager, K.K., Agostini, R., Nattiv, A. & Drinkwater, B. Zinman, B., Zuniga-Guajardo, S. & Kelly, D. (1984) (1993) The female athlete triad: disordered eating, Comparison of the acute and longterm effects of amenorrhea, osteoporosis. Medicine and Science in exercise on glucose control in Type I diabetes. Dia- Sports and Exercise 25, 775–777. betes Care 7, 515–519. Chapter 19

Sport and Bone

ILKKA VUORI AND ARI HEINONEN

Introduction bone. This happens typically as a consequence of immobilization. Bone is a metabolically active tissue that is Different sports load the skeleton at various continuously formed and lost during one’s sites in different ways. The induced strains vary lifetime. The basic form and development of in localization, magnitude, number or cycles, the bones comprising the skeleton are genet- rate of development, and distribution at the ically determined, but their mass and architec- bone site. All these variables have been shown to ture are influenced by several factors. The be associated with the regulation of bone mass most important of these are mechanical, nutri- (Lanyon, 1996). However, the type, intensity, tional and hormonal factors. The significance of frequency and duration of exercise that best mechanical factors, i.e. physical loading, was enhances bone mineral accumulation are still recognized over 100 years ago, when Wolff largely unknown. The extent to which a bone (1892) suggested that bone accommodates the can alter its form due to exercise and the extent habitual stress imposed upon it. Based on a to which growing and mature bones have great number of experimental, epidemiological similar adaptive capacities also remain unclear and interventional studies, Frost (1987) has pro- (Biewener & Bertram, 1993). posed a ‘mechanostat’ theory to explain the Thorough investigation and analysis of bone adaptation of bone architecture and mass to its characteristics of athletes practising various typical mechanical environment. This theory sports is important because sports offer a large maintains that physical loading causes locally variety of ‘natural experiments’ that would be microscopical structural deformations called difficult or impossible to conduct in any other strains in the bone. The strains induce various way. The knowledge gained may be valuable biophysical and chemical events that influence not only in a descriptive sense but also in testing the metabolism and thus the structure of ideas and hypotheses related to bone metabo- bone. Under habitual loading conditions the lism and physical characteristics, examining ‘mechanostat’ is in balance, resulting in mainte- dose–response issues and evaluating potential nance of bone mass and architecture. When benefits and risks to bone health of various loading exceeds the customary loading of the sports at different ages. bone, the strain-induced events result in increased bone formation. Therefore athletes in Bone turnover some disciplines have unusually strong bones. If the loading is less than what the bone is adapted Physical loading influences bone mass, geometry to, the lack of stimuli caused by the strain leads to and internal architecture through bone turnover. diminished local bone formation and loss of Three tissue-level mechanisms, growth, model- 280 sport and bone 281

ling and remodelling, are involved in bone mainly determined by movement conditions turnover. Each of them has a specific purpose and (velocity of body segments, number of repeti- mechanical loading can influence all of them. tions, the muscular activity) and boundary con- Growth determines the bone size. Growth can ditions (anthropometric factors, fitness level, only add, not remove, bone (Parfitt, 1994). The type of shoes, surface and weather) (Nigg, 1985). growth of bone stops at around 16–18 years of Thus changes in movement conditions affect age. Consequently, the highest or peak bone the kinematics and kinetics of the movement mass and areal density are achieved around and probably also the stress on, and strain of, age 20 (Matkovic et al., 1994; Haapasalo et al., bone. Therefore, the differences in the movement 1996a). Growth is under strong genetic influence, and boundary conditions of different sports may especially the maternal influence on daughters induce various strain distributions and different (Jouanny et al., 1995). However, mechanical strain rates on bones. The rate of force applica- loading, nutrition and hormonal factors also tion rather than the magnitude of force may be influence growth. more important for the degree of strain. In Modelling is simultaneous removal and for- tennis, for instance, the forces and the influence mation of bone at different sites by two mediator of the friction of the playing surface produce mechanisms, called resorption and formation high torques on the bones of the lower extremity drifts. It continues throughout life. Modelling (Nigg, 1985). Furthermore, the relationship determines the shape of bones and increases between force and acceleration–deceleration (F= bone strength by improving geometric proper- ma) implies that sports involving impact loading ties and adding mass (Kimmel, 1993). (e.g. highly accelerating and decelerating move- Bone remodelling is a process by which bone is ments) may produce high stresses and thus effec- removed and formed at the same site but at dif- tive strains on bones. ferent times. It maintains the functional compe- Each bone can be regarded as a mechanical tence of bone by replacing aged bone with new unit whose characteristics are adjusted to the bone and repairing microcracks at scattered loca- demands of the loading environment. Bone tions on bone surfaces through a biologically adapts to changes in the effective stresses by coupled activation–resorption–formation sequ- adjusting its characteristics in a direction that ence (Jee, 1988; Frost, 1990, 1992; Turner, 1991). In tends to keep the internal strain within a physio- a normal adult, activation and resorption last logically reasonable range. If mechanical loading 1 month and formation another 3 months; thus or disuse causes the strain level to shift outside the time scale for one complete remodelling the ‘customary mechanical range’, the bone is cycle, called sigma, is about 4 months (Jee, 1988; either overloaded or underloaded, which leads Frost, 1989). Mineralization is completed in to bone adaptation and imbalance between bone another 3–4 months (Jee, 1988). Bone remodel- formation and resorption. An example of adapta- ling is a complex process that is regulated by the tion of bone to altered loading conditions is il- balance between physiological signals due to lustrated in Fig. 19.1. The capability of bone to mechanical factors and those due to systemic respond to mechanical loading is probably deter- non-mechanical factors (polypeptide, steroid mined by a genetically controlled set-point that and thyroid hormones) as well as local factors has been further modified by past site-specific (growth factors and prostaglandins) (Lanyon, loading and several biochemical factors related 1987, 1990, 1996; Canalis, 1993). to age and disease. Biochemical agents can influ- ence bone mass independently or they can influ- ence bone structure by changing the set-point Mechanical adaptation of bone of the mechanical feedback system (Frost, 1987, The magnitude of the force and the rate of force 1993; Lanyon, 1987, 1996; Turner, 1991). application affecting the human skeleton are All the strain-related variables, namely magni- 282 medical issues

20 *** *** 15 ** * * 10

5

0 Difference (%)

–5 Weight Squash Aerobic Orien- Speed Cross- Cyclists Physically active lifters players dancers teers skaters country referents skiers

–10 (a)

30

25 ***

20 *** *** ** 15 * 10 5 Difference (%) 0

–5 Weight Squash Aerobic Orien- Speed Cross- Cyclists Physically active –10 lifters players dancers teers skaters country referents skiers High-magnitude High-impact Repetitive Non- Normal, high level loading loading loading weight physical activity (b) bearing

Fig. 19.1 Relative difference in weight-adjusted bone mineral density (BMD) at the most loaded lower limb sites of different female athlete groups (n = 18–30) and a physically active reference group (n = 25) compared with that of the sedentary reference group (n = 25). (a) Proximal tibia BMD and (b) calcaneus BMD. The grouping of the athletes was based on the specific bone-loading characteristics of the respective sports. The bars indicate the 95% confidence intervals. *, P < 0.05; **, P < 0.01; ***, P < 0.001. (From Heinonen, 1997 with permission.)

tude, cycles, rate and pattern of distribution, high mechanical forces and/or high rates of force are integrated into dynamic loading conditions. application produced in versatile movements. However, the exact characteristics of an optimal stimulus for mechanically induced bone forma- Other factors modifying bone tion are not known. According to current knowl- adaptation to mechanical loading edge, an effective exercise programme should involve high strains and/or high strain rates and Frost (1983, 1987) has proposed a hypothesis for unusual strain distributions. In practical terms, a feedback control system that describes the effective exercise regimens should consist of interaction between mechanical and other sport and bone 283

factors, such as nutrition, age, hormonal stimuli (BMC), while other important parameters and body composition. Bone mass is also deter- related to bone strength, such as bone size and mined by several interacting genetic, metabolic diameter, cortex–cavity ratio in long bones, geo- and environmental factors (Brandi et al., 1994; metric shape and trabecular architecture, have Bronner, 1994). Genetic influences account for been assessed in only a few studies (Genant et al., 60–80% of the interindividual variation of bone 1996; Sievänen et al., 1996). Dual energy X-ray mass as assessed in the adult years (Pocock et al., absorptiometry is the method of choice for mea- 1987; Slemenda et al., 1991; Seeman et al., 1996). In suring BMC and areal BMD. Most studies report addition, adequate calcium intake is considered the results as BMD. However, BMD does not rep- essential in order to attain and maintain optimal resent true material density or apparent density bone mineral mass and size (Dawson-Hughes and depends strongly on bone size and matura- et al., 1990; Johnston et al., 1992; Bronner, 1994; tion of subjects (Bailey et al., 1996; Genant et al., Parfitt, 1994; Nieves et al., 1995; Specker, 1996). 1996; Sievänen et al., 1996). In many studies on Decreased oestrogen influence as reflected in athletes the subjects have been children or ado- menstrual irregularities and amenorrhoea is lescents and since body size and phase of sexual associated with low lumbar spine bone mineral maturity have great influence on bones, these density (BMD) (Drinkwater et al., 1984; Marcus variables need to be controlled. Quantitative et al., 1985; Prior et al., 1990; Myburgh et al., computed tomography and peripheral quantita- 1993), but other bone sites may also be affected tive computed tomography offer new possibil- (Drinkwater et al., 1990). Therefore, in female ities for assessing bone geometry and mass athletes a significant risk factor for stress frac- distribution and for estimating bone strength tures is low bone density (Bennell et al., 1996). (Genant et al., 1996; Sievänen et al., 1997). Complex associations exist between various Broadband ultrasound attenuation has also been parameters of body composition and bone used to study bone mineral mass and other char- density. A positive association may be explained, acteristics of bone strength that are potentially at least in part, by skeletal responses to mechani- independent of density (Genant et al., 1996). cal forces induced by greater body weight and a The vast majority of studies have been cross- weight-related beneficial effect of higher oestro- sectional and only a few have included follow-up gen concentrations (Slemenda, 1995; Albala et al., or have investigated the effects of training pro- 1996). Lean mass seems to be a stronger predictor grammes. An inherent problem in cross-sectional of bone density or mass than fat mass (Nichols studies is the possible self-selection of subjects. et al., 1995; Young et al., 1995; Chen et al., 1997), Studies on athletes practising unilateral sports, although Reid et al. (1992) found that total such as racquet sports, offer possibilities for body fat mass was the most significant predictor escaping this bias. Studies of tennis and squash of total body BMD in premenopausal and post- players show large side-to-side differences in menopausal women. In addition, muscle mass BMD and BMC in the players’ arms but no sig- is positively related to bone density in older men nificant differences in BMD or BMC in the non- and women (Doyle et al., 1970; Snow-Harter et al., dominant arm of the players and control subjects 1990; Hughes et al., 1995). The weight of muscle (Haapasalo et al., 1994; Kannus et al., 1995), indi- reflects the forces exerted on the bone to which it cating that local mechanical loading can greatly is attached, and muscle weight is an important increase bone mass, at least in growing subjects. determinant of bone mass (Doyle et al., 1970). Consequently, carefully designed cross-sectional studies on female athletes could offer valuable insights into the effects of various long-standing Methodological considerations exercise habits. The most commonly assessed bone parameters It has been shown convincingly that mechani- have been BMD and bone mineral content cal loading influences bone only at the sites 284 medical issues

where it causes strains, i.e. the effects are site spe- that the adolescent growth spurt is the only time cific. Therefore the effects of various sports on in life when bone is added substantially to both bones should be sought and expected at loaded the inside and outside of the cortices (Parfitt, sites. If the exercise mainly involves the lower 1994). Furthermore, trabecular bone is more limb, it may improve femoral neck bone density sensitive than cortical bone to changes in hor- with no effect on the radius. Thus, if exercise monal concentrations, which are especially large training is intended to be osteogenic, it should at puberty. These features may partially explain provide loading targeted to specific sites, e.g. the why the ability of bone to adapt to mechanical femoral neck or lumbar vertebrae. loading is greater during growth than during maturity (Slemenda et al., 1994; Gunnes & Lehmann, 1996). In a cross-sectional study of Bone mineral density and content in female tennis and squash players, Kannus et al. female athletes (1995) showed that the influence of mechanical BMD or BMC has been assessed in female ath- loading on the BMC of the playing arm is about letes representing at least 20 sports. Most of the two times greater if playing is begun before studies have been cross-sectional. In order to compared with after menarche (Fig. 19.2). reveal true associations between bone character- This finding suggests that in order to attain istics and sports, the studies have to be analysed the highest possible peak bone mass the bones in a theoretically sound way. Thus, the character- should be loaded effectively at a rather young istics of both the athletes, e.g. age, and of the age, during the few years before and at puberty. sport, especially the loading characteristics, have to be taken into account. Bones of female athletes representing various sports Bones of child and adolescent athletes Table 19.1 is an attempt to assess the loading and The response of the skeleton to sport may vary at consequently strain characteristics of sports in different stages of growth and maturation due to which bone mineral measurements of female factors such as hormonal influences. It is known athletes have been determined. Tables 19.2–19.4

30

25

20

15 Fig. 19.2 Benefit of mechanical loading with respect to bone 10

BMC difference (%) mineral content (BMC). The BMC of the playing arm (humeral shaft) of the subjects was about two 5 times greater if the girls started playing at or before, rather than 0 after, menarche. The bars >5 3–50–21–56–15 >15 represent the 95% confidence Time before menarche Time after menarche Referents intervals. (From Kannus et al., (years) (years) 1995 with permission.) sport and bone 285

Table 19.1 Assessment of the loading characteristics of the different sports in which bone measurements of female athletes have been made

Loading characteristics

Sport Weight-bearing High magnitude High impact Repetitive Varied

Strength sports Body-building xxx xxx x x x Power-lifting xxx xxx x x x Weight-lifting xxx xxx xx x xx

Endurance sports Running xx x xx xxx xx Orienteering xx x xx xxx xx Speed skating xx x xx xxx xx Cross-country skiing xx x x xxx x Rowing x x x xxx x Cycling x x x xxx x Swimming 0 x x xxx x

Speed and power Aerobic dancing xxx xx xxx xxx xxx Ballet dancing xxx xx xxx xx xxx Gymnastics xxx xx xxx xx xxx Figure skating xxx xx xxx xx xxx Basketball xxx xx xxx xx(x) xxx Soccer xxx xx xxx xx(x) xxx Volleyball xxx xx xxx xx xxx Squash xxx xx xxx xx xxx Tennis xxx xx xxx xx xxx

Assumption: duration of exposure is sufficient. xxx, high, broad; xx, medium; x, low, limited; 0, none.

summarize the main features and findings of studies on mature female athletes representing valid studies carried out on female athletes rep- strength sports. In all studies, the BMD of the ath- resenting various sports, classified on the basis of letes at the loaded sites is substantially greater their loading characteristics. Figure 19.1 has been than that in the control subjects. constructed on the same basis and shows the The results of the study of Heinonen et al. summary of results of studies that have used the (1993) are also shown in Fig. 19.1. Although the same design and methodology in the same possiblity of self-selection to competition in laboratory, thus allowing good comparability strength sports by subjects with stronger or between various types of sports. better-adapting bones cannot be excluded, there is no evidence that this has occurred. Studies on bone mineral mass of athletes in female tennis and squash players showing no high-magnitude loading sports difference in BMD or BMC of the non-playing arm between athletes and controls (Haapasalo Table 19.1 shows that strength sports produce et al., 1994; Kannus et al., 1995) do not suggest high-magnitude loading of bones. Table 19.2 any substantial selection bias. However, prospec- summarizes the findings of three cross-sectional tive weight-training studies on women have 286 medical issues

Table 19.2 Bone mineral mass in female athletes taking part in high-magnitude loading sports (results selected from cross-sectional studies)

Bone mineral mass

Difference between Age athletes Reference Athlete group No. (years) Bone site and controls (%) Technique

Davee et al. (1990) Muscle-building 9 20–30 L2–L4 + 10* DPA Controls 9 Heinonen et al. Weight-lifters 18 25 ± 5 L2–L4 + 15* DXA (1993) Femoral neck + 10* Distal femur + 19* Patella + 22* Proximal tibia + 12* Calcaneus + 4* Distal radius + 29* Controls 25 23 ± 3 Heinrich et al. Body-builders 11 26 ± 5 L2–L4 + 12* DPA (1990) Femoral neck + 15* Ward triangle + 23* Greater trochanter + 12* Proximal radius + 9SPA Distal radius + 16* Controls 18 25 ± 4

*P < 0.05. DPA, dual photon absorptiometry; DXA, dual-energy X-ray absorptiometry; SPA, single photon absorptiometry.

demonstrated only small to moderate (0.8–3.8%) et al., 1994; Friedlander et al., 1995). Bone-loading gain in regional bone mineral mass (Gleeson effects are likely to be substantially less in these et al., 1990; Peterson et al., 1991; Pruitt et al., 1992; exercises compared with those used by weight- Snow-Harter et al., 1992; Nelson et al., 1994; Vuori lifters, whose training consists of a number of et al., 1994; Friedlander et al., 1995; Lohman et al., different exercises using free weights. This type 1995) or no effect (McCartney et al., 1995; Pruitt of training not only produces high-magnitude et al., 1995; Heinonen et al., 1996b; Sinaki et al., strains but also a favourable rate and distribution 1996). The likely explanations for the differences of the strains in terms of osteogenesis. between cross-sectional and prospective training studies include more intensive, strenuous and bone mineral mass of longer training started in childhood or adoles- athletes in repetitive loading cence in the athletes compared with the subjects weight-bearing sports in the training studies. Furthermore, in many of the prospective studies, training consisted of The most commonly practised sport that slow, smooth, similar repetitions of movements involves a large number of repetitive loadings produced by the use of various types of training is running (Table 19.1). Several studies have machine (Peterson et al., 1991; Pruitt et al., 1992; shown that mineral mass of the loaded bones, Snow-Harter et al., 1992; Nelson et al., 1994; Vuori e.g. several sites in the lower legs and lumbar sport and bone 287

spine, of female athletes in running sports is fast walking, the direction and rate of loading greater than in control subjects (Table 19.3, Fig. on the lower limb are altered by the short heel 19.1). However, the difference is not as great as strike and high ground reaction forces between athletes in strength sports and control (Subotnick, 1985; Grove & Londeree, 1992) and subjects. In cross-country skiers and speed hip reaction forces (Bergman et al., 1993) com- skaters there is, or tends to be, greater regional pared with ordinary walking. This mechanism bone mineral mass at the loaded sites compared might also explain why there seems to be an with control subjects (Table 19.3, Fig. 19.1). In intensity threshold (70–90% of maximal oxygen these sports the movements are gliding, resulting consumption), corresponding to sufficient speed in very small, or no, impact with the ground; also of walking or running for aerobic training to they are likely to produce less stress on various influence regional bone mineral mass (Dalsky et sites in the lower legs than running. The reaction al., 1988; Hatori et al., 1993; Martin & Notelovitz, forces acting on the lower limb during running 1993; Heinonen et al., 1998). can be two to five times body weight (Subotnick, 1985) and those on the vertebrae can be 1.75 bone mineral mass of athletes in times body weight (Capozzo, 1983). Thus, the high-impact sports greater regional bone mineral mass at loaded sites of athletes in running sports is probably due Speed and power sports are characterized by to both the great number of loading cycles and fast, forceful, acceleratory and deceleratory, the moderate impact in running. The regional impact-producing movements, often in multiple bone mineral mass of rowers and cyclists (Table directions. These sports produce strains in 19.3, Fig. 19.1) as well as of swimmers (Orwoll et bones at a high rate and in multiple directions al., 1989; Risser et al., 1990; Fehling et al., 1995; Lee (Table 19.1). On the basis of animal experiments et al., 1995; Taaffe et al., 1995, 1997) has not been (Lanyon, 1992, 1996; Rubin & McLeod, 1996), the found to be greater in the athletes compared with osteogenic effect of the loading profile produced controls. The reason is very likely the partial or by speed and power sports should be greater complete lack of weight-bearing activity in these than that caused by strength or endurance sports. sports. This notion is supported by the results There are no published data on regional bone of both cross-sectional and prospective studies mineral mass of competitive walkers. In addi- on female athletes (Table 19.4), as well as by con- tion, the data regarding the influence of occupa- trolled training studies. The differences in areal tional or recreational walking are contradictory. bone mineral mass at loaded sites between speed In premenopausal women there were no differ- and power athletes and referents (Table 19.4, ences in weight-adjusted regional bone mineral Fig. 19.1) are generally larger than those in mass between mail and newspaper carriers strength and endurance athletes (Tables 19.2 & walking 6km daily and more sedentary office 19.3, Fig. 19.1). workers (average walking distance about 2km Direct comparisons of groups of athletes cor- daily) of the same age and from the same work roborate this picture. One of our previous studies sites (Uusi-Rasi et al., 1994). In postmenopausal showed that, compared with regularly exercising women both habitual walking (>12km·week–1) controls, squash players had the highest weight- (Krall & Dawson-Hughes 1994) and walking adjusted BMD values (7–19%) at all measured plus callisthenics (Dalsky et al., 1988; Hatori et al., sites of any sport group (Heinonen et al., 1995). 1993; Krall & Dawson-Hughes, 1994; Kohrt et al., Robinson et al. (1995) investigated bone mineral 1995; Prince et al., 1995) have been found to have mass in two groups of competitive young female positive influence on the loaded sites. It may be athletes, gymnasts and runners, with different that only fast walking causes sufficient strain in skeletal loading patterns. The gymnasts exhib- the bone tissue (Rubin & Lanyon, 1982). During ited higher bone mineral mass in the femoral 288 medical issues

Table 19.3 Bone mineral mass in female athletes taking part in repetitive loading (weight-bearing) sports (results selected from cross-sectional studies)

Bone mineral mass

Difference between Age athletes and Reference Athlete group No. (years) Bone site controls (%) Technique

Dook et al. (1997) Running and 20 46 ± 3 Whole body + 7* DXA field hockey Regional leg + 7* Regional arm + 3 Sedentary 20 46 ± 2 controls Harber et al. (1991) Eumenorrhoeic 17 27 ± 5 Calcaneus - 2 CST runners Amenorrhoeic 11 26 ± 6 Calcaneus 0 runners Normoactive 14 27 ± 7 controls Heinonen et al. Orienteers 30 23 ± 3 L2–L4 0 DXA (1993) Femoral neck + 2 Distal femur + 5* Patella + 3 Proximal tibia + 4* Calcaneus + 4 Distal radius + 1 Cross-country 28 21 ± 3 L2–L4 0 skiers Femoral neck + 5 Distal femur + 5 Patella + 2 Proximal tibia + 3 Calcaneus + 3 Distal radius - 1 Active controls 25 23 ± 3 Heinonen et al. Orienteers 30 23 ± 3 L2–L4 + 8 DXA (1995) Femoral neck + 3 Distal femur + 6* Patella + 4 Proximal tibia + 7* Calcaneus + 11* Distal radius - 4 Speed skaters 14 21 ± 9 L2–L4 + 6 Femoral neck + 4 Distal femur + 7* Patella + 5 Proximal tibia + 6 Calcaneus + 3 Distal radius - 6

Continued sport and bone 289

Table 19.3 (Continued)

Bone mineral mass

Difference between Age athletes and Reference Athlete group No. (years) Bone site controls (%) Technique

Cross-country 28 21 ± 3 L2–L4 + 3 skiers Femoral neck + 5 Distal femur + 5 Patella + 2 Proximal tibia + 5* Calcaneus + 9* Distal radius - 7* Sedentary 25 24 ± 5 controls Kirk et al. (1989) Long-distance 10 25–35 T12–L3 + 1 QCT runners Mid-radius + 12 SPA Sedentary 10 controls Long-distance 9 55–65 T12–L3 - 7 runners Mid-radius + 1 Sedentary 9 controls Lane et al. (1986) Long-distance 6 56 L1 + 35* QCT runners Matched 6 56 controls Myerson et al. Eumenorrhoeic 13 30 ± 1 Total body + 10* DPA (1992) runners Amenorrhoeic 13 30 ± 1 Total body - 7 runners Controls 12 27 ± 1 Suominen et al. Long-distance 18 66–85 Calcaneus + 12 and + 6SPA (1992) runners, skiers Population 42 70–81 sample Wolman et al. Runners 21 25–28 Femoral shaft + 8* DPA (1991) Rowers 36 24–26 Femoral shaft + 2 Sedentary 13 27–30 controls

*P < 0.05. CST, compton scattering technique; DPA, dual photon absorptiometry; DXA, dual-energy X-ray absorptiometry; QCT, quantitative computed tomography; SPA, single photon absorptiometry. Table 19.4 Bone mineral mass in female athletes taking part in sports producing strains on bones at a high rate (e.g. impacts) and usually from many directions (results selected from cross-sectional studies)

Bone mineral mass

Difference between Age athletes and Reference Athlete group No. (years) Bone site controls (%) Technique

Dook et al. (1997) Basketball and 20 46 ± 3 Whole body + 8* DXA netball Regional leg + 8* Regional arm + 4 Sedentary controls 20 46 ± 2 Düppe et al. (1996) Active football 96 18 ± 4 Total body + 4* DXA players Lumbar spine + 5 Femoral neck + 11* Trochanter + 11* Ward’s + 11* triangle Controls 90 20 ± 5 Former football 25 40 ± 5 Total body + 4* players Lumbar spine - 2 Femoral neck + 7* Trochanter + 11* Ward’s + 9* triangle Controls 57 37 ± 4 Fehling et al. Volleyball players 8 20 ± 1 L2–L4 + 11* DXA (1995) Femoral neck + 15* Ward’s + 17* triangle Total body + 13* left arm + 5* right arm + 7* left leg + 15* right leg + 12* right pelvis + 19* Gymnasts 7 20 ± 1 L2–L4 + 14* Femoral neck + 15* Ward’s + 17* triangle Total body + 11* left arm + 15* right arm + 16* left leg + 10* right leg + 10* right pelvis + 15 Controls 13 20 ± 1 Fogelholm et al. Gymnasts 12 17 ± 1 L2–L4 + 7* DXA (unpublished Femoral neck + 17* observations) Distal radius 0 Soccer players 12 19 ± 2 L2–L4 + 14* Femoral neck + 16* Distal radius + 10* Controls 12 17 ± 1

Continued sport and bone 291

Table 19.4 (Continued)

Bone mineral mass

Difference between Age athletes and Reference Athlete group No. (years) Bone site controls (%) Technique

Haapasalo et al. Squash players 19 18–32 Proximal + 9* DXA (1994) humerus Humeral + 10* shaft Radial shaft + 1* Ulnar shaft - 1* Distal radius + 10* Distal ulna + 24* Calcaneus + 12* Controls 19 19–33 Heinonen et al. Triple jumpers 4 23 ± 4 L2–L4 + 38* DXA (unpublished Femoral neck + 26* observations) Distal femur + 34* Patella + 25* Proximal tibia + 35* Calcaneus + 35* Distal radius + 11 Controls 25 24 ± 5 Heinonen et al. Squash players 18 25 ± 4 L2–L4 + 14* DXA (1995) Femoral neck + 17* Distal femur + 11* Patella + 7* Proximal tibia + 13* Calcaneus + 19* Distal radius + 11* Aerobic dancers 27 28 ± 4 L2–L4 + 3 Femoral neck + 9* Distal femur + 3 Patella + 2 Proximal tibia + 6* Calcaneus + 14* Distal radius - 8* Controls 25 24 ± 5 Jacobson et al. Tennis players 11 18–22 Spine + 11* DPA (1984) Distal radius + 17* SPA Mid-radius + 12* Metatarsal + 23* Age-matched 11 controls Kannus et al. Tennis and squash 105 16–50 Proximal + 10* DXA (1995) players humerus Humeral + 10* shaft Radial shaft + 3 Distal radius + 8*

Continued p. 292 292 medical issues

Table 19.4 (Continued)

Bone mineral mass

Difference between Age athletes and Reference Athlete group No. (years) Bone site controls (%) Technique

Calcaneus + 11* Controls 50 16–48 Kirchner et al. Gymnasts 26 20 ± 0.2 Lumbar spine + 18* DXA (1995) Total + 21* proximal femur Femoral neck + 22* Ward’s + 25* triangle Whole body + 10* Controls 26 20 ± 0.2 Kirchner et al. Former gymnasts 18 36 ± 1 Lumbar spine + 16* DXA (1996) Femoral neck + 18* Ward’s + 22* triangle Whole body + 9* Controls 15 37 ± 1 Lee et al. (1995) Volleyball players 11 19 ± 1 Total body + 17 DXA Lumbar spine + 18 Femoral neck + 11 Trochanter + 17 Ward’s + 4 triangle Spine + 6* Pelvis + 10* Left arm + 12* Right arm + 13* Left leg + 17* Right leg + 15* Basketball players 7 20 ± 2 Total body + 9* Lumbar spine + 14* Femoral neck + 20* Trochanter + 24* Ward’s + 18* triangle Spine + 5* Pelvis + 11* Left arm + 12* Right arm + 17* Left leg + 15* Right leg + 17* Soccer players 9 19 ± 1 Total body + 4 Lumbar spine + 6* Femoral neck + 10* Trochanter + 16* Ward’s + 12 triangle

Continued sport and bone 293

Table 19.4 (Continued)

Bone mineral mass

Difference between Age athletes and Reference Athlete group No. (years) Bone site controls (%) Technique

Spine + 5 Pelvis + 7* Left arm + 1 Right arm + 3 Left leg + 11* Right leg + 11* Sedentary controls 11 22 ± 1 Nichols et al. Gymnasts 11 19 ± 1 Preseason: DXA (1994) lumbar + 8* spine femoral + 11* neck Controls 11 21 ± 2 Nichols et al. Basketball players 14 19 ± 1 L2–L4 + 10* DXA (1995) Femoral neck + 14* Total body + 10* Leg + 15* Arm + 8* Gymnasts 15 19 ± 1 L2–L4 + 9* Femoral neck + 11* Total body + 5* Leg + 7* Arm + 12* Tennis players 6 23 ± 4 L2–L4 + 4 Femoral neck + 3* Total body + 6* Leg + 9* Arm + 6* Volleyball players 13 19 ± 1 L2–L4 + 13* Femoral neck + 14* Total body + 10* Leg + 15* Arm + 8 Non-athletes 12 21 ± 2 Pearce et al. (1996) Ballet dancers: DXA < 40 months 17 14 ± 0.2 Lumbar spine - 2 oligomenorrhoea Femoral neck + 9* Ward’s + 10* triangle Trochanter + 9* Arms - 4 > 40 months 24 18 ± 0.2 Lumbar spine - 4 oligomenorrhoea Femoral neck + 4 Ward’s + 4 triangle Trochanter + 2

Continued p. 294 294 medical issues

Table 19.4 (Continued)

Bone mineral mass

Difference between Age athletes and Reference Athlete group No. (years) Bone site controls (%) Technique

Arms - 8 Controls 46 18 ± 0.2 Risser et al. (1990) Volleyball players 12 20 ± 2 Lumbar spine + 15* DPA Calcaneus + 26* SPA Basketball players 9 20 ± 1 Lumbar spine + 12 Calcaneus + 36* Non-athletes 13 20 ± 1 Robinson et al. Gymnasts 21 22 ± 3 Whole body + 2 DXA (1995) Lumbar spine + 6 Femoral neck + 12* Controls 19 19 ± 2 Slemenda & Figure skaters 22 10–23 Total body + 7* DXA Johnston (1993) Spine + 6 Trunk + 8* Legs + 10* Pelvis + 14* Arm + 4 Controls 22 10–23 Taaffe et al. (1995) Gymnasts 13 19 ± 1 Whole body + 3 DXA Lumbar spine + 8 Femoral neck + 15* Trochanter + 15* Controls 19 19 ± 2 Taaffe et al. (1997) Gymnasts, 8-month 26 20 ± 1 Whole body + 1 DXA cohort Lumbar spine + 6 Femoral neck + 14 Controls 14 19 ± 2 Gymnasts, 12- 8 19 ± 1 Whole body + 4 month cohort Lumbar spine + 4 Femoral neck + 20* Controls 11 20 ± 2

*P < 0.05. DPA, dual photon absorptiometry; DXA, dual-energy X-ray absorptiometry; SPA, single photon absorptiometry. neck and lumbar spine (6–12%) compared with were controlled, the impact-loading group (gym- runners and controls. Taaffe et al. (1995) found nasts and volleyball players) had higher bone similar results: young female gymnasts had mineral mass than swimmers and controls. The greater bone mineral mass at both appendicular very substantial differences between the playing and axial sites compared with swimmers and and non-playing arm sites in squash and tennis controls. Fehling et al. (1995) and Kirchner et al. players (Jacobson et al., 1984; Haapasalo et al., (1995) also showed that when height and weight 1994; Kannus et al., 1995; Nichols et al., 1995) sport and bone 295

also speak for the effectiveness of high-impact However, preliminary evidence suggests that if loading as an osteogenic stimulus. The strongest an athlete decreases the intensity and volume of evidence for this view is provided by recent her training but still remains physically active, at prospective studies and clinical trials. Young least part of the training-induced bone mass is female gymnasts had a higher bone mineral mass retained (Kirchner et al., 1996). in the lumbar spine compared with controls, and Studies on weight-lifters and athletes involved the bone mass increased even further after 27 in unilateral sports, such as tennis and squash, weeks of gymnastic training (Nichols et al., 1994). have probably explored the upper limits of adap- Taaffe et al. (1997) demonstrated that BMD of tive capacity attainable for human bones through the lumbar spine and femoral neck responded natural exercise. This is because the amount, dramatically to 8 and 18 months of gymnastic intensity, duration and even versatility of the training in young women. training of these athletes is hard to surpass and Clinical trials also support the aforementioned also because they started their systematic train- concept. In our recent study (Heinonen et al., ing during the optimal phase of growth and 1996a), in which an exercise regimen with a maturation. This optimal phase has also been rapidly rising force profile (jumping) was identified by cross-sectional studies on athletes; applied for 18 months, we showed significant prospective training studies on this issue are in increases in BMD (1.4–3.7%) at the loaded sites progress. Studies on athletes in unilateral sports (lumbar spine, femoral neck, distal femur, have also provided strong evidence that the patella, proximal tibia and calcaneus) in pre- unusually high bone mass at the loaded sites is menopausal women. The training consisted of the result of training and not self-selection and aerobic jumping and step exercises, in which genetic factors. Furthermore, studies on athletes the magnitude of the ground reaction forces was have revealed the risks of excessive training gradually increased by increasing the height of volume and intensity, i.e. fatigue fractures, hor- the foam fences and the number of step-benches monal imbalance and osteopenia. (Heinonen et al., 1996a). Bassey and Ramsdale Experimental studies on animals have shown (1994, 1995) and Grove and Londeree (1992) that the magnitude and rate of development of also used an impact training regimen and have strains are more powerful osteogenic characteris- shown an increase or maintenance of bone tics of physical loading than the number of strain mineral mass in premenopausal and post- cycles. Cross-sectional studies on athletes reveal menopausal women. similar findings. These have been further corro- borated by training studies showing that the strongest osteogenic effect in non-athletic Conclusion women has been induced by exercises producing Studies on athletes provide a wealth of ‘natural a high rate of strain (as impact) at high magni- experiments’ with which to gain information tude and from many directions. and insight about the influence and significance Cumulative evidence shows that bones are of physical loading on human bones. Cross- no different from other tissues and organs of the sectional studies strongly support the adaptation body. Training strengthens them to tolerate the hypothesis expressed by Wolff (1892) more than stress caused by training, but they get weaker 100 years ago and also the ‘mechanostat’ theory and lighter when stress decreases. Consequently, of Frost (1987). Thus, a substantial increase in the bones of athletes training sensibly tolerate physical loading produced by sports activity even temporary excess stresses without damage leads to a local increase in bone mineral mass, if the internal milieu determined by hormonal while unloading below the habitual level, and nutritional factors is also in balance. On the beneath the ‘physiological window’ (Turner, other hand, errors in training such as an unduly 1991), produces a local decrease in bone mass. rapid increase in volume or intensity, inappro- 296 medical issues

priate training during recovery from injuries or Bennell, K.L., Malcom, S.A., Thomas, S.A. et al. (1996) strengthening muscles excessively by using Risk factors for stress fractures in track and field ath- letes. A twelve-month prospective study. American drugs may lead to serious bone damage. Journal of Sports Medicine 24, 810–818. Bergman, G., Graichen, F. & Rohlman, A. (1993) Hip Recommendations for future research joint loading during walking and running, measured in two patients. Journal of Biomechanics 26, 969–990. There are still many opportunities for acquiring Biewener, A.A. & Bertram, J.E.A. (1993) Skeletal strain patterns in relation to exercise training during new knowledge on how bone responds to physi- growth. Journal of Experimental Biology 185, 51–69. cal loading by studying athletes. Assessment Brandi, M.L., Bianchi, M.L., Eisman, J.A. et al. (1994) techniques such as quantitative computed Genetics of osteoporosis. Calcified Tissue International tomography can be used to study the geometric 55, 161–163. properties and adaptations of bones and estimate Bronner, F. (1994) Calcium and osteoporosis. American Journal of Clinical Nutrition 60, 831–836. their strength more accurately than bone mass Canalis, E. (1993) Regulation of bone remodelling. In measurement. These techniques are important M.J. Favus (ed.) Primer on the Metabolic Bone Disease because training may result in an improvement and Disorders of Mineral Metabolism, 2nd edn, pp. in bone strength due to changes in bone geome- 33–37. Raven Press, New York. try and material quality without a notable Capozzo, A. (1983) Force actions in the human trunk during running. Journal of Sports Medicine 23, 14–22. increase in bone mineral mass. In addition, the Chen, Z., Lohman, T.G., Stini, W.A., Ritenbaugh, C. & role of the entire biomechanical environment Aickin, M. (1997) Fat or lean tissue mass: which one should be taken into consideration in future is the major determinant of bone mineral mass in studies. The knowledge that will be acquired healthy postmenopausal women? Journal of Bone and from these studies will be especially valuable Mineral Research 12, 144–151. Dalsky, G.P., Stocke, K.S., Ehsani, A.A., Slatopolsky, E., for the development of ‘bone-training’ methods Lee, W.C. & Birge, J.S. (1988) Weight-bearing exercise for the prevention of osteoporosis as well as for training and lumbar bone mineral content in post- the treatment and rehabilitation of patients with menopausal women. Annals of Internal Medicine 108, injuries and bone diseases. The applications may 824–828. include training machines comparable to those Davee, A.M., Rosen, C.J. & Adler, R.A. (1990) Exercise patterns and trabecular bone density in college used for strength and aerobic training; in fact, women. Journal of Bone and Mineral Research 5, the first versions of these machines have been 245–250. developed. Dawson-Hughes, B., Dallal, G.E., Krall, E.A., Sadowski, L., Sahyoun, N. & Tannenbaum, S. (1990) A controlled trial of the effect of calcium supplemen- References tation on bone density in postmenopausal women. New England Journal of Medicine 322, 878–883. Albala, C., Y´yñez, M., Devoto, E., Sostin, C., Zeballos, Dook, J.E., James, C., Henderson, N.K. & Price, R.I. L. & Santos, J.L. (1996) Obesity as a protective factor (1997) Exercise and bone mineral density in mature for postmenopausal osteoporosis. International female athletes. Medicine and Science in Sports and Journal of Obesity 20, 1027–1032. Exercise 29, 291–296. Bailey, D.A., Faulkner, R.A. & McKay, H.A. (1996) Doyle, F., Brown, J. & Lachance, C. (1970) Relation Growth, physical activity, and bone mineral between bone mass and muscle weight. Lancet i, acquisition. Exercise and Sports Sciences Reviews 24, 391–393. 233–266. Drinkwater, B.L., Nilson, K., Chesnut, C. III, Bremner, Bassey, E.J. & Ramsdale, S.J. (1994) Increase in femoral W.J., Shainholtz, S. & Southworth, M.B. (1984) Bone bone density in young women following high- mineral content of amenorrheic and eumenorrheic impact exercise. Osteoporosis International 4, 72–75. athletes. New England Journal of Medicine 311, 277– Bassey, E.J. & Ramsdale, S.J. (1995) Weight-bearing 286. exercise and ground reaction forces: a 12-month ran- Drinkwater, B.L., Bruemner, B. & Chesnut, C.H. (1990) domized controlled trial of effects on bone mineral Menstrual history as determinant of current bone density in healthy postmenopausal women. Bone 16, density in young athletes. Journal of the American 469–476. Medical Association 263, 545–548. sport and bone 297

Düppe, H., Gärdsell, P., Johnell, O. & Ornstein, E. (1996) females. Journal of Bone and Mineral Research 11, Bone mineral density in female junior, senior and 1751–1760. former football players. Osteoporosis International 6, Haapasalo, H., Sievänen, H., Kannus, P., Heinonen, A., 437–441. Oja, P. & Vuori, I. (1996b) Dimensions and estimated Fehling, P.C., Alekel, L., Clasey, J. & Rector, A. (1995) mechanical characteristics of the humerus after A comparison of bone mineral densities among long-term tennis loading. Journal of Bone and Mineral female athletes in impact loading and active loading Research 11, 864–872. sports. Bone 17, 205–210. Harber, V.I., Webber, L.E., Sutton, J.R. & MacDougall, Friedlander, A.L., Genant, H.K., Sadowsky, S., Byl, J.D. (1991) The effect of amenorrhea on calcaneal N.N. & Gluer, C.C. (1995) A two-year program of aer- bone density and total bone turnover in runners. obics and weight training enhances bone mineral International Journal of Sports Medicine 12, 505–508. density of young women. Journal of Bone and Mineral Hatori, M., Hasegawa, A., Adachi, H. et al. (1993) The Research 10, 574–585. effects of walking at anaerobic threshold level on Frost, H.M. (1983) The skeletal intermediary organiza- vertebral bone loss in postmenopausal women. tion. Metabolic Bone Disease and Related Research 4, Calcified Tissue International 52, 411–414. 281–290. Heinonen, A. (1997) Exercise as an osteogenic stimu- Frost, H.M. (1987) Bone ‘mass’ and the ‘mechanostat’: lus. Studies in Sport, Physical Education and Health a proposal. Anatomical Record 219, 1–9. No. 49. Academic dissertation, University of Frost, H.M. (1989) Some effects of basic multicellular Jyväskylä. unit-based remodeling on photon absorptiometry of Heinonen, A., Oja, P., Kannus, P., Sievänen, H., trabecular bone. Bone and Mineral 7, 47–65. Mänttäri, A. & Vuori, I. (1993) Bone mineral density Frost, H.M. (1990) Skeletal structural adaptations to in female athletes of different sports. Bone and mechanical usage (SATMU). 2. Redefining Wolff’s Mineral 23, 1–14. law: the remodeling problem. Anatomical Record 226, Heinonen, A., Oja, P., Kannus, P. et al. (1995) Bone 414–422. mineral density in female athletes representing Frost, H.M. (1992) The role of changes in mechanical sports with different loading characteristics of the usage set points in the pathogenesis of osteoporosis. skeleton. Bone 17, 197–203. Journal of Bone and Mineral Research 7, 253–261. Heinonen, A., Kannus, P., Sievänen, H. et al. (1996a) Frost, H.M. (1993) Suggested fundamental concepts Randomised controlled trial of effect of high-impact in skeletal physiology. Calcified Tissue International 52, exercise on selected risk factors for osteoporotic frac- 1–4. tures. Lancet 348, 1343–1347. Genant, H.K., Engele, K., Fuerst, T. et al. (1996) Heinonen, A., Sievänen, H., Kannus, P., Oja, P. & Vuori, Noninvasive assessment of bone mineral and struc- I. (1996b) Effects of unilateral strength training and ture: state of the art. Journal of Bone and Mineral detraining on bone mineral mass and estimated Research 11, 707–730. mechanical characteristics of upper limb bones in Gleeson, P.B., Protas, E.J., LeBlanc, A.D., Schneider, V.S. young women. Journal of Bone and Mineral Research & Evans, H.J. (1990) Effects of weight lifting on bone 11, 490–501. mineral density in premenopausal women. Journal of Heinonen, A., Oja, P., Sievänen, H., Pasanen, M. & Bone and Mineral Research 5, 153–158. Vuori, I. (1998) Effect of two training regimens on Grove, K.A. & Londeree, B.R. (1992) Bone density in bone mineral density in healthy perimenopausal postmenopausal women: high impact vs. low impact women: a randomized controlled trial. Journal of Bone exercise. Medicine and Science in Sports and Exercise 24, and Mineral Research 13, 483–490. 1190–1194. Heinrich, C.H., Going, S.B., Pamenter, R.W., Perry, Gunnes, M. & Lehmann, E.H. (1996) Physical activity C.D., Boyden, T.W. & Lohman, T.G. (1990) Bone and dietary constituents as predictors of forearm cor- mineral content of cyclically menstruating female tical and trabecular bone gain in healthy children resistance and endurance trained athletes. Medicine and adolescents: a prospective study. Acta Paediatrica and Science in Sports and Exercise 22, 558–563. Scandinavica 85, 19–25. Hughes, V.A., Frontera, W.R., Dallal, G.E., Lutz, K.J., Haapasalo, H., Kannus, P., Sievänen, H., Heinonen, A., Fisher, E.C. & Evans, W.J. (1995) Muscle strength and Oja, P. & Vuori, I. (1994) Long-term unilateral loading body composition: associations with bone density and bone mineral density and content in female in older subjects. Medicine and Science in Sports and squash players. Calcified Tissue International 54, Exercise 27, 967–974. 249–255. Jacobson, P.C., Beaver, W., Grubbs, S.A., Taft, T.N. & Haapasalo, H., Kannus, P., Sievänen, H. et al. (1996a) Talmage, R.V. (1984) Bone density in women: college Development of mass, density, and estimated athletes and older athletic women. Journal of mechanical characteristics of bones in caucasian Orthopaedic Research 2, 328–332. 298 medical issues

Jee, W.S.S. (1988) The skeletal tissues. In L. Weiss (ed.) nisms, and relationship with estrogen of the mechan- Cell and Tissue Biology. A Textbook of Histology, 6th edn, ically adaptive process in bone. Bone 18, S37–S43. pp. 213–254. Urban & Schwerzenberg, Baltimore. Lee, E.J., Long, K.A., Risser, W.L., Poindexter, H.B.W., Johnston, C.C., Miller, J.Z., Slemenda, C.W. et al. (1992) Gibbons, W.E. & Goldzierh, J. (1995) Variations in Calcium supplementation and increases in bone bone status of contralateral and regional sites in mineral density in children. New England Journal of young athletic women. Medicine and Science in Sports Medicine 327, 82–87. and Exercise 27, 1354–1361. Jouanny, P., Guillemin, F., Kuntz, C., Jeandel, C. & Lohman, T., Going, S., Pamenter, R. et al. (1995) Effects Pourel, J. (1995) Environmental and genetic factors of resistance training on regional and total bone affecting bone mass: similarity of bone density mineral density in premenopausal women: a ran- among members of healthy families. Arthritis and domized prospective study. Journal of Bone and Rheumatism 38, 61–67. Mineral Research 10, 1015–1024. Kannus, P., Haapasalo, H., Sankelo, M. et al. (1995) McCartney, N., Hicks, A.L., Martin, J. & Webber, C.E. Effects of starting age of physical activity on bone (1995) Long-term resistance training in the elderly: mass in dominant arm of tennis and squash players. effects on dynamic strength, exercise capacity, Annals of Internal Medicine 123, 27–31. muscle, and bone. Journal of Gerontology 50A, Kimmel, D.B. (1993) A paradigm for skeletal strength B97–B104. homeostasis. Journal of Bone and Mineral Research 8, Marcus, R., Cann, C., Madvig, P. et al. (1985) Menstrual S515–S522. function and bone mass in elite women distance Kirchner, E.M., Lewis, R.D. & O’Connor, P.J. (1995) runners. Annals of Internal Medicine 102, 158–163. Bone mineral density and dietary intake of female Martin, D. & Notelovitz, M. (1993) Effects of aerobic college gymnasts. Medicine and Science in Sports and training on bone mineral density of postmenopausal Exercise 27, 543–549. women. Journal of Bone and Mineral Research 8, Kirchner, E.M., Lewis, R.D. & O’Connor, P.J. (1996) 931–936. Effect of past gymnastics participation on adult bone Matkovic, V., Jelic, T., Wardlaw, G.M. et al. (1994) mass. Journal of Applied Physiology 80, 226–232. Timing of peak bone mass in caucasian females and Kirk, S., Sharp, C.F., Elbaum, N. et al. (1989) Effect of its implication for the prevention of osteoporosis: long-distance running on bone mass in women. inference from a cross-sectional model. Journal of Journal of Bone and Mineral Research 4, 515–522. Clinical Investigation 93, 799–808. Kohrt, W.M., Snead, D.B., Slatopolsky, E. & Birge, S.J. Myburgh, K.H., Bachrach, L.K., Lewis, B., Kent, K. & (1995) Additive effects of weight-bearing exercise Marcus, R. (1993) Low bone mineral density at axial and estrogen on bone mineral density in older and appendicular sites in amenorrheic athletes. women. Journal of Bone and Mineral Research 10, Medicine and Science in Sports and Exercise 25, 1303–1311. 1197–1202. Krall, E.A. & Dawson-Hughes, B. (1994) Walking is Myerson, M., Gutin, B., Warren, M.P. et al. (1992) Total related to bone density and rates of bone loss. body bone density in amenorrheic runners. American Journal of Medicine 96, 20–26. Obstetrics and Gynecology 79, 973–978. Lane, N.E., Bloch, D.A., Jones, H.H., Marshall, W.H., Nelson, M.E., Fiatarone, M.A., Morganti, C.M., Trice, I., Wood, P.D. & Fries, J.F. (1986) Long-distance Greenberg, R.A. & Evans, W.J. (1994) Effects of high- running, bone density and osteoarthritis. Journal of intensity strength training on multiple risk factors the American Medical Association 255, 1147–1151. for osteoporotic fractures. A randomized controlled Lanyon, L.E. (1987) Functional strain in bone tissue trial. Journal of the American Medical Association 272, as an objective and controlling stimulus for adaptive 1909–1914. bone remodeling. Journal of Biomechanics 20, 1083– Nichols, D.L., Sanborn, C.F., Bonnick, S.L., Benezra, V., 1093. Gench, B. & Dimarco, N.M. (1994) The effects of gym- Lanyon, L.E. (1990) Bone loading: the functional deter- nastics training on bone mineral density. Medicine minant of bone architecture and a physiological and Science in Sports and Exercise 26, 1220–1225. contributor to the prevention of osteoporosis. In R. Nichols, D.L., Sanborn, C.F., Bonnick, S.L., Gench, B. & Smith (ed.) Osteoporosis, pp. 63–78. Royal College of Dimarco, N. (1995) Relationship of regional body Physicians, London. composition to bone mineral density in college Lanyon, L.E. (1992) Control of bone architecture by females. Medicine and Science in Sports and Exercise functional load bearing. Journal of Bone and Mineral 27, 178–182. Research 7, S369–S375. Nieves, J.W., Golden, A.L., Siris, E., Kelsey, J.L. & Lanyon, L.E. (1996) Using functional loading to influ- Lindsay, R. (1995) Teenage and current calcium ence bone mass and architecture: objectives, mecha- intake are related to bone mineral density of hip and sport and bone 299

forearm in women aged 30–39 years. American of amenorrhea and oligomenorrhea. Journal of Bone Journal of Epidemiology 141, 342–351. and Mineral Research 10, 26–35. Nigg, B.M. (1985) Biomechanics, load analysis and Rubin, C.T. & Lanyon, L.E. (1982) Limb mechanics as sports injuries in the lower extremities. Sports a function of speed and gait: a study of functional Medicine 2, 367–379. strain in the radius and tibia of horse and dog. Journal Orwoll, E.S., Ferar, J., Oviatt, S.K., McClung, R.M. & of Experimental Biology 101, 187–211. Huntington, K. (1989) The relationship of swimming Rubin, C.T. & Mcleod, K.J. (1996) Inhibition of osteope- exercise to bone mass in men and women. Archives of nia by biophysical intervention. In R. Marcus, D. Internal Medicine 149, 2197–2200. Feldman & J. Kelsey (eds) Osteoporosis, pp. 351–371. Parfitt, A.M. (1994) The two faces of growth: benefits Academic Press, San Diego. and risks to bone integrity. Osteoporosis International Seeman, E., Hopper, J.L., Young, N.R., Formica, C., 4, 382–398. Goss, P. & Tsalamandris, C. (1996) Do genetic factors Pearce, G., Bass, S., Young, N., Formica, C. & Seeman, explain associations between muscle strength, lean E. (1996) Does weight-bearing exercise protect mass, and bone density? A twin study. American against the effect of exercise induced oligomenor- Journal of Physiology 270, E320–E327. rhea on bone density? Osteoporosis International 6, Sievänen, H., Heinonen, A. & Kannus, P. (1996) 448–452. Adaptation of bone to altered loading environment: Peterson, S.E., Peterson, M.D., Raymond, G., Gilligan, a biomechanical approach using x-ray absorptiomet- C., Checovich, M.M. & Smith, E.L. (1991) Muscular ric data from the patella of a young woman. Bone strength and bone density with weight training in 19, 55–59. middle-aged women. Medicine and Science in Sports Sievänen, H., Koskue, V., Rauhio, A., Kannus, P., and Exercise 23, 499–504. Heinonen, A. & Vuori, I. (1998) Peripheral quantita- Pocock, N.A., Eisman, J.A., Hopper, J.L., Yeates, M.G., tive computed tomography in human long bones: Sambrook, P.N. & Eben, S. (1987) Genetic determi- evaluation of in vitro and in vivo precision. Journal of nants of bone mass in adults: a twin study. Journal of Bone and Mineral Research 13, 871–882. Clinical Investigation 80, 706–710. Sinaki, M., Wahner, H.W., Bergstrahl, E.J. et al. (1996) Prince, R., Devine, A., Dick, I. et al. (1995) The effects Three-year controlled, randomized trial of the effect of calcium supplementation (milk powder or tablets) of dose-specific loading and strengthening exercise and exercise on bone density in postmenopausal on bone mineral density of spine and femur in women. Journal of Bone and Mineral Research 10, nonathletic, physically active women. Bone 19, 1068–1075. 233–244. Prior, J.C., Vigna, M.Y., Schecter, M.T. & Burgess, A.E. Slemenda, C.W. (1995) Body composition and skeletal (1990) Spinal bone loss and ovulatory disturbances. density: mechanical loading or something more. New England Journal of Medicine 323, 1221–1227. Journal of Clinical Endocrinology and Metabolism 80, Pruitt, L.A., Jackson, R.D., Bartels, R.L. & Lehnhard, 1761–1763. H.J. (1992) Weight training effects on bone mineral Slemenda, C.W. & Johnston, C.C. (1993) High intensity density in early postmenopausal women. Journal of activities in young women: site specific bone mass Bone and Mineral Research 7, 179–185. effects among male figure skaters. Bone and Mineral Pruitt, L.A., Taaffe, D.R. & Marcus, R. (1995) Effects of 20, 125–132. a one-year high-intensity vs. low-intensity resistance Slemenda, C.W., Miller, J.Z., Hui, S.L., Reister, T.K. & training program on bone mineral density in older Johnston, C.C. Jr (1991) Role of physical activity in women. Journal of Bone and Mineral Research 10, the development of skeletal mass in children. Journal 1788–1795. of Bone and Mineral Research 6, 1227–1233. Reid, I.R., Plank, L.D. & Evans, M.C. (1992) Fat mass Slemenda, C.W., Reister, T.K., Hui, S.L., Miller, J.Z., is an important determinant of whole body bone Christian, J.C. & Johnston, C.C. (1994) Influences on density in premenopausal women but not in men. skeletal mineralization in children and adolescents: Journal of Clinical Endocrinology and Metabolism 75, evidence for varying effects of sexual maturation 779–782. and physical activity. Journal of Pediatrics 125, Risser, W.L., Lee, E.J., Leblanc, A., Poindexter, H.B.W., 201–207. Risser, J.M.H. & Schneider, V. (1990) Bone density in Snow-Harter, C.M., Bouxsein, M.L., Lewis, B.T., eumenorrheic female college athletes. Medicine and Charette, S., Weinstein, P. & Marcus, R. (1990) Muscle Science in Sports and Exercise 22, 570–574. strength as a predictor of bone mineral density in Robinson, T.L., Snow-Harter, C., Taaffe, D.R., Gillis, D., young women. Journal of Bone and Mineral Research 5, Shaw, J. & Marcus, R. (1995) Gymnasts exhibit higher 589–595. bone mass than runners despite similar prevalence Snow-Harter, C., Bouxsein, M.L., Lewis, B.T., Carter, 300 medical issues

D.R. & Marcus, R. (1992) Effects of resistance and Turner, C.H. (1991) Homeostatic control of bone struc- endurance exercise on bone mineral status of young ture: an application of feedback theory. Bone 12, women: a randomized exercise intervention trial. 203–217. Journal of Bone and Mineral Research 7, 761–769. Uusi-Rasi, K., Nygård, C.-H., Oja, P., Pasanen, M., Specker, B.L. (1996) Evidence for an interaction Sievänen, H. & Vuori, I. (1994) Walking at work and between calcium intake and physical activity. Journal bone mineral density of premenopausal women. of Bone and Mineral Research 11, 1539–1544. Osteoporosis International 4, 336–340. Subotnick, S.I. (1985) The biomechanics of running: Vuori, I., Heinonen, A., Sievänen, H., Kannus, P. & Oja, implications for prevention of foot injuries. Sports P. (1994) Effects of unilateral strength training and Medicine 2, 144–153. detraining on bone mineral density and content in Suominen, H., Cheng, S. & Rahkila, P. (1992) Physical young women: a study of mechanical loading training and bone in elderly male and female on humans bones. Calcified Tissue International 55, athletes. In Abstracts of the 3rd International Conference 59–67. of Physical Activity, Aging and Sports, pp. 90–91. Wolff, J. (1892) Das Gesetz der Transformation der University of Jyväskylä, Jyväskylä. Knochen. Berlin, Germany. Cited in A. Hirschwald. Taaffe, D.R., Snow-Harter, C., Connolly, D.A., Wolman, R.L., Faulman, L., Clark, P., Hesp, R. & Robinson, T.L., Brown, M.D. & Marcus, R. (1995) Harries, M.G. (1991) Different training patterns and Differential effects of swimming vs. weight-bearing bone mineral density of the femoral shaft in elite, activity on bone mineral status of eumenorrheic ath- female athletes. Annals of the Rheumatic Diseases 50, letes. Journal of Bone and Mineral Research 10, 586–593. 487–489. Taaffe, D.R., Robinson, T.L., Snow, C.M. & Marcus, R. Young, D., Hopper, J.L., Nowson, C.A. et al. (1995) (1997) High-impact exercise promotes bone gain in Determinants of bone mass in 10- to 26-year-old well-trained female athletes. Journal of Bone and females: a twin study. Journal of Bone and Mineral Mineral Research 12, 255–260. Research 10, 558–567. Chapter 20

Women with Disabilities

KAREN P. DEPAUW

Introduction but have yet to gain the visibility afforded male athletes with disabilities (Sherrill, 1997). Individuals with disabilities have participated in sport, including competitive sport, for much of Historical perspectives the 20th century. Despite this, athletes with dis- abilities are only now gaining recognition as ath- Similar to many able-bodied women who have letes. They are experiencing increased visibility, participated in sport and sought competitive greater inclusion and ‘true’ acceptance in sport. opportunities throughout history, females with As this century comes to a close, disability sport disabilities have also sought physical activity is finally coming into its own. and sport. Although history primarily records Disability sport refers to sport ‘that has been the experiences of men, women with disabilities designed for or specifically practiced by athletes have participated in a variety of sport events with disabilities’ (DePauw & Gavron, 1995). As spanning the 20th century. an umbrella term, ‘disability sport’ is understood Women with disabilities have competed in the throughout the world to encompass sport for Olympic Games. For example, Liz Hartel (post individuals with disabilities and includes polio, Denmark) won a silver medal in dressage numerous international competitive events, pri- at the 1952 Helsinki Olympics. More recently, Ms marily the Paralympic Games, World Games for Neroli Fairhall, representing New Zealand, com- the Deaf and the International Special Olympics peted in archery during the 1984 Olympic Games (for a thorough discussion of disability sport, see in Los Angeles. As a fully acknowledged DePauw & Gavron, 1995). Olympian, she competed from her wheelchair. In The experience of athletes with disabilities in addition to these women who participated in full sport is complicated by the intersection of gender Olympic events, male and female athletes with and disability, as well as by the type of impair- disabilities competed in their first exhibition ment (e.g. spinal cord injury or cerebral palsy), events at the 1984 Winter Olympics in Sarajevo the severity of impairment (e.g. paraplegia or and the 1984 Summer Olympics in Los Angeles. quadriplegia, visual impairment or blindness) Exhibition events for the Winter Games (selected and the sport. In the fight for rights as athletes, alpine and Nordic events for physically impaired much of the struggle in disability sport has been and blind athletes) and the Summer Games focused on disability rather than on gender or (1500m wheelchair for men, 800m wheelchair race/ethnicity (see DePauw & Gavron, 1995). for women) have continued since then. In 1997, Female athletes with disabilities, fewer in after a concerted effort to integrate athletes number than their male counterparts, have been with disabilities into the Olympic Games, the present in disability sport since the early 1920s President of the International Olympic Commit- 301 302 medical issues

tee (IOC), Juan Antonio Samaranch, agreed to summer and winter competitions every 4 years bring a proposal to the IOC to incorporate these in the year following the Olympic Games. The two events as part of the Olympic Games. International Special Olympics also includes Although these efforts have not yet been success- girls and women with mental retardation among ful, there is increasing acknowledgement of dis- the competitors. ability sport by the IOC and the general public. The Boston Marathon stands as an additional Women with disabilities have also participated example of competitive opportunities for ath- in élite national and international competitions letes with disabilities. Wheelchair athletes were beyond the Olympic Games. The Paralympic among its entrants as early as 1974. The first Games represent the largest single event in female wheelchair competitor, Sharon Rahn which female athletes with disabilities are found. (Hedrick), won the 1977 Women’s Wheelchair The Summer Paralympic Games were founded Division with a time of 3 hours 48min 51s. Since by Sir Ludwig Guttman 50 years ago at Stoke then, not only have the times decreased dramati- Mandeville Hospital in Aylesbury, England. The cally but the gap between the winning times for first Paralympic Games, held in 1960 in Rome, women and for men has narrowed as well (Fig. marked the deliberate attempt by Guttman to 20.1). Currently, wheelchair men regularly finish link these games to the Olympic Games (Tiessen, under 1 hour 30min and wheelchair women 1996). Since then, the Summer Paralympic under 1 hour 45min. Although the performances Games and the Olympic Games have shared the have improved, the number of wheelchair same country (Germany 1972, Canada 1976, USA women competitors remains relatively few 1984) and, more recently, the same city for the (three to four per year). Summer and Winter Games (Seoul 1988, The Boston Marathon is but one example of Albertville 1992, Barcelona 1992, Lillehammer marathons and other road races that regularly 1994, Atlanta 1996). Bidding for the Olympic offer competitive divisions for athletes with dis- Games now includes consideration for the Para- abilities. These have resulted in increased oppor- lympic Games as well (e.g. Nagano 1998, Sydney tunities for male and female athletes with 2000, Salt Lake City 2002). Although competitors, disabilities to compete professionally in wheel- females have been underrepresented in the Para- chair road racing and marathons. Competitive lympic Games (DePauw, 1994; Sherrill, 1997). sport opportunities at the collegiate and even the According to Sherrill (1997), the male–female interscholastic level exist as well. Individuals ratio for the Barcelona Paralympic Games was 3: with physical impairments in selected uni- 1 and decreased to 4:1 at the 1996 Atlanta Para- versities, such as the University of Illinois and lympic Games. In Atlanta, of the 104 participat- Wright State University, and deaf athletes at Gal- ing countries 49 (47%) brought no female athletes laudet University have been provided with colle- and most countries brought fewer than nine giate sport experiences, including athletic female athletes (Sherrill, 1997). Given this trend scholarships in some cases. Although these sport and growing concern, the International Para- opportunities have been available to female as lympic Committee (IPC) Sports Council estab- well as male athletes with disabilities, the lished a Women’s Initiative to address the issue numbers have favoured men (DePauw & of female representation and participation in Gavron, 1995). future Paralympic Games. In an attempt to provide a historical perspec- In addition to the Paralympic Games, a large tive of sport for women with disabilities, a selec- contingent of women participates in the World tion of ‘firsts’ and other significant milestones are Games for the Deaf. Women were among the first highlighted in the Appendix. Selected world competitors in the 1924 World Games for the records held by female athletes with disabilities Deaf (Paris) and continue to participate in the appear in Table 20.1. women with disabilities 303

04:26

03:53

03:20

02:46

02:13

01:40 Time of winner (min : s) 01:06

00:33

00:00 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 Year

Fig. 20.1 Winning times for the wheelchair divisions of the first 15 years of the Boston Marathon. , men; , women.

rights movement forced society to view disabil- Disability, sport and society ity in the context of social relationships (Hanks & Poplin, 1981; Brown & Smith, 1989; Chappell, Disability rights movement 1992; Shapiro, 1993) and therefore as socially con- Throughout history, individuals with disabilities structed (constituted for, and by, those with have resided in the margins of society. The his- power). Viewing disability as a social construct torical roots of disability can be traced back to the forces us to reconceptualize sport as well. medical model that described those with disabil- ities as having a limiting condition that adversely Sport as contested terrain affected one’s performance (World Health Organization, 1980). This definition places the Historically, sport has been viewed as the ‘problem in the person’ and thereby avoids any domain of the élite. Furthermore, sport has been consideration of the role of society in the ‘cre- dominated by males and masculinity and has ation’ of disabling conditions. The traditional played a significant role in the preservation of a medical approach to disability tends to empha- patriarchal social order (Theberge, 1985). The size categorization and disability-specific pro- sporting ideals of physicality and masculinity grammes. Thus, it follows that individuals with have served as the basis for certain groups to be disabilities continue to be marginalized in excluded from, or marginalized within, sport. society and removed from its various social insti- Among the marginalized groups are women and tutions (e.g. education, employment) including individuals with disabilities and some interest- sport. ing parallels can be drawn among the groups. The disability rights movement, the most Although female athletes and athletes with recent of the civil rights movements, has chal- disabilities are participants in sport and have lenged us to revisit the traditional definition of made great strides towards acceptance as ath- disability (Shapiro, 1993). That is, the disability letes, this is far from complete. Inclusion is 304 medical issues

Table 20.1 Selected world records held by female athletes with disabilities

Event* Record Name

Athletics 100m (T12) 12.43s R. Takbulatova (former USSR) 200m (T11) 26.32s B. Mendoza (Spain) 200m (T32) 35.30s L. Mastandrea (USA) 400m (T10) 57.79s P. Santamarta (Spain) 1500m (T11) 4min 37.02s R. Batalova (former USSR) 1500m (wheelchair) 3min 30.45s L. Sauvage (Australia) Discus (F42, 43, 44) 38.92m J. Barrett (USA) Long jump (F11) 5.31m R. Lazaro (Spain) Shot put (F12) 12.54m T. Sivakova (former USSR)

Swimming 100m backstroke (S7) 1min 26.41s K. Hakonard (Iceland) 200m breaststroke (B3) 3min 3.24s G. Tjernberg (Sweden) 50m butterfly (S7) 42.65s E. Nesheim (Norway) 100m butterfly (S10) 1min 9.76s G. Dashwood (Australia) 100m butterfly (B3) 1min 7.07s E. Scott (USA) 100m freestyle (B2) 1min 4.33s T. Zorn (USA) 100m freestyle (S10) 1min 4.01s C. Hengst (Germany) 400m freestyle (S10) 4min 43.79s G. Dashwood (Australia)

* Classification of disability is given in brackets. B, blind swimming; F, field; S, swimming; T, track. T10, visually impaired, no light perception; T11/F11/B2, visually impaired, 2/60 vision; T12/F12/B3, visually impaired, 2/60 to 6/60 vision; T32, cerebral palsy, full upper body strength, independent wheelchair propulsion; F42, 43, 44, ampututations (single above knee, double below knee, single below knee); S7, good hand and arm propulsion, good trunk control, hips level, stand or sit dive start (includes individuals with amputations, cerebral palsy and other physical impairments); S10, full hand and arm propulsion, full trunk control, strong leg kick, dive start and propulsion in turns.

related to conformity to the ideals of physicality sport has been written through the eyes of white within the limits of masculinity. As the ideals of males with spinal cord injuries who use a wheel- physicality and masculinity are questioned and chair for sport competitions. Specifically, the first redefined we will see more inclusion and accep- competitive events for athletes with disabilities tance in sport of women and female athletes with in premier competitions (e.g. Olympic Games, disabilities (Fig. 20.2). Beyond the experience of marathon races) were wheelchair events. Male able-bodied female athletes, female athletes with and female athletes who use a wheelchair exem- disabilities face a double jeopardy in sport, that plify the ideals of physicality (e.g. athletic of being female and of having an impairment. It beautiful body, strength, endurance, grace) and follows that conformity to the ideals of sport athletic performance (e.g. upper body physical- assumes even greater significance. ity with lower spinal cord lesions or lower Given that disability is socially constructed, limb amputations), but are still required disability sport has been, and will continue to be, to conform to stereotypically masculine and influenced and constructed by and through feminine images. society. For example, the history of disability Sport has been viewed as a reflection of society. women with disabilities 305

Research perspectives

Background

Beginning in the1970s, research on sport for indi- viduals with disabilities was focused in two areas: (i) physiological aspects of sport perfor- mance (i.e. fitness, response to exercise); and (ii) biomechanical aspects (i.e. wheelchair propul- sion) of sport performance (DePauw, 1988). Males with spinal cord injury or recovering from polio were utilized as subjects for these early research studies. Although limited, the findings of these studies provided the basis for the follow- ing three general statements. 1 Individuals with disabilities demonstrate physiological responses to exercise similar to those of athletes without disabilities. Any differ- ences are identified with alterations in functional muscle mass, due to factors such as paralysis, amputation, osteoporosis in paralysed limbs or severity of the physical impairment, or are observed because of difficulties in comprehen- sion, motivation or mechanical inefficiency Fig. 20.2 Since 1974, wheelchair basketball has been related to specific types of impairment (e.g. considered a premier sport for female athletes with dis- abilities. (© Disability Today Publishing Group / Dan mental retardation, cerebral palsy) (Shephard, Galbraith.) 1990). In some cases, it remains unclear whether the differences in physiological responses are due to differences in physiological function or in assessment techniques. Recently, sport has been examined for its role in 2 Although a specific disability may affect the the production and reproduction of social degree of intensity, duration and frequency of inequality (Donnelly, 1996). That is, sport has exercise, evidence suggests that physiological served to produce and reinforce dominant socie- training effects can be achieved with individuals tal values that are often rooted in power and with disabilities. For example, the type of activity oppression. On the other hand, sport can also be (endurance vs. strength) influences maximum a site for resistance to those same dominant cul- oxygen consumption, e.g. wheelchair athletes tural values and for the production of social who compete in track and swimming events equality. Much of current disability sport, includ- have larger maximum oxygen uptake than those ing female athletes with disabilities, reflects the who compete in strength events. able-bodied model of sport and has therefore 3 Movement efficiency of wheelchair propulsion contributed to the reproduction of dominant has been studied in terms of rim diameter, stroke cultural values. On the other hand, the mere frequency, seat height, technique, speed, level of presence of athletes with disabilities in sport is impairment and sporting event (sprint vs. dis- an act of resistance and can contribute to the tance). With the decrease in mass of the chair, in transformative power of sport and effect change addition to individual adaptations to seat height in sport and society. and inclination, wheel camber and handrim 306 medical issues

Fig. 20.3 Improved technology and training have enhanced wheelchair racing for women with disabilities into a highly visible and competitive sport. (© Disability Today Publishing Group / Dan Galbraith.)

sizes, athletic performance (movement effi- gender, ethnicity and disability; (v) differences ciency) has increased substantially (Fig. 20.3) and similarities among athletes with and without (DePauw, 1996). disabilities, especially from physiological, bio- These statements emphasize the complexity of mechanical, sport injury and nutritional perspec- research about athletes with disabilities. Yet only tives; (vi) demographics of disability sport, two aspects of sport performance (physiology including youth sport; and (vii) legal, philoso- and biomechanics) have been highlighted and phical and historical bases of sport. These have research studies have used a highly selective served as a framework for much of the disability subject pool (e.g. white males with spinal cord sport research conducted to date. injuries or post polio who use wheelchairs). Since Recently, Reid (1998) performed a documen- the 1970s, disability sport research has become tary analysis of the disability sport research con- more sport specific, disability specific, perfor- ducted over a 10-year period using the seven mance related and subdiscipline related (e.g. research areas outlined above. He identified a sport sociology, sport physiology, sport medi- total of 344 articles on disability sport published cine) (DePauw, 1988). However, given the com- between 1986 and 1996; only 149 of these were plexity of disability sport, it is not surprising that data-based publications. He concluded that the a significant body of scientific literature is still number of data-based publications was not suffi- lacking. cient to contribute significantly to the body of Under the auspices of the Committee on Sport knowledge about disability sport and to advance for the Disabled of the United States Olympic the field. It is clear that a concerted research effort Committee, the following seven research areas is needed to increase the body of knowledge. have been identified for disability sport Efforts to revise and re-establish research (DePauw, 1986): (i) effects of training and/or priorities are currently underway through the competition, including fitness, sport perfor- Sport Science Committee of the International mance and sport classification; (ii) selection and Paralympic Committee. training of coaches, volunteers and officials; (iii) technological advances, including prostheses Female athletes with disabilities and wheelchair design; (iv) sociological/psycho- logical aspects of sport, including motivation, In a recent literature review, Turk (1996) found impact of society on sport and influence of age, the number of studies limited although there was women with disabilities 307

‘growing interest in exercise for persons with dis- letes; males with disabilities have been found to abilities’. She reported that while women were be stronger than females with disabilities. represented in a number of these studies, women These findings can be used as the foundation were found more frequently in studies on arthri- for further studies designed to investigate the tis, were less well represented in studies of spinal impact of sex and/or type and severity of impair- cord injuries and were missing altogether from ment (disability) on physiological performance. other studies. Because females have not been studied system- Women with disabilities were likewise found atically, the studies to date ‘fall short of speaking to be underrepresented in a literature review to the experience of women with spinal cord reported by DePauw (1996). Up to 1993 the litera- injury or the experience of other women with ture produced only a few studies on selected physical disabilities such as cerebral palsy’ physiological parameters of individuals with (DePauw, 1996). disabilities (i.e. body composition, pulmonary Although females with disabilities do partici- function, cardiovascular response, handgrip, pate in physical activity and sport (Fig. 20.4), forearm cranking and training regimens). very little is known about the physical activity The subjects for these investigations were patterns of girls and women with disabilities. A primarily active males with spinal cord comprehensive study conducted by Fitness injuries who used wheelchairs for physical activ- ity. None of the studies were conducted with females only. Among the findings of these studies were the following (adapted from Shep- hard, 1990). 1 Normal wheelchair propulsion does not provide a sufficient stimulus to maintain physi- cal condition. 2 Amputation and muscle atrophy due to impairment may restrict lean body mass and adversely influence accurate measures of body composition and prediction of ideal body mass. 3 Resting oxygen consumption and cardiac output may be lessened because of physical impairment (e.g. limb paralysis). 4 Increase in heart rate with exercise in spinally injured tetraplegics is less than that found in able-bodied individuals. 5 Regular participation in wheelchair sport increases cardiac stroke volume. 6 Shoulder and elbow strength in wheelchair users is greater than that in able-bodied individuals. 7 Maximum oxygen uptake is more limited in spinally injured tetraplegics compared with paraplegics; wheelchair athletes have the advan- tage of peak oxygen uptake and peak power output relative to their inactive peers. Fig. 20.4 Blind runner and sighted guide finish a 8 Higher values for isometric and isokinetic middle-distance race in stride. (© Disability Today muscle force data are found in wheelchair ath- Publishing Group / Dan Galbraith.) 308 medical issues

Canada provides the clearest data about these should be undertaken to identify and under- patterns. The results of this study indicate that stand those biological and mechanical responses only 31% of the females were physically active and adaptations to exercise that are gender and but that these females sought higher levels of disability dependent and to investigate their participation. relationship to sport performance (DePauw, Gender-specific or gender-neutral phenomena 1996). This approach could be helpful in deter- have not been systematically studied in disabil- mining research foci and in providing meaning- ity sport (DePauw, 1994; DePauw & Gavron, ful results for athletes with disabilities. 1995). Although some sport studies have Research on females athletes with disabilities included females and some have used female should draw on the literature about sport perfor- subjects only, definitive findings about the mance in general, as well as specific research on female experience and the performances of female athletes. In addition to research about female athletes with disabilities are lacking in the sport performance, disability sport research can scientific literature. Although female athletes also examine the experience of female athletes with disabilities are being sought as subjects in with disabilities, including the influence of the sport studies, the results of these studies are not social context of sport and the sociopsychological yet available. perspectives of gender, race, disability, class and sexual orientation in disability sport. Morris (1992) has advocated emancipatory research, Recommendations for future research through which traditional notions of disability It is apparent that more research is needed that are challenged. In order to conduct emancipatory specifically addresses female athletes with dis- research, it is necessary to design studies in col- abilities. In order to study physical activity/exer- laboration with female athletes with disabilities cise among females with disabilities, DePauw so that the results are applicable and meaningful (1996) argued for research on the biological or to them. mechanical responses to exercise among women via a model of interaction between gender and Conclusion disability (impairment). When this model is extended to disability sport, it implies that there Many argue that sport is a microcosm of society. are: (i) biological and mechanical responses that As a social institution, it is certain that sport are gender and disability independent (i.e. cannot remain unaffected by the political, social responses that occur regardless of one’s sex or and cultural changes occurring throughout the physical impairment, such as an increase in heart world. A number of social changes have taken rate and improved performance after training); place during the 20th century: virtually all social and (ii) biological and mechanical responses to institutions, from the religious to the military, exercise that are gender or disability specific or have been profoundly influenced by challenges dependent (i.e. responses that vary with sex, from women, members of racial and ethnic with impairment or with the interaction of sex minority groups, lesbians and gays, and indi- and impairment, such as thermal regulation, viduals with disabilities. The target of these maximum oxygen uptake or gait efficiency). protests are those who control most major social For those responses that do not vary with sex institutions in society; those who hold power or impairment, it follows that the physiological over others and those with privilege. and mechanical principles that exist for able- Disability sport has come a long way in its bodied athletes can be applied to athletes with relatively short history. Female athletes with disabilities, including females; this information disabilities are beginning to gain visibility and can be drawn from the existing research litera- acceptance as athletes alongside their male coun- ture. On the other hand, when the responses vary terparts. Though the disability sport movement with sex or with disability, or both, research came together around disability, concerns about women with disabilities 309

equity within disability sport are increasing and M.A. Nosek & M.A. Turk (eds) Women with Physical gender is but the first of these issues to face dis- Disabilities: Achieving and Maintaining Health and Well-Being, pp. 391–406. Paul H. Brookes Publishing ability sport. Co., Baltimore. World Health Organization (1980) International Classifi- References cation of Impairments, Disabilities, and Handicaps: A Manual of Classification Relating to the Consequence of Brown, H. & Smith, H. (1989) Whose ‘ordinary life’ is Disease. WHO, Geneva. it anyway? Disability, Handicap and Society 4, 105– 119. Chappell, A.L. (1992) Towards a sociological critique of Appendix: selected ‘firsts’ and the normalization principle. Disability, Handicap and significant milestones for women Society 7, 35–50. with disabilities DePauw, K.P. (1988) Sport for individuals with disabili- ties: research opportunities. Adapted Physical Activity 1924 First International Silent Games (Paris, Quarterly 5, 80–89. France); women among the competitors. DePauw, K.P. (1994) A feminist perspective on sport 1952 Liz Hartel (post polio, Denmark) wins and sports organizations for persons with disabili- silver medal in dressage at Summer ties. In R.D. Steadward, E.R. Nelson & G.D. Wheeler (eds) VISTA ’93: The Outlook, pp. 467–477. Rick Olympic Games. Hansen Centre, Edmonton, Alberta. 1957 First US National Wheelchair Games DePauw, K.P. (1996) Adapted physical activity and (New York) includes women. sport. In D.M. Krostoski, M.A. Nosek & M.A. Turk 1960 First International Games for Disabled (eds) Women with Physical Disabilities: Achieving and (Paralympics) in Rome, Italy; women Maintaining Health and Well-being, pp. 419–430. Paul H. Brookes Publishing Co., Baltimore. among the competitors. DePauw, K.P. & Gavron, S.J. (1995) Disability and Sport. 1968 International Special Olympics founded Human Kinetics Publishers, Champaign, Illinois. by Eunice Kennedy Shriver; first competi- Donnelly, P. (1996) Approaches to social inequality in tion held in Chicago; girls and women the sociology of sport. Quest 48, 221–242. among competitors. Fitness Canada. Physical Activity and Women with Dis- abilities: A National Survey. Fitness Canada Women’s 1974 UNESCO conference establishes right of Program, Ottawa. individuals with disabilities to participate Hanks, M. & Poplin, D.E. (1981) The sociology of physi- in physical education and sport; rights cal disability: a review of literature and some secured for females as well as males. conceptual perspectives. Deviant Behavior: An Inter- 1977 Sharon Rahn (Hedrick) becomes the first disciplinary Journal 2, 309–328. Morris, J. (1992) Personal and political: a feminist per- athlete to win the women’s wheelchair spective on researching physical disability. Disability, division of the Boston Marathon with a Handicap and Society 7, 157–166. winning time of 3 hours 48min 51s. Reid, G. (1998) A documentary analysis of research pri- 1982 Karen Farmer (a single-leg amputee) orities in disability sport. Adapted Physical Activity becomes one of the first to earn an athletic Quarterly 2, 168–178. Shapiro, J. (1993) No Pity: People with Disabilities Forging scholarship and to compete in the track a New Civil Rights Movement. Times Books, New York. team for Eastern Washington University. Shephard, R.J. (1990) Fitness in Special Populations. Karen also the first winner of the Women’s Human Kinetics Publishers, Champaign, Illinois. Sports Foundation Up and Coming Sherrill, C. (1997) Paralympic Games 1996: feminist Award in the physically challenged divi- and other concerns. What’s your excuse? Palaestra 13, 32–38. sion. Theberge, N. (1985) Toward a feminist alternative to Blind women compete for the first time sport as a male preserve. Quest 37, 193–202. in the World Goal Ball Championships at Tiessen, K. (1996) Paralympic history. In Xth Paralympic Butler University. Games: The Official Commemorative Program, p. 24. 1983 First international women’s wheelchair Disability Today Publishing Group. Turk, M.A. (1996) The impact of disability on fitness in basketball tounament held in France sepa- women: musculoskeletal issues. In D.M. Krostoski, rately from the Paralympics. 310 medical issues

1984 Neroli Fairhall (New Zealand) becomes gold medal in 800m wheelchair event in a first wheelchair athlete to be eligible for time of 2min 11.49s. and compete in Summer Olympic Games; 1989 Seven women (and seven men) become competes in women’s archery. first winners of the US Disabled Athletes First wheelchair races as exhibition of the Year Award. events for 1984 Olympic Games: 1500m 1990 Dr Donalda Ammons is appointed the won by Paul Van Winkle (Belgium) in 3 first deaf female director of the US team min 58.5s; 800m won by Sharon Rahn for the World Games for the Deaf. Hedrick (USA) in 2min 15.5s. 1991 Jean Driscoll (USA) becomes the first October issue of Runner’s World is the athlete with a disability to win the first commercial magazine to run a full- Sudafed Female Athlete of the Year. length article on a disabled athlete, Linda Sue Moucha (USA) is the first athlete Down, a Class 5 cerebral palsied athlete with a disability to attend the Inter- who completed the 1982 New York national Olympic Academy in Greece. Marathon in 11 hours 15min. Jan Wilson is named the first Coordina- 1988 Candace Cable-Brooks wins the women’s tor, Disabled Sport Programs, US Olympic wheelchair division of the Boston Committee. Marathon for the sixth time in 2 hours 1992 Connie Hansen (Denmark) and Candace 10min 44s. Cable (USA) become the only two women After her gold medal performance to compete in all Summer Olympic exhibi- in the disabled skiing exhibition event tion events. during the Winter Olympics in Calgary, Tanni Grey (UK) is named the Sunday Daina Golden becomes an official Times Sportswoman of the Year by Her spokesperson for the ChapStick Chal- Majesty the Queen. lenge for Disabled Skiing and signs a Tricia Zorn (USA) wins 12 medals (10 corporate sponsorship agreement with gold, 2 silver) at the Paralympic Games in Subaru, who supply the official car for the Barcelona (also won 12 at 1988 Paralympic US Disabled Ski Team. Games in Seoul, South Korea). Winter Olympics in Calgary include 1994 Monique Kalkman (The Netherlands) exhibition events (three alpine, blind earns the title of Amsterdam’s Sports- Nordic) for males and females. woman of the Year. Summer Olympics (South Korea) 1996 Jean Driscoll (USA) becomes the first include wheelchair races as exhibition athlete to win the Boston Marathon for the events (1500m for men, 800m for seventh time. women); Sharon Hedrick wins second (Adapted from DePauw & Gavron, 1995.). Chapter 21

Exercise-related Anaemia

SALLY S. HARRIS

–1 Introduction 0.5g·dl lower in Blacks, while Hct is 4% higher for each 1000m (3280 feet) increase in altitude. Anaemia is one of the most common medical On an individual basis, significant overlap exists conditions encountered among adolescent and between normal and abnormal values, so the adult women, and may be more common in diagnosis of anaemia must be made relative to an female athletes than non-athletes for a variety of individual’s baseline normal range. For example, reasons. When unrecognized and untreated, an Hb value of 13g·dl–1, although within the anaemia can impair athletic performance and normal range, may represent anaemia for a general well-being. Anaemia is easily diagnosed woman whose normal baseline Hb level is and treated and is usually preventable, and 13.5g·dl–1. Alternatively, an Hb value of therefore is particularly amenable to screening. 11.5g·dl–1, although below the normal range, Iron-deficiency anaemia is the most common may not represent anaemia for a woman in type of anaemia seen among female athletes. whom this is the normal baseline level. Although frank anaemia is easy to diagnose, mild iron-deficiency anaemia can be difficult to Dilutional pseudoanaemia: distinguish from non-anaemic iron deficiency ‘sports anaemia’ and other types of exercise-related anaemias. Two types of anaemia are unique to athletes: In active women, low Hb and Hct values may not dilutional pseudoanaemia and exercise-induced represent disease if they are due to dilutional haemolysis. These conditions must be differenti- psuedoanaemia, also referred to as ‘sports ated from iron-deficiency anaemia when evalu- anaemia’. In this condition a natural dilution of ating and treating anaemia in female athletes. Hb occurs as a result of the increased plasma volume associated with endurance exercise train- Criteria for anaemia: interpretation of ing, resulting in artificially low values of Hb and haemoglobin and haematocrit values Hct. The acute effect of exercise is to reduce plasma volume by 10–20%, resulting in haemo- By strict criteria, anaemia is present if haemoglo- concentration. Three mechanisms are thought to bin (Hb) or haematocrit (Hct) values fall below cause this change: (i) increased capillary hydro- the normal range. In adolescent and adult static pressure due to increased mean arterial females, the normal range for Hb is between 12 pressure and muscular compression on venules; and 16g·dl–1 and for Hct is between 36% and (ii) increased tissue osmotic pressure due to pro- 46%. Normal ranges represent two standard duction of lactic acid and other metabolites; and deviations from the mean (i.e. 95% of the popula- (iii) filtered plasma lost as perspiration. A com- tion will fall into this range). Hb is typically pensatory rise in baseline plasma volume then 311 312 medical issues

occurs due to exercise-induced release of aldos- running activities and seems to be associated terone, renin and vasopressin. This increase in with duration of activity (Selby & Eichner, 1986). plasma volume is proportional to the amount and In these circumstances, RBCs may be damaged intensity of endurance exercise. For example, a by injury caused by muscular contraction, acido- 5% increase in plasma volume can result from a sis or increased body temperature. moderate jogging programme, while the training This form of anaemia can be distinguished of an élite distance runner can induce a 20% from other forms by the diagnostic triad of increase (Brown et al., 1985). The increase in macrocytosis, reticulocytosis and low haptoglo- plasma volume appears and disappears within a binaemia with or without haemoglobinuria. few days of initiation or cessation of training. Macrocytosis occurs because older, smaller RBCs The compensatory increase in plasma volume are preferentially destroyed. Reticulocytosis artificially lowers Hb and Hct values. Although occurs in response to haemolysis; however, it is Hb concentration decreases due to this dilutional often absent if haemolysis is mild. Low haptoglo- effect, red blood cell mass remains normal or is bin occurs because destroyed RBCs release Hb often increased; therefore, the oxygen-carrying that is then bound by haptoglobin and removed capacity of the blood is not impaired (hence the by the liver. If the haptoglobin supply in the term ‘pseudoanaemia’). In fact, the phenomenon bloodstream is depleted, free Hb is excreted into may represent a favourable adaptive response to the urine producing haemoglobinuria. training whereby increased plasma volume and The condition is most commonly observed in less viscous blood allows increased oxygen middle-aged distance runners, particularly those delivery to tissues during exercise. who are overweight, run on hard surfaces, wear This condition is most commonly observed in poorly cushioned shoes and run with a stomping élite endurance athletes, in previously sedentary gait. Prevention and treatment therefore focuses individuals initiating an exercise programme on encouraging runners to have lean body com- and among athletes who are increasing their position, run on soft surfaces, run light on their training intensity. This type of anaemia can be feet and wear well-cushioned shoes and insoles. distinguished from iron-deficiency anaemia For most athletes, exercise-induced haemolysis because it is not hypochromic or microcytic, iron is of little consequence, since it is rarely severe indices are normal, it does not respond to iron enough to cause appreciable iron loss. However, supplementation and it is unlikely to result in the potential for haemolysis to limit RBC mass severe anaemia. can cause fractional physiological differences that may result in a competitive disadvantage for world-class athletes. Exercise-induced haemolytic anaemia Exercise-induced haemolytic anaemia results Iron-deficiency anaemia from intravascular haemolysis during exercise and can result in iron depletion. Intravascular Pathophysiology: the three stages of haemolysis can occur in both high- and low- iron deficiency impact sports. In high-impact sports such as running, it is thought that the physical trauma of There are three stages of iron deficiency. Iron repetitive hard foot strikes leads to the destruc- stores are depleted before clinically recognized tion of red blood cells (RBCs). For this reason the anaemia occurs. In stages I and II, which repre- terms ‘runner’s macrocytosis’ and ‘foot strike sent non-anaemic iron deficiency, Hb and Hct haemolysis’ have been used to describe this con- levels are normal. Low Hb and Hct values are dition. However, intravascular haemolysis has only present in stage III, which represents clini- also been documented among competitive cally recognized anaemia. The characteristics of swimmers and other athletes not participating in each stage are shown in Table 21.1. exercise-related anaemia 313

Table 21.1 Stages of iron deficiency deficiency anaemia from other exercise-related anaemias (Table 21.3). In most cases, however, Stage I: iron depletion a ferritin level will be sufficient to make the Characterized by ferritin < 12mg·l-1 indicating depletion of iron stores in the bone marrow diagnosis. Other indices of iron status remain normal (haemoglobin, haematocrit, free erythrocyte ferritin protoporphyrin (FEP), serum iron, total iron- binding capacity (TIBC), transferrin saturation) Ferritin is the most useful indicator of iron defi- Duration of several months ciency because it most closely reflects the status Stage II: iron-deficient erythropoiesis of iron stores in the body. A serum ferritin con- Characterized by decreased iron transport, marked by centration of <12mg·l–1 represents complete low serum iron, increased TIBC, decreased depletion of iron stores in the bone marrow; transferrin saturation, increased FEP 12–20mg·l–1 represents minimal iron stores; >20 Haemoglobin and haematocrit remain normal –1 Duration of several weeks mg·l represents adequate iron stores. An average ferritin value for young women is 30 Stage III: iron-deficiency anaemia µg·l–1. Ferritin values are elevated by acute This is the stage that is clinically recognized as inflammation, infection and liver disease. Train- anaemia ing intensity can also affect ferritin values, as Characterized by diminished haemoglobin production Low haemoglobin and haematocrit well as other haematological indicators of iron Decreased mean corpuscular volume status. During high-intensity training, ferritin Hypochromic microcytic red blood cells decreases while serum iron and transferrin satu- ration increase. When training is reduced, these changes reverse and ferritin increases while transferrin saturation decreases (Banister & Hamilton, 1985). While ferritin and Hb values Differential diagnosis of iron deficiency usually suffice to make the diagnosis of iron defi- When frank anaemia is present, the diagnosis of ciency and distinguish it from other exercise- iron-deficiency anaemia can be made on the basis related anaemias (Table 21.3), occasionally other of RBC indices alone. These will indicate the iron indices are needed to sort out the effects that classic findings of hypochromic (low mean cor- inflammation, infection and training can have on puscular volume) microcytic (low mean corpus- iron status. cular Hb concentration) anaemia. Medical history is usually sufficient to distinguish iron- Prevalence of iron deficiency in deficiency anaemia from the other causes of female athletes hypochromic microcytic anaemia, such as lead toxicity (rare outside of childhood), thalassaemia Iron deficiency is a prevalent condition among (associated family history and ethnicity) and women due to iron loss in menstrual blood. For chronic disease. Since Hb and Hct values below this reason, the prevalence is higher in females the normal range, as well as hypochromic and than males after puberty. Adolescent girls may be microcytic changes, are very late indicators of particularly susceptible because of increased iron anaemia, it is often necessary to look beyond Hb needs to meet the demands of growth and to and Hct when screening for the earlier stages of counteract the onset of menses; their suboptimal iron-deficiency anaemia. There are numerous dietary practices may play a role as well. Simi- haematological indicators of iron status (Table larly, pregnant women need additional iron to 21.2) whose values are affected during different support red cell volume expansion and the stages of iron deficiency (see Table 21.1) and growth of the fetus and placenta. Postmeno- which can be helpful in differentiating iron- pausal women and amenorrhoeic women have 314 medical issues

Table 21.2 Diagnostic tests for iron deficiency

Test Normal range (women)

Haemoglobin 12–16g·dl-1 (1.86–2.48mmol·l-1) Haematocrit 36–46% Serum ferritin concentration 12–150mg·l-1 in females 15–200mg·l-1 in males Transferrin saturation 20–55% Serum iron 40–150mg·dl-1 in females (7.16–26.85mmol·l-1) 50–160mg·dl-1 in males (8.95–28.64mmol·l-1) Total iron-binding capacity 250–400mg·dl-1 (44.75–71.60mmol·l-1) Serum erythroprotoporphyrin < 1.24mmol·l-1 concentration Mean corpuscular volume 80–100fl Mean corpuscular haemoglobin 4.81–5.74mmol·l-1 concentration Reticulocyte count 0.5–1.5% Haptoglobin 30–175mg·dl-1 (6.20–27.90mmol·l-1)

Table 21.3 Laboratory test profile of exercise-related anaemias

Haemoglobin/ Reticulocyte haematocrit Red blood cell size Serum ferritin count

Non-anaemic iron deficiency --Ø-

Iron-deficiency anaemia ØØØ-

Dilutional pseudoanaemia Ø---

Exercise-induced anaemia Ø≠-≠or -

≠, increase; Ø, decrease; -, no change. reduced iron needs due to lack of menstruation. status of female athletes to be similar or some- In the USA, the prevalence of non-anaemic iron what worse than non-athletes (Parr et al., 1984; deficiency in the general population is estimated Brown et al., 1985; Risser et al., 1988). However, to be approximately 30% for adult women and studies of some female athletes have shown a 39% for adolescent girls; the prevalence of iron- substantially higher prevalence, particularly in deficiency anaemia is just under 6% for both ado- high-school runners (Plowman & McSwegin, lescent and adult females (Expert Scientific 1981; Brown et al., 1985) and swimmers Working Group, 1985). (Rowland & Kelleher, 1989). In general, studies in It is unclear whether the prevalence is higher high-school and college female athletes report among female athletes than non-athletes because prevalences of 0–19% for iron-deficiency prevalence estimates vary according to the popu- anaemia and 20-62% for non-anaemic iron defi- lation studied. Most studies have shown the iron ciency (Plowman & McSwegin, 1981; Nickerson exercise-related anaemia 315

& Tripp, 1983; Clement & Asmundson, 1984; Parr gastrointestinal losses et al., 1984; Brown et al., 1985; Nickeson et al., 1985; Haymes et al., 1986; Risser et al., 1988; Occult gastrointestinal blood loss is common in Haymes & Spillman, 1989; Nickerson et al., 1989; runners. An estimated 8–85% of runners test pos- Rowland & Kelleher, 1989). itive for faecal occult blood following their runs (McMahon et al., 1984; Stewart et al., 1984; McCabe et al., 1986; Robertson et al., 1987; Baska Effects of training on iron status et al., 1990) and 2% of marathon runners A higher than normal prevalence of iron defi- and triathletes have visible blood in stools ciency among some female athletes suggests that after races (Eichner, 1989). Average gas- training may contribute to negative iron balance. trointestinal loss of iron for a sedentary woman A study in female field hockey players found a is 0.45mg daily (Dubach et al., 1955). A recent progressive decline in ferritin values over each of study showed that physically active women three consecutive seasons (30–37% reduction of expending >2520kJ (600kcal) daily during exer- ferritin per season), normalizing between cise lost 1mg of iron through faecal blood loss seasons (Deihl et al., 1986). Studies following the daily, which was twice as much as that lost by iron status of female high-school and college ath- sedentary women expending <420kJ (100kcal) letes over a competitive season found that 16% of daily during exercise (Lampe et al., 1991). males and 20% of females with initially normal Although the exact cause is unclear, gastroin- iron status developed non-anaemic iron defi- testinal blood loss probably occurs as a result of ciency but none developed anaemia (Frederick- bowel ischaemia. Some evidence suggests that son et al., 1983; Nickerson et al., 1985, 1989; individuals who experience gastrointestinal Haymes et al., 1986; Rowland et al., 1987; Risser et symptoms during exercise, such as diarrhoea al., 1988). Most athletes who developed non- or cramping, have higher gastrointestinal anaemic iron deficiency were treated with iron blood loss. Use of aspirin or non-steroidal anti- supplementation; therefore it is unknown what inflammatory drugs may also increase gastroin- proportion would have developed anaemia in testinal blood loss. the absence of intervention. In most studies, the development of non-anaemic iron deficiency impaired gastrointestinal during training was found to be preventable by absorption of iron iron supplementation. Poor response in some studies may have been due to inadequate iron Iron absorption from the gastrointestinal tract dosage, poor compliance or ongoing gastro- usually increases in response to iron deficiency. intestinal blood loss. However, evidence suggests that this compen- satory response is blunted in athletes. For example, one study found that iron-deficient Mechanisms of iron deficiency in athletes runners absorb 16% of iron from the gastro- Besides exercise-induced haemolysis, a number intestinal tract compared with 30% in iron- of other mechanisms may contribute to negative deficient non-athletes (Ehn et al., 1980). iron balance during training. These mechanisms include loss of iron through the gastrointestinal sweat losses tract, sweat, urine or menses; impaired gastroin- testinal absorption of iron; and inadequate iron Iron lost in sweat by female runners during exer- intake. However, the predominant cause of iron cise averages 0.28mg·h–1 (Lamanca et al., 1988). deficiency is inadequate iron intake to compen- Unless exercise is prolonged, iron loss through sate for menstrual loss of iron. sweat is usually negligible. 316 medical issues

urinary losses to obtain the RDA of iron. However, many female athletes consume <8400kJ (2000kcal) Urinary loss of iron can occur due to haematuria daily, particularly female athletes participating resulting from urinary tract microtrauma or in sports emphasizing lean body physique. In haemoglobinuria secondary to marked intravas- addition, many female athletes eat a modified cular haemolysis. Under usual circumstances, vegetarian diet, which poses increased risk due urinary loss of iron is minimal. to lower bioavailability and quantities of iron in non-meat foods. menstrual losses Effects on performance Menstrual blood loss is the primary source of iron loss in female athletes and non-athletes. Anaemia clearly impairs physical performance Average menstrual blood loss during a period is and correlates with diminished maximum approximately 34ml (Hallberg et al., 1966), which oxygen consumption, decreased physical work translates to an additional iron requirement of capacity, lower endurance, increased lactic aci- 0.55mg daily (Haymes, 1993). However, men- dosis and increased fatigue (Nickerson & Tripp, strual blood loss during a period can range from 1983; Risser et al., 1988; Rowland et al., 1988). The 1.6 to 200ml and therefore iron loss can vary sig- correlation between Hb levels and exercise nificantly (Hallberg et al., 1966). Women who lose capacity and diminished performance by ath- more than 60ml during a period are more sus- letes participating in endurance events is well ceptible to iron deficiency (Hallberg et al., 1966). known. The unresolved question is whether iron The method of contraception may also affect the deficiency in the absence of anaemia (non- amount of blood lost per menses; use of oral con- anaemic iron deficiency) impairs performance. traceptives can decrease blood loss by 50%, while In the absence of a reduction in Hb levels, iron use of an intrauterine device can double the deficiency is unlikely to reduce oxygen delivery amount of blood loss (Hallberg & Rossander- to the tissues, as is the case when anaemia is Hulten, 1991). While one would expect amenor- present. However, non-anaemic iron deficiency rhoeic athletes to have a lower prevalence of iron may diminish performance by other mecha- deficiency because they do not menstruate, a nisms, for example impairment of iron- study of élite marathon runners found that the dependent metabolic processes at the cellular prevalence was higher in amenorrhoeic than level such as energy production by mitochond- eumenorrhoeic runners (Deuster et al., 1986). Pre- rial cytochromes. sumably a lower dietary intake of iron counter- Studies in rats suggest that iron deficiency acts the protective effect of lack of menstruation in the absence of anaemia can impair physical in these amenorrhoeic runners. performance and endurance capacity (Finch et al., 1976; McLane et al., 1981). However, these inadequate dietary intake of iron findings have not been replicated in humans. Celsing et al. (1986) induced anaemia in men by Inadequate dietary intake of iron is the pre- repeated phlebotomies and then reinfused RBCs eminent cause of iron deficiency in female ath- in order to restore RBC volume, creating a non- letes. In the USA, the recommended daily anaemic iron-deficient state. Although maximal allowance (RDA) for iron to meet basal require- oxygen consumption and endurance were ments is 15mg of females and 10mg for males. clearly diminished when the men were tested The iron needs of some women may be appre- while anaemic, both measures returned to ciably greater. The average diet in the USA con- normal when RBC volume was restored tains 5–7mg of iron per 4200kJ (1000kcal). (although the men were still iron deficient), Therefore, women need 12.6MJ (3000kcal) daily suggesting that anaemia impairs performance exercise-related anaemia 317

as a consequence of reduced oxygen-carrying sumed non-anaemic iron deficiency do respond capacity. to iron supplementation and will show increases Studies of the effects of iron supplementation in Hb values that can lead to improvements in on the performance of non-anaemic iron-defi- performance. Therefore, these women are actu- cient athletes have produced conflicting results. ally mildly anaemic, although their Hb falls No studies have shown improvements in within the normal range, and will benefit from maximal oxygen consumption, although studies iron supplementation. One must weigh the in female runners following iron supplementa- potential benefits of supplementation against the tion have shown improvements in measures of potential risks, such as cost of supplementation, endurance, such as treadmill times (Rowland et gastrointestinal distress and haemochromatosis al., 1988), run times (Yoshida et al., 1990), lower associated with overdosage. blood lactate levels during submaximal exercise (Schoene et al., 1983; Lamanca & Haymes, 1989) Screening for iron deficiency and appreciable improvements in treadmill times that did not reach statistical significance The clinical manifestations of iron deficiency are (Lamanca & Haymes, 1989). In many instances, rare unless anaemia is severe. Potential signs and iron supplementation also led to improvements symptoms of iron deficiency include exercise in Hb levels, suggesting that the beneficial effects fatigue, muscle burning, nausea, dyspnoea, were seen because of correction of a mild pagophagia, pica, pallor, koilonychia, cheilosis anaemia. These studies illustrate two important and glossitis. Non-haematological manifesta- points: (i) it is clinically difficult to distinguish tions of iron deficiency include susceptibility to mild anaemia from non-anaemic iron deficiency; infection, impaired attention span and altered and (ii) although an Hb value may technically mental function (Oski, 1979; Dallman, 1982; fall in the normal range, it may nevertheless rep- Bruner et al., 1996). However, in most cases the resent mild anaemia that will respond to iron condition will be asymptomatic and will not be supplementation. However, other studies have recognized unless screening blood work is done. failed to show beneficial effects on performance While it would be ideal to screen all female ath- of the iron supplementation of non-anaemic letes for iron deficiency on a yearly basis, in iron-deficient athletes (Matter et al., 1987; New- many settings this is not feasible and the cost house et al., 1989; Fogelholm et al., 1992), suggest- may be prohibitive. Therefore screening should ing that when Hb levels are not improved iron be directed towards those athletes at highest risk. supplementation does not improve perfor- Table 21.4 lists risk factors for anaemia that can mance, despite an increase in ferritin levels. be addressed during a medical history to identify

Should non-anaemic iron deficiency be treated? Table 21.4 Risk factors for anaemia in female athletes

Iron should not be administered solely to Disadvantaged socioeconomic background improve athletic performance, as it is unclear Dietary restriction: vegetarian diet, weight-loss diets whether non-anaemic iron deficiency impairs or fad diets Intense or prolonged endurance training performance. Iron therapy may be indicated for Personal or family history of anaemia, bleeding non-anaemic iron-deficient athletes in order to disorders or chronic disease prevent development of anaemia and reduce the Excessive menstrual flow: increased duration, non-haematological manifestations of iron defi- frequency or volume ciency. From a practical standpoint, it is often dif- Use of anti-inflammatory medications Volunteer blood donor ficult to distinguish non-anaemic iron deficiency Childbirth from mild anaemia. Many women with pre- 318 medical issues

Table 21.5 Prevention of iron deficiency: strategies to Table 21.6 Treatment of iron deficiency: iron increase dietary intake of iron supplementation

Ingest iron-rich foods Dosage Meat sources: lean red meat, dark meat of poultry, For iron-deficiency anaemia (ferritin < 12mg·l-1, low fish haemoglobin) Non-meat sources: cereals, pasta and bread enriched 50–100mg elemental iron three times daily with iron, dried fruits, beans, tofu, spinach (6mg·kg-1 daily), e.g. 325mg ferrous sulphate Meat sources of iron are absorbed better than non- three times daily meat sources of iron Confirm response to supplementation by rise of Enhance iron absorption from foods by concurrently 1g·dl-1 in haemoglobin after 4–6 weeks ingesting foods containing vitamin C, such as fruit Serum haemoglobin concentration is usually juices completely corrected within 2 months Avoid inhibitors of iron absorption: tannic acid (tea), Reticulocytosis is seen in 5–10 days phytic acid (wheat bran), calcium salts (milk), Continue treatment for 6–8 months to replenish iron antacids stores and restore normal ferritin level Cook in iron skillets For non-anaemic iron deficiency (ferritin 12–20mg·l-1, If unable to meet daily iron needs through diet, a normal haemoglobin) supplement containing the RDA for iron (15mg), 50–100mg elemental iron once daily*, e.g. 325mg such as a multivitamin with iron, is recommended ferrous sulphate daily Continue supplementation until ferritin > 20mg·l-1 RDA, recommended daily allowance. (several months)*

Practical tips Iron salts contain varying amounts of elemental iron: those for whom further evaluation would be a sulphate, 20%; fumarate, 11%; gluconate, 33% priority. Ferrous salts are better absorbed than ferric salts There is little difference in rate of absorption among various ferrous salt forms Prevention of iron deficiency Ferrous sulphate is cheapest Avoid sustained-release or enteric-coated products Preventive efforts should focus on ensuring ade- Enhance absorption by taking supplements with quate dietary intake of iron. This depends on not vitamin C, without other competing supplements, on an empty stomach only the amount of iron ingested but also the Side-effects of gastrointestinal symptoms are lessened bioavailability of iron sources. Strategies to by gradual progression of the dosage from once increase dietary intake of iron are presented in daily to three times daily as tolerance develops Table 21.5. The bioavailability of iron is greater in food sources than in iron supplements so it *Risser & Risser (1990). is preferable to meet daily iron needs through food sources. However, if unable to meet daily iron needs through diet alone, iron supplements References containing the RDA for iron (15mg) are recommended. Banister, E.W. & Hamilton, C.L. (1985) Variations in iron status with fatigue modelled from training in female distance runners. European Journal of Applied Treatment of iron deficiency Physiology 54, 16–23. Baska, R.S., Moses, F.M., Graeber, G. & Kearny, G. Iron supplementation is the mainstay of treat- (1990) Gastrointestinal bleeding during an ultrama- ment of iron deficiency, as it is usually not feasi- rathon. Digestive Diseases and Science 35, 276–279. ble to increase dietary intake of iron sufficiently Brown, R.I., McIntosh, S.M. & Seaboth, V.R. (1985) Iron status of adolescent female athletes. Journal of Adoles- to reverse iron deficiency. Dosage and practical cent Health Care 6, 349–352. tips for iron supplementation are provided in Bruner, A.B., Joffe, A., Duggan, A.K., Casella, J.F. & Table 21.6. Bandt, J. (1996) Randomised study of cognitive exercise-related anaemia 319

effects of iron supplementation in non-anemic iron- women. International Journal of Sports Medicine 10, deficient adolescent girls. Lancet 348, 992–996. 430–433. Celsing, F., Blomstrand, E., Werner, B., Pihlstedt, P. & Haymes, E.M., Puhl, J.L. & Temples, T.E. (1986) Train- Ekblom, B. (1986) Effects of iron deficiency on ing for crosscountry skiing and iron status. Medicine endurance and muscle enzyme activity in man. Med- and Science in Sports and Exercise 18, 162–167. icine and Science in Sports and Exercise 18, 156–161. Lamanca, J. & Haymes, E. (1989) Effects of dietary iron Clement, D.B. & Asmundson, R.C. (1984) Iron status supplementation on endurance. Medicine and Science and sports performance. Sports Medicine 1, 65–74. in Sports and Exercise 21, S77. Dallman, P.R. (1982) Manifestations of iron deficiency. Lamanca, J.J., Haymes, E.M., Daly, J.A., Moffatt, R.J. & Seminars in Hematology 19, 19–30. Waller, M.F. (1988) Sweat iron loss of male and Deihl, D.M., Lohman, T.G., Smith, S.C. & Kertzer, R. female runners during exercise. International Journal (1986) The effects of physical training on iron status of Sports Medicine 9, 52–55. of female field hockey players. International Journal of Lampe, J.W., Slavin, J.L. & Apple, F.S. (1991) Iron status Sports Medicine 7, 264–270. of active women and the effect of running a Deuster, P.A., Kyler, S.B., Moser, P.B., Vigersky, R.A., marathon on bowel function and gastrointestinal Singh, A. & Schoomaker, E.B. (1986) Nutritional blood loss. International Journal of Sports Medicine 12, intakes and status of highly trained amenorrheic and 173–179. eumenorrheic women runners. Fertility and Sterility McCabe, M.E., Peura, D.A., Kadakia, S.C., Bocek, Z. & 46, 636–643. Johnson, L.F. (1986) Gastrointestinal blood loss asso- Dubach, R., Moore, C.V. & Callender, S. (1955) Studies ciated with running a marathon. Digestive Diseases in iron transportation and metabolism. IX. The excre- and Science 31, 1229–1232. tion of iron as measured by the isotope technique. McLane, J.A., Fell, R.D., McKay, R.H., Winder, W.W., Journal of Laboratory and Clinical Medicine 45, 599– Brown, E.B. & Holloszy, J.O. (1981) Physiological and 615. biochemical effects of iron deficiency on rat skeletal Ehn, L., Carmark, B. & Hoglund, S. (1980) Iron status in muscle. American Journal of Physiology 241, C47–C54. athletes involved in intense physical activity. Medi- McMahon, L.F., Ryan, M.J. & Larson, D.L. (1984) Occult cine and Science in Sports and Exercise 12, 61–64. gastrointestinal blood loss in marathon runners. Eichner, E.R. (1989) Gastrointestinal bleeding in ath- Annals of Internal Medicine 100, 846–847. letes. Physician and Sportsmedicine 17, 128–140. Matter, M., Stittfall, I., Graves, J. et al. (1987) The effect Expert Scientific Working Group (1985) Summary of a of iron and folate therapy on maximal exercise per- report on assessment of the iron nutritional status of formance in female marathon runners with iron and the United States population. American Journal of folate deficiency. Clinical Science 72, 415–422. Clinical Nutrition 42, 1318–1330. Newhouse, I.J., Clement, D.B., Taunton, J.E. & McKen- Finch, C.A., Miller, L.R., Inamdar, A.R., Person, R., zie, D.C. (1989) The effect of prelatent/latent iron Seiler, K. & Mackler, B. (1976) Iron deficiency in the deficiency on physical work capacity. Medicine and rat. Journal of Clinical Investigation 58, 447–453. Science in Sports and Exercise 21, 263–268. Fogelholm, M., Jaakkola, L. & Lampisjavi, T. (1992) Nickerson, H.J. & Tripp, A.D. (1983) Iron deficiency Effects of iron supplementation in female athletes in adolescent cross-country runners. Physician and with low serum ferritin concentration. International Sportsmedicine 11, 60–66. Journal of Sports Medicine 13, 158–162. Nickerson, H.J., Holubets, M., Tripp, A.D. & Pierce, Frederickson, L.A., Puhl, J.L. & Runyan, W.S. (1983) W.E. (1985) Decreased iron stores in high school Effects of training on indices of iron status of young female runners. American Journal of Diseases of Chil- female crosscountry runners. Medicine and Science in dren 139, 1115–1119. Sports and Exercise 15, 271–276. Nickerson, H.J., Holubets, M. & Weiler, B.R. (1989) Hallberg, L. & Rossander-Hulten, L. (1991) Iron Causes of iron deficiency in adolescent athletes. requirements in menstruating women. American Journal of Pediatrics 114, 657–659. Journal of Clinical Nutrition 54, 1047–1058. Oski, F.A. (1979) The nonhematologic manifestations Hallberg, L., Hogdahl, A.M., Nilsson, L. & Rybo, G. of iron deficiency. American Journal of Diseases of Chil- (1966) Menstrual blood loss: a population study. Acta dren 133, 315–322. Obstetricia et Gynecologica Scandinavica 45, 320–351. Parr, R.B., Bachman, L.A. & Moss, R.A. (1984) Iron defi- Haymes, E.M. (1993) Dietary iron needs in exercising ciency in female athletes. Physician and Sportsmedicine women: a rational plan to follow in evaluating iron 12, 81–86. status. Medicine, Exercise, Nutrition and Health 2, Plowman, S.A. & McSwegin, P.C. (1981) The effects of 203–212. iron supplementation on female cross country Haymes, E.M. & Spillman, D.M. (1989) Iron status of runners. Journal of Sports Medicine and Physical Fitness women distance runners, sprinters, and control 21, 407–416. 320 medical issues

Risser, W.L. & Risser, J.M. (1990) Iron deficiency in Schoene, R.B., Escourrou, P., Robertson, H.T., Nilson, adolescents and young adults. Physician and K.L., Parsons, J.R. & Smith, N.J. (1983) Iron repletion Sportsmedicine 18, 87–101. decreases maximal exercise lactate concentration in Risser, W.L., Lee, E.J., Poindexter, H.B. et al. (1988) Iron female athletes with minimal iron deficiency deficiency in female athletes: its prevalence and anaemia. Journal of Laboratory and Clinical Medicine impact on performance. Medicine and Science in Sports 102, 306–312. and Exercise 20, 116–121. Selby, G.B. & Eichner, E.R. (1986) Endurance swim- Robertson, J.D., Maughan, R.J. & Davidson, R.J.L. ming, intravascular hemolysis, anemia, and iron (1987) Faecal blood loss in response to exercise. depletion: new perspective on athlete’s anemia. British Medical Journal 295, 303–305. American Journal of Medicine 81, 791–794. Rowland, T.W. & Kelleher, J.F. (1989) Iron deficiency in Stewart, J.G., Ahlquist, D.A., McGill, D.B., Ilstrup, athletes: insights from high school swimmers. Ameri- D.M., Schwartz, S. & Owen, R.A. (1984) Gastroin- can Journal of Diseases of Children 143, 197–200. testinal blood loss and anemia in runners. Annals of Rowland, T.W., Black, S.A. & Kelleher, J.F. (1987) Iron Internal Medicine 100, 843–845. deficiency in adolescent endurance athletes. Journal Yoshida, T., Udo, M. & Chida, M. (1990) Dietary iron of Adolescent Health Care 8, 322–326. supplement during severe physical training in com- Rowland, T.W., Deisroth, M.B., Green, G.M. & Kelleher, petitive female distance runners. Sports Training and J.F. (1988) The effect of iron therapy on the exercise Medical Rehabilitation 1, 279–285. capacity of nonanemic iron-deficient adolescent runners. American Journal of Diseases of Children 142, 165–169. Chapter 22

Nutritional and Pharmacological Ergogenic Aids

PRISCILLA M. CLARKSON AND MELINDA M. MANORE

Introduction performance. They are usually divided into three general categories: macronutrients, micronutri- Use of dietary supplements to improve perfor- ents and metabolic intermediates. In general, mance dates back as far as 400 BC. However, in macronutrients, such as supplemental carbohy- the 20th century, many new supplements have drate, amino acids and medium-chain triglyc- been developed, and their use has grown pre- erides (MCTs), contribute to improved athletic cipitously. This increased interest in supplements performance by providing additional energy or has been largely due to a better understanding of essential substrates required for fuelling the how muscles function and what fuels are used body before and during exercise and refuelling to provide energy (Grivetti et al., 1996). Nutri- or repairing the body after exercise. Micronutri- tional supplements to enhance performance are ents (vitamins and minerals) act to improve popular with athletes, and sales of these prod- overall health and thus may improve perfor- ucts abound. However, when dietary interven- mance indirectly. It is difficult to document tions are not sufficient to gain a competitive improved athletic performance by supplement- edge, many athletes turn to pharmaceutical ing with a single vitamin and/or mineral unless interventions. there is a deficiency initially. Consequently, this Today a wealth of studies exist on the effects of chapter does not address vitamin and mineral various nutrients as ergogenic aids. However, use in active females as a means of improving the science of sport is no different from the athletic performance directly. However, some of science of medicine, and most studies have been the metabolic intermediates that are frequently undertaken using males as subjects. Likewise, marketed as ergogenic aids are discussed. studies of the effects of drugs on performance have predominantly used male subjects. Thus, Macronutrients we do not have a full understanding of the effective-ness of ergogenic aids in female ath- carbohydrate letes. This chapter reviews nutritional and phar- maceutical ergogenic aids and emphasizes the Carbohydrate is one of the most extensively state of knowledge of these interventions in researched and reviewed nutritional ergogenic female subjects. aids for the enhancement of exercise perfor- mance (Coggan & Coyle, 1991; Sherman, 1991, Nutritional ergogenic aids 1995; Sherman & Wimer, 1991; Costill & Harg- reaves, 1992; Coyle, 1992, 1995). It is well estab- Nutritional ergogenic aids are substances that if lished that providing adequate carbohydrate added to the diet may directly enhance sports before, during and after exercise improves 321 322 medical issues

exercise performance (Coyle, 1992, 1995). This response to a 4-day high-carbohydrate diet. ergogenic effect may be due to a number of Conversely, the males increased glycogen mechanisms (Coyle, 1992, 1995; Walberg-Rankin, content by 41% and exercise performance by 5%. 1995). The muscles require carbohydrate to fuel The females also oxidized more lipid and less exercise and to replenish the body’s glycogen carbohydrate and protein during exercise than stores after exercise. Thus, carbohydrate fed the men. before or after exercise increases glycogen stores, A couple of factors may contribute to the while carbohydrate fed during exercise provides gender differences observed in the study by the body with additional fuel and helps maintain Tarnopolsky et al. (1995). First, the absolute blood glucose. This additional energy, whether amount of carbohydrate consumed daily was stored or provided exogenously during exer- different: the females on the typical and high- cise, improves performance (Coyle, 1992, 1995; carbohydrate diets consumed 5.9 and 7.7g·kg–1 Tsintzas et al., 1993). The amount of carbohydrate respectively, while the males consumed 7.9 and required both during and after exercise depends 9.6g·kg–1 respectively. Fallowfield and Williams on the intensity and duration of the exercise, (1993) report that a carbohydrate supplement of the level of physical training and the nutritional 5.8g·kg–1 did not replenish glycogen levels after state of the individual. However, it is generally exhaustive exercise in male runners, while recommended that athletes consume a high- a supplement of 8.8g·kg–1 was adequate. Carbo- carbohydrate diet (6–10g·kg–1) during periods of hydrate loading studies typically provide a car- intense exercise training (Walberg-Rankin, 1995). bohydrate intake >8.5g·kg–1; however, this level The amount of energy provided by carbohydrate of carbohydrate is not attainable for active (percentage of energy intake) will depend on the females consuming <11.76MJ (2800kcal) daily. total energy intake; for most female athletes Thus, for the females in the study by Tarnopolsky consuming 10.5–14.7MJ (2500–3500kcal) daily, et al. (1995) to achieve the same relative level of this means that about 50–70% of energy will glycogen storage as observed in the men, more come from carbohydrate. carbohydrate may be required. Second, this There is very limited research that has specifi- study was conducted in the follicular phase of cally examined the carbohydrate needs of active the menstrual cycle. Nicklas et al. (1989) have females and the gender differences in carbohy- reported greater glycogen repletion during the drate metabolism during exercise. However, luteal phase vs. the follicular phase. recent research indicates that trained females In summary, the studies cited above indicate oxidize more lipids and less carbohydrate and that trained females utilize fuel substrates differ- protein during exercise compared with males ently from males and that the ergogenic effect of matched for training (Tarnopolsky et al., 1990, a high-carbohydrate diet may not be as readily 1995; Phillips et al., 1993). In addition, females apparent in females. However, females still appear to store muscle glycogen differently require carbohydrate to replace muscle glycogen in response to a high-carbohydrate diet. used during exercise. Based on these studies and Tarnopolsky et al. (1995) examined the ability others (Keith et al., 1991; Walberg-Rankin, 1995), of matched endurance-trained males and active women appear to need a minimum carbo- females to increase muscle glycogen content hydrate requirement of 5–6g·kg–1 during periods in response to a high-carbohydrate diet (75% of exercise training. In order to obtain the same of energy from carbohydrate vs. 55–60% in a ergogenic effect as frequently observed in men, typical diet). Differences in exercise performance this carbohydrate intake might need to be higher. and substrate metabolism during 60min of However, the ergogenic effect of carbohydrate · –1 cycling at 75% VO2max were also examined. feeding (30–70g·h ) during exercise appears to Females did not increase glycogen content nor be similar in males and females (Tsintzas et al., did exercise performance time increase in 1993). nutritional and pharmacological ergogenic aids 323

protein supplements and documented, there is little evidence that sup- amino acids plemental BCAA improves exercise performance (van Hall et al., 1995; Blomstrand et al., 1997) Athletes frequently supplement their diet with or prevents exercise-related fatigue. However, protein powders and/or single amino acids (i.e. other studies report decreased perceived exer- branched-chain amino acids (BCAA), lysine, tion (7% decrease) and mental fatigue (15% arginine and ornithine). The popularity of these decrease) during moderate-intensity exercise · supplements is evidenced by the numerous (70% VO2max for 60min) but not during products available for sale at health food stores, maximum exercise (Blomstrand et al., 1997). in sports magazines and local drug stores. Single amino acids or combinations of amino Protein powders are marketed to athletes as a acids (i.e. ornithine and arginine) are marketed way of increasing their total protein intake and, as a dietary means of stimulating muscle growth in turn, increasing muscle mass and repairing and/or facilitating fat loss through the endoge- muscle tissue damage associated with exercise. nous production and release of human growth Competitive athletes, regardless of gender, have hormone (HGH) (Macintyre, 1987) and/or greater protein requirements than their seden- insulin (Bucci et al., 1992). These hormones are tary counterparts (Phillips et al., 1993; Lemon, anabolic in nature and therefore athletes believe 1995). However, there is no research supporting that increasing endogenous secretion will the hypothesis that protein powders and/or improve muscle mass and strength. There is amino acids are better sources of this protein no evidence to suggest that either arginine or than food or that they offer an ergogenic edge. ornithine, or any mixture of amino acids, in- During exercise, blood levels of BCAA creases strength, power or the endogenous pro- decrease as the exercising muscles use these duction of either HGH (Bucci, 1994) or insulin amino acids as a source of energy (Ahlborg et al., (Bucci et al., 1992). 1974; Lehmann et al., 1995; Blomstrand et al., All the studies that have examined the use of 1997). Researchers have hypothesized that pro- supplemental amino acids as a way of increasing viding supplemental BCAA during exercise endogenous anabolic hormone production have would help maintain blood BCAA and decrease used male subjects, except for the study by Bucci endogenous protein oxidation. This in turn has et al. (1992). These authors included three female been hypothesized to improve muscular perfor- and nine male body-builders in their study, in mance. Studies of both acute (Maresh et al., 1994; which supplemental ornithine was given and Varnier et al., 1994; Blomstrand et al., 1995) and insulin production measured; however, all data chronic (Bigard et al., 1996) exercise report no were presented in aggregate form. Similarly, all strong evidence to support this hypothesis. human studies that have examined the mecha- Another mechanism whereby BCAA may nism of the central fatigue hypothesis have used influence exercise performance is by preventing male subjects or did not classify results by central fatigue (Davis, 1995; Meeusen & De Meir- gender. leir, 1995). The central fatigue hypothesis states that the decline in blood BCAA observed with medium-chain triglycerides exercise causes an increase in brain serotonin levels, which in turn cause a deterioration in MCTs are composed of medium-chain fatty acids sport and exercise performance. As blood BCAA (MCFAs) that are 6–12 carbons in length. These levels decrease, the competitive inhibition of fats are found naturally in coconut and palm tryptophan across the blood–brain barrier is kernel oils or are prepared synthetically by the removed. This allows more tryptophan to enter hydrolysis of coconut oil (Bach & Babayan, 1982). the brain, resulting in greater serotonin pro- MCTs are metabolized differently from regular duction. Although this mechanism is well fats and oils: (i) most MCFAs are quickly 324 medical issues

absorbed from the gut directly into the portal quently decreases. They also can be used system and transported to the liver rather than during endurance exercise events (i.e. triathlons, passing through the lymphatic system (Swift et marathons, etc.) to increase energy intake above al., 1990); (ii) they do not require carnitine for that provided by carbohydrate drinks or sports transport into the mitochondria of heart, liver or bars. We have successfully used MCTs with kidney of adults; and (iii) they are quickly oxi- female triathletes to increase energy intake dized and used for energy with little opportunity during exercise (M. Manore, personal communi- for storage as fat (Bach & Babyan, 1982; Johnson cation). However, athletes should experi- et al., 1990). MCTs are becoming more popular ment with this fat prior to competitions in with athletes because they are energy dense order to avoid any unexpected gastrointestinal [34.9kJ·g–1 (8.3kcal·g–1)], providing twice the disturbances. energy per gram of carbohydrate. In addition, they are easily absorbed (Beckers et al., 1992) Metabolic intermediates and preferentially used for energy before carbohydrate (Jeukendrup et al., 1995). If MCTs carnitine are consumed as part of a high-carbohydrate isocaloric diet, ketone production is minimal Carnitine is a vitamin-like substance produced in (Bach & Babayan, 1982). Thus, these fats may the body from the amino acids methionine and be added to the athlete’s diet in order to lysine. The enzymes involved in carnitine syn- increase daily energy intake (i.e. when an athlete thesis also require vitamin C, vitamin B6, niacin needs to gain weight) or to boost energy intake and iron as cofactors (Broquist, 1994). Carnitine during an exercise event when immediate energy is obtained in the diet from red meats and dairy is needed (i.e. added to sports beverages or products, while vegetables, cereals and fruits foods). have negligible amounts. Thus, vegans have low Because MCTs are absorbed rapidly into the dietary intakes of carnitine. Supplemental carni- bloodstream as MCFAs and metabolized as tine can be found in either the L or D form; L- quickly as glucose, it has been hypothesized that carnitine is the active form, while D-carnitine they may enhance performance by sparing causes depletion of L-carnitine within the body glycogen utilization during exercise (Berning, and can have potentially toxic effects (Wagen- 1996). Endurance studies using trained males maker, 1991). · exercising for 60–120min at 60–70% VO2max show The majority of the body’s carnitine is found in no carbohydrate-sparing effect of supplemental muscle (98%) where it has a number of physio- MCTs (Décombaz et al., 1983; Massicotte et al., logical functions that could possibly affect exer- 1992; Borghouts et al., 1995). Studies using either cise performance, thus making it a potential a combination of moderate- and high-intensity ergogenic aid (Wagenmaker, 1991; Heinonen, exercise or only high-intensity exercise show 1996). However, the most common reason given mixed results. Some report a carbohydrate- for supplementation with carnitine is the role it sparing effect (Van Zyl et al., 1996), while others plays in fatty acid metabolism. Carnitine is a do not (Horowitz et al., 1995). All the above component in several enzymes involved in trans- studies used male subjects or did not give the porting long-chain fatty acids across the inner gender of their subjects. No study has specifi- mitochondrial membrane for b-oxidation. Thus, cally examined the use of MCTs as an ergogenic it has been hypothesized that supplemental aid in female athletes. carnitine increases the transfer of lipids across Although the research does not support a clear the mitochondrial membrane during prolonged ergogenic effect for MCTs, they can be used to exercise, increasing fat oxidation and sparing increase total daily energy intake during periods muscle glycogen. This alteration in substrate of intense training, when energy intake fre- metabolism should improve performance and nutritional and pharmacological ergogenic aids 325

delay fatigue. One fundamental premise of this there is no evidence that females, including hypothesis is that supplemental carnitine will vegans, are at risk for carnitine deficiency increase muscle concentrations of carnitine, thus (Lombard et al., 1989). altering cellular metabolism. However, research now indicates that while supplemental carnitine coenzyme q (2–5g daily for >14 days) increases both blood 10 and urinary carnitine concentrations, it does not Coenzyme Q10 (ubiquinone) is a naturally occur- change total muscle carnitine levels signifi- ring lipid-soluble substance that is synthesized cantly (Décombaz et al., 1992; Barnett et al., 1994; endogenously. It functions primarily as an elec- Vukovich et al., 1994; Constantin-Teodosiu et al., tron carrier in mitochondria but may have a sec- 1996). Numerous reviews of the literature have ondary role as an antioxidant in muscle. It has concluded that supplemental carnitine does not been hypothesized that supplemental coenzyme increase fat oxidation or decrease carbohydrate Q10 could increase the rate of flux through the oxidized in healthy active individuals during electron-transport chain and thus enhance ATP exercise (Wagenmaker, 1991; Clarkson, 1992; production. In addition, coenzyme Q10 might Brass & Hiatt, 1994; Kanter & Williams, 1995; help to scavenge free radicals and regenerate the Heinonen, 1996). This is true even when muscle antioxidant form of vitamin E, thus acting as an glycogen is depleted, making less carbohydrate antioxidant (Jenkins, 1993; Beyer, 1994). available for oxidation (Décombaz et al., 1993). Studies that have examined the performance-

Thus, there is no convincing evidence to suggest enhancing effects of coenzyme Q10 have pro- that supplemental carnitine alters substrate oxi- duced inconclusive results. Numerous studies dation during endurance exercise or improves have found no ergogenic effect of supplementa- performance in healthy adults. However, sup- tion on exercise performance in healthy young plemental carnitine is used in clinical settings trained or sedentary males (Braun et al., 1991; where the ability to synthesize carnitine endoge- Snider et al., 1992; Laaksone et al., 1995) or nously is compromised. In these situations, sup- middle-aged untrained males (Porter et al., 1995). plemental carnitine does improve lipid oxidation Conversely, Karlsson et al. (1996) report a posi- (Broquist, 1994). tive relationship between muscle ubiquinone Carnitine is also frequently added to products levels and maximal exercise performance and advertised as ‘fat burners’ or dieting agents. the onset of blood lactate accumulation. Karlsson These products supposedly increase the body’s et al. (1992) also report lower plasma concentra- oxidation of fat at rest and thus alter body com- tions of ubiquinone in trained male athletes com- position (i.e. decrease body fat). There is no theo- pared with sedentary controls. retical basis for this assumption and no research Studies that have examined the antioxidant data supporting this hypothesis. Yet these prod- effect of coenzyme Q10 have also produced ucts are popular with athletes and the general mixed results. Some report positive effects of public who want to decrease body fat. supplementation (Karlsson et al., 1996; Karlsson, Most research studies that have examined the 1997), while others report no effect (Braun et al., ergogenic effects of carnitine have used male 1991) or increased cell damage (Malm et al., 1996) subjects. Those studies that have included with supplementation. Currently, there appears females usually do not report results based on to be no strong evidence that coenzyme Q10 gender; thus, specific information on how improves exercise performance. However, its females differ from males with regard to carni- role as an antioxidant is still equivocal. tine supplementation and exercise performance None of the studies examining the ergogenic is not available. Females do have a smaller total effect of coenzyme Q10 on exercise performance body carnitine pool than males due to their have included female athletes. Hence, specific smaller muscle mass (Heinonen, 1996). However, information on how females differ from males 326 medical issues

with regard to coenzyme Q10 supplementation in testing this assumption is that the washout and exercise performance is not available. period from the muscle after creatine supple- mentation is 4–6 weeks, which makes crossover creatine phosphate designs impractical. Greenhaff et al. (1993) exam- ined the effect of creatine supplementation on Creatine supplementation is one of the newest repeated bouts of maximal isokinetic contrac- ergogenic aids to hit the sports market (Green- tions interspersed with a 1-min rest period. They haff, 1995; Maughan, 1995). The popularity of found that supplementation significantly in- creatine soared after the 1992 Olympic Games, creased muscle peak torque by 5–7%. All subjects when British athletes, including a gold medallist, in the creatine treatment group (six males) reported using the supplement (Anderson, 1993). improved with supplementation; three females Besides being present in the diet (flesh foods), cre- were included in the study but all were in the atine is synthesized in the liver from the amino placebo group. acids lysine and arginine. Creatine is then trans- Subsequent studies using high-intensity exer- ported to the muscle where 95% of the body’s cre- cise, such as sprint swimming, running and atine is found. Within the resting muscle, 60% cycling, have shown mixed results. Some of this creatine is found as creatine phosphate researchers report no effect (Burke et al., 1996; (CP). Oral supplementation of creatine decreases Mujika et al., 1996; Redondo et al., 1996; Odland et endogenous synthesis, but this is reversible when al., 1997), while others report positive results supplementation stops. The creatine pool is rela- (Balsom et al., 1993; Birch et al., 1994). These dis- tively stable with approximately 1.7% (2g) of the crepancies may be due to a number of factors: (i) pool turning over daily. However, the size of this no increase in muscle creatine in response to pool depends on a number of factors, such as supplementation due to high initial muscle dietary intake, gender, age and amount of muscle creatine levels; (ii) muscle creatine is not the mass. Ingestion of 20g of exogenous creatine (4g limiting factor in some of the exercise protocols daily for 5 days) increases muscle creatine levels used, such as sprint swimming; and (iii) the by about 20% (Hultman et al., 1996). length of active recovery between exercise bouts Individuals with the lowest muscle creatine varies greatly among studies. Consequently, the levels appear to respond the most to creatine ergogenic effect of creatine is still debatable, and supplementation (Harris et al., 1992). Thus, may depend on the type of exercise, the initial some individuals may benefit more than others. muscle creatine level and other factors associated In addition, creatine taken with high levels of with performance. carbohydrate appears to augment creatine reten- Many of the studies that have examined the tion in the muscle (Green et al., 1996). However, ergogenic effect of creatine included females in the muscle does have an upper limit for creatine their subject pool; however, no study has specifi- uptake that cannot be exceeded. Once the muscle cally examined whether females respond dif- is saturated, the concentration of creatine will not ferently to creatine supplementation compared increase even though high doses of supplemen- with men. Because many female athletes limit tal creatine are still being used (Greenhaff, 1995). their intake of flesh foods or practise a vegetarian Within the muscle, CP is used to regenerate lifestyle, their intake of dietary creatine may be ATP from ADP. Since the availability of CP is low. These individuals may benefit from creatine one of the limiting factors in muscle perfor- supplementation if they participate in high- mance during short-term high-intensity exercise intensity exercise. (Greenhaff, 1995), it follows that supplemental creatine could boost muscle CP levels. If CP Pharmacological interventions increases, it could increase the ability to regener- ate ATP both during and after repeated bouts of The use of drugs to enhance athletic performance high-intensity exercise. One confounding factor has had a long and varied history. The popularity nutritional and pharmacological ergogenic aids 327

of certain drugs waxes and wanes. In the late Karpovich (1959) investigated the effects of 1940s and 1950s, amphetamines were popular 10–20mg amphetamine on treadmill run to because they were purported to be used by exhaustion and performance of other track and German soldiers as stimulants to ward off fa- swim tests in male college students and noted tigue and enhance performance in battle. Most only minimal performance enhancement with recently, ephedrine has been the stimulant of the drug. Other studies also reported no perfor- choice. Anabolic steroids became popular in the mance changes when male subjects were given 1950s after Russian athletes were suspected of amphetamines (Haldi & Wynn, 1946; Blyth et al., taking them. The ease of testing for anabolic 1960; Golding & Barnard, 1963; Blum et al., 1964; steroids has prompted athletes to seek drugs, Williams & Thompson, 1973). Blum et al. (1964) such as growth hormone, that cannot be detected did include some female subjects but their data by urinalysis. Recent attention has also focused were pooled with the males. Although there was on clenbuterol as a drug to increase muscle mass considerable interindividual variability in the because it is believed to have less side-effects. responses, some subjects showed performance Athletes who want to lose weight fast or cut benefits in most of the studies. weight for competition have long been known to Smith and Beecher (1959, 1960) performed six use diuretics. For more lasting weight loss, many experiments on male athletes who were given athletes, especially female athletes, have turned 0.2mg·kg–1 amphetamine sulphate before to new drugs that have been developed to treat several types of exercise. Over 67% of the athletes obese individuals. The following sections briefly performed better with the amphetamines com- review research on drugs used to enhance per- pared with the placebo group, with improve- formance or alter body composition. ments ranging from 0.6% to 4.0%. With the drug, the athletes felt bold, elated and ‘revved up’ before the performance and perceived that they Drugs used as stimulants had improved coordination, strength and amphetamines endurance. The action of amphetamines in altering pain Amphetamines have been used to enhance per- perception was highlighted in a field study by formance because they stimulate the central Cuthbertson and Knox (1947), in which 55 male nervous system and also mimic sympathetic soldiers were kept without sleep for 24hours. neural activity. Prior to 1950, the effects of The soldiers were then placed into three amphetamines on performance were examined marching groups, one group receiving 15mg because of their potential usefulness as ergogenic methedrine, another group receiving placebo aids for soldiers (Wagner, 1989). Most studies and the third group receiving either methedrine used males as subjects and found improvement or placebo. There appeared to be no effect of in some motor tasks, although there was a large the amphetamine on marching performance. interindividual variability in the responses (Alles However, there were more complaints of severe & Feigen, 1942; Cuthbertson & Knox, 1947). In foot trouble in the placebo group, even though one study of three subjects (one female), the the severity of blisters was greater in the group effect of 20mg of benzedrine on several psy- who took the amphetamines. The number of sol- chomotor tasks, including reaction time, hand- diers who fell out of the march was greater in the grip, speed of movement and steadiness, was placebo group compared with the drug group. examined in a double-blind design (Thornton et Although performance was not enhanced by the al., 1939). Although the female responded simi- drug, subjects felt better. larly to the males in several tests, she showed a Studies that found performance benefits more marked increase in maintained handgrip reported that amphetamines may mask fatigue, (holding time) performance (121%) compared enhance ability to tolerate discomfort and allow with the two males (9% and 58%). subjects to exercise longer (Wyndham et al., 1971; 328 medical issues

Chandler & Blair, 1980). However, ampheta- active ingredient, i.e. appetite suppressant, in mines could also diminish performance because commercially available diet pills (Greenway, of a failure to detect warning signs for serious 1992). health complications, for example ignoring the Limited data exist concerning the effects of early signs of heat stroke (Wyndham et al., 1971). ephedrine on performance. Bright et al. (1981) Athletes may ignore pain from injuries while studied six male subjects who were given 60 and taking amphetamines, which could exacerbate 120mg ephedrine (or placebo) before submaxi- the injury (Laties & Weiss, 1981). We know little mal treadmill exercise. No significant difference about the effects of amphetamines on female ath- was found in the time to reach 85% of predicted letes, although there is no reason to suspect that maximum heart rate, blood pressure or recovery they would be any more or less effective than in heart rate. Two subjects showed sinus arrhyth- males or result in less interindividual variability mias during recovery on the 120-mg dose. In a in response. study of male cyclists, Gillies et al. (1996) found The use of amphetamines in college athletes that 120mg pseudoephedrine taken 120min has dropped in the past 10 years for both prior to a 40-km cycling time trial and 90min males and females. A survey performed by prior to isometric strength tests did not affect the National Collegiate Athletic Association cycling performance time or isometric strength (NCAA) examined the responses of 13914 ath- of the quadriceps muscle. The authors concluded letes from 637 institutions; 34% of the respon- that a single therapeutic dose did not enhance dents were females. It was found that 4.7% of performance in well-trained cyclists. female softball players and swimmers took Two studies have assessed the effects of amphetamines, while £3% of male athletes in ephedrine in females. Clemons and Crosby various sports took the drug. Also, the reason (1993) gave 60mg pseudoephedrine or placebo athletes use amphetamines has changed. In 1993, to 10 female subjects 70min before performing a most athletes reported that they took ampheta- graded exercise test. There was no difference in mines in order to improve performance and total exercise time or several other physiological provide more energy. In 1997, there was an changes, except that heart rate during and after increase in the number of respondents who exercise was higher in the ephedrine group. reported that they used amphetamines as an Sidney and Lefcoe (1978) administered 24mg appetite suppressant, while there was a signifi- ephedrine and 130mg theophylline to six male cant drop in those indicating they used ampheta- and six female track athletes. These drugs did not mines to improve performance (NCAA, 1997). affect simple reaction time, handgrip strength or Amphetamines are effective appetite suppres- isometric holding time but resulted in a 4% sants. However, because of their side-effects, increase in the number of sit-ups that could be other drugs are more commonly used for this performed. There was no difference between the purpose. These are described in the section on drug and placebo on time to exhaustion for a drugs used to alter body weight. high- or low-intensity treadmill run or on psy- chomotor performance. Data for the females and ephedrine males were not presented separately so it is not clear whether the changes were similar for males Ephedrine is structurally related to the ampheta- and females. mines and also functions as a central nervous One study reported that females and males system stimulant but is not as potent as the differ in their subjective response to ephedrine amphetamines (Wagner, 1991). Examples of the (Chait, 1994). Capsules containing the drug or ‘ephedrines’ are ephedrine, pseudoephedrine placebo, which were distinguishable only by and phenylpropanolamine (Cowan, 1994). colour, were offered to the subjects; then on a Phenylpropanolamine is commonly found as the subsequent occasion subjects were able to choose nutritional and pharmacological ergogenic aids 329

one or none. Subjects were told that capsules of No recent studies of the effects of cocaine the same colour always contained the same sub- ingestion on performance exist other than the stance. Males chose ephedrine more frequently effects of coca leaf chewing in Peruvian males. (33.3%) than females (9.3%). Males also showed a The leaves of the coca plant (Erythroxylon coca) very positive mood response to the drug. This naturally contain cocaine. These studies, which study highlights the fact that males and females were not well controlled, reported only small may respond differently to drugs, and this may benefits from chewing coca leaves (Hanna, 1970, influence whether they take the drug and/or 1971). It was concluded that coca exerted an whether the drug is effective. In fact, the NCAA effect by altering the perception of effort so that survey found that the use of ephedrine was quite the effects of fatigue were reduced (Hanna, 1971). low for female athletes (<1.9%) compared with Two other studies examined the physiological male athletes (1.5–5.3%). About half the respon- response to coca chewing before exercise and dents claimed that the main reason for using found that chewers had increased fatty acid ephedrine was to improve athletic performance. levels in the blood before the exercise and these Ephedrine has also been used as an agent remained elevated during exercise (Favier et al., for causing weight loss, but it is not known to 1996; Spielvogel et al., 1996). The authors sug- what extent female athletes use the drug for gested that the increased free fatty acid levels in this purpose. There are no studies to show the blood may benefit endurance performance, that ephedrine acts as a ‘fat burner’ in order although the mechanism to explain this is not to promote leanness in athletes, although it is clear. rumoured that athletes who want to maintain Although few studies have examined the low body weight and who want to increase effect of cocaine on performance, there does not muscle definition are using ephedrine (see seem to be any significant performance benefits section Thermogenic and anorectic agents). from using cocaine. In fact, the euphoria that cocaine produces may cause athletes to perform cocaine poorly but think they are performing well. According to the NCAA survey, cocaine use by Cocaine functions as a stimulant of the central both males and females has declined dramati- nervous system and sympathetic nervous cally since 1985. It appears that the reason for use system. It stimulates the release of noradrenaline is more social than any direct ergogenic benefits. from neurones and also blocks the reuptake of The percentage of female athletes using cocaine noradrenaline and dopamine, thereby potentiat- ranges from 0.2% for track and field athletes to ing the effects of these transmitters. Athletes who 1.8% for softball athletes; the range for males is use cocaine do so mainly as a social drug rather 0.6–2.1%. than as a performance enhancer. However, the sense of euphoria that cocaine produces could caffeine allow an athlete to perceive that they are faster and stronger than they actually are (Tennant, Several excellent reviews on caffeine and perfor- 1984; Lombardo, 1986; Haupt, 1989). mance have been published (Dodd et al., 1993; Studies on the effects of cocaine have all been Tarnopolsky, 1994; Spriet, 1995). Caffeine may performed using only male subjects. A few early exert an ergogenic effect by acting on the central reports suggested that cocaine could increase nervous system, increasing free fatty acids in the work time, improve performance or enhance blood and/or acting directly on skeletal muscle recovery (see Conlee, 1991). However, Asmussen (Spriet, 1997). In some individuals, especially and Bøje (1948) gave 129mg cocaine to three male those who are sensitive to caffeine, ingestion athletes 15min before two cycling ergometer could impair performance of motor skills by tests and found no improvement in performance. exacerbating tremor (Wagner, 1991). Review of 330 medical issues

the many studies on the effects of caffeine shows (Astrup et al., 1992a). However, Donelly and that moderate doses (5–7mg·kg–1) taken about 1 McNaughton (1992) have reported that caffeine hour before exercise benefits performance, with increased metabolic rate above normal levels in the exception of sprint exercises lasting <90s, untrained females during, and for a short period · high-intensity exercise (>90% VO2max) and incre- of time after, exercise. The effectiveness of caf- mental exercise tests (Tarnopolsky, 1994; Spriet, feine combined with exercise to enhance weight 1995). Beneficial effects of ingestion of caffeine loss has not been fully investigated. have been found in both recreationally active and trained individuals. The mechanisms to explain Drugs used to reduce heart rate and tremor the ergogenic effect that occurs across a wide variety of exercise types remain to be determined b-blockers (Spriet, 1997). Most studies of the ergogenic effect of caffeine The b-adrenergic blockers prevent binding of the have used males as subjects or included a small neurotransmitter noradrenaline to its receptors, number of females; however, the female data which reduces the stimulatory effects of the sym- were pooled with the male data. There may be pathetic nervous system. Hence, b-blockers can reasons to suspect that females could respond reduce heart rate and tremor, a valuable effect for differently to caffeine. Oestrogen and caffeine are sporting activities like shooting where steadi- metabolized similarly, such that oestrogen can ness is important (Tesch, 1985; Williams, 1991). affect the half-life of caffeine and possibly affect The b-blockers have proved useful in treating the response to caffeine. Urinary clearance of stage-fright in musicians, although most studies caffeine is reduced in females using oral con- have used males as subjects (James et al., 1977; traceptive (Schwenk, 1997). Further studies of Brantigan et al., 1982). Those participating in the effects of caffeine on exercise performance in sports like pistol shooting and ski jumping can females is warranted. Also, studies should benefit from the reduced anxiety provided by b- control the menstrual status because of the inter- blockers (Imhof et al., 1969; Siitonen et al., 1997; action between oestrogen and caffeine (Spriet, Videman et al., 1979; Antal & Good, 1980; Kruse et 1997). al., 1986). Females given an acute dose of caffeine exhib- Previous studies have shown that there is a ited increased excretion of minerals in the urine large interindividual variability in response to b- similar to that in males (Massey & Wise, 1992). blockers; while many athletes improve perfor- Differences in body size and composition mance, some show impaired performance. Very between males and females were accounted few females were included in these studies and for by calculating mineral–creatinine ratios. their data were pooled with the male data, so it However, because females have lower body is not clear whether females exhibit, or benefit stores of minerals, they lost proportionally more from, reduced heart rate and tremor after tak- of their body stores (Massey & Wise, 1992). Con- ing b-blockers. In a recent study, Eston and sidering that calcium is lost in this manner, Thompson (1997) examined perceived exertion chronic caffeine consumption could negatively during exercise in a control group and in patients affect bone mineral density. Chronic use of exces- taking the cardioselective b-blocker atenolol. sive caffeine as an ergogenic aid, in addition to Females taking the drug had the lowest pre- normal dietary use (coffee, soda, etc.), could dicted maximal work rate, which suggests that jeopardize mineral status in female athletes who the drug may affect females differently. Because do not ingest sufficient quantities of minerals in b-blockers reduce heart rate, decrease cardiac · their diet. output and reduce VO2max, they probably impair Caffeine has also been used to promote weight performance that is metabolically stressful loss but, by itself, has not been proved effective (Tesch, 1985; Wilmore, 1988). nutritional and pharmacological ergogenic aids 331

is higher (Strauss et al., 1985; Strauss & Yesalis, Drugs used to alter body weight 1991; Cordova, 1996). Terney and McLain (1990) anabolic–androgenic steroids and found that 3.9% of female high-school athletes growth hormone and 6.6% of male high-school athletes reported taking steroids. Korkia (1996) reported that of Anabolic steroids are synthetic derivatives of 349 females who attended gyms in England, testosterone. Although they have been synthe- Scotland and Wales, eight (2.3%) responded that sized to maximize anabolic effects, some andro- they had taken anabolic steroids. genic effects are still produced. Several reviews Strauss and Yesalis (1991) reported that female of anabolic–androgenic steroids and perfor- athletes were taking steroids in order to increase mance have been published (Haupt & Rovere, strength and muscle mass, the same reasons that 1984; Lamb, 1984; Hough, 1990; Lombardo et al., males take steroids. Strauss et al. (1985) reported 1991; Bahrke & Yesalis, 1994; Bahrke et al., 1996). that 10 weight-trained females who took ana- Published studies have primarily used males as bolic steroids used stacking and cycling tech- subjects. Many studies lack controls for diet and niques and took up to nine times the exercise and used doses lower than those used by manufacturer’s recommended doses. Females athletes. Bhasin et al. (1996), in a well-controlled who took steroids had abnormalities of the men- study, examined the effects of 600mg testos- strual cycle and depressed levels of high-density terone (a supraphysiological dose) weekly for 10 lipoprotein cholesterol (Cordova, 1996). The sec- weeks in four groups of males who had weight- ondary male sex characteristics caused by the training experience: (i) placebo with no exercise; androgenic effects of anabolic steroids have (ii) testosterone with no exercise; (iii) placebo perhaps reduced the likelihood of female athletes with resistance training; and (iv) testosterone taking these drugs. with resistance training. Dietary intake and exer- HGH is a peptide hormone secreted by the cise level were controlled. The non-exercising anterior pituitary that regulates growth and subjects taking testosterone were found to have a metabolism. There are a few studies of the effects larger increase in muscle size and strength than of HGH on muscle mass, and these have used the non-exercising controls. However, the males young and older males as subjects (Christ et al., who exercised and injected testosterone demon- 1988; Rudman et al., 1990; Yarasheski et al., 1992, strated the greatest increase in both muscle size 1993, 1995; Deyssig et al., 1993; Taafe et al., 1994; and strength. For example, the increases in fat- Welle et al., 1996). Findings were fairly consistent free mass for the non-exercise plus placebo in that HGH increased fat-free mass but did not group, non-exercise plus testosterone group, increase protein synthesis in the muscle. Thus, exercise plus placebo group and exercise plus HGH may increase lean body mass and decrease testosterone group were 0.01%, 4.6%, 2.8% and fat mass. However, the increase in lean tissue is 9.3%, respectively. Also, the corresponding in- probably not skeletal muscle but may reflect creases in bench-press forces were 2.9%, 12.6%, increases in fluid retention or increases in con- 19.8% and 37.3%. nective tissue or organ mass (Wirth & Gieck, We uncovered no studies that have assessed 1996). the effects of anabolic steroids in female athletes, For both anabolic–androgenic steroids and although studies of therapeutic doses do show HGH there is a paucity of well-controlled studies that body weight is increased (American College in females. It is unlikely that HGH will be any of Sports Medicine, 1987). In the NCAA survey, more effective at increasing muscle mass in <1% of female athletes used anabolic steroids; females than it is in males. However, because softball players showed the highest use (0.9%). females are taking anabolic–androgenic steroids, This value is consistent with the results of some it is important to understand the effects in studies, while others suggest that the rate of use females. A well-controlled study, such as that of 332 medical issues

Bhasin et al. (1996), using females as subjects is While recent attention has focused on the role needed. of b2-agonists in increasing muscle mass, earlier concern was that these drugs may exert stimula- -agonists tory effects and thereby enhance performance. b 2 Because b2-agonists are used in the treatment of Clenbuterol has received recent attention as a asthma, it was important to identify their possi- drug for enhancing muscle mass. Clenbuterol ble ergogenic effects in order to determine and its relatives, salbutamol (albuterol) and whether asthmatic athletes had an advantage orciprenaline (metaproterenol), are classified as when taking b2-agonists. In the treatment of sympathomimetic amines (Cowan, 1994) and act asthma these drugs are inhaled, which limits the at b2-adrenergic receptors. When used in aerosol amount administered. Three studies of males form, their action is relatively selective for the found that therapeutic aerosol doses of salbuta- receptors in bronchial muscle. Aerosol forms of mol or salmeterol (structurally related to salbuta- b2-agonists are used in the treatment of asthma mol) did not produce ergogenic effects in trained (Morton & Fitch, 1992). Clenbuterol has a long athletes (Meeuwisse et al., 1992; Lemmer et al., half-life of about 35hours compared with 5hours 1995; Morton et al., 1996). McKenzie et al. (1983) for salbutamol; the long half-life may allow clen- examined the effects of aerosol salbutamol on buterol to have anabolic effects (Schwenk, 1997). treadmill performance in 10 highly trained In studies on animals, clenbuterol has been female and 9 highly trained male athletes and shown to result in muscle hypertrophy, reported no benefit of the drug on performance. decreases in fat deposition and conversion of Data were analysed by gender and neither group slow-twitch fibres to fast-twitch fibres (Spann & showed an ergogenic effect. In contrast, two Winter, 1995; Dodd et al., 1996). However, there studies reported that inhaled salbutamol exerted are no studies that have examined the effects of an ergogenic effect on power output (Bedi et al., clenbuterol on muscle mass gains in humans. 1988; Signorile et al., 1992). One of these studies Two studies have assessed the effects of clen- (Signorile et al., 1992) tested eight males and buterol or orciprenaline on the recovery of seven females, but whether gender influenced strength and muscle mass after injury in male the results is not known as the data were not patients. These studies generally showed a faster analysed by gender. The differences among the recovery of strength (Maltin et al., 1993; Signorile studies are probably due to the fact that the latter et al., 1995), but only the latter study reported an study used recreational athletes rather than the improvement in muscle size. Martineau et al. trained athletes used in the other studies (Spann (1992) found that salbutamol improved strength & Winter, 1995). However, Bedi et al. (1988) but did not affect lean body mass in healthy reported performance benefits of salbutamol in males. Another study examined the effect of trained cyclists (14 males and 1 female). Thus, the salbutamol during a resistance training pro- data are equivocal on whether aerosol b2- gramme for 9 weeks in subjects whose gender agonists improve performance. Also, whether was not specified (presumably male) and also these drugs have different effects in males and found that the drug improved strength but not females has not been comprehensively exam- muscle mass (Caruso et al., 1995). Although b2- ined, but it seems unlikely. agonists can enhance strength, the mechanisms responsible are not clear. No change in muscle thermogenic and anorectic agents mass was found in most of these studies, although this is the primary reason athletes use Many female athletes try to achieve a low body these drugs. However, the amount of the drug weight because they believe it is associated with taken by athletes is probably much greater. improved performance. When dieting fails, some Whether these drugs increase strength or muscle athletes have turned to pharmacological inter- mass in females has yet to be determined. ventions. Drugs have been identified that act as nutritional and pharmacological ergogenic aids 333

agonists to receptors in the sympathetic nervous catecholaminergic agents (Atkinson & Hubbard, system, which is a primary regulator of dietary 1994). Recently, the drugs fenfluramine (dexfen- thermogenesis (Landsberg & Young, 1993). fluramine) and fluoxetine, which act as sero- Ephedrine has both thermogenic (energy toninergic agents, have also proved successful as expending) and anorectic (appetite suppressant) anorectic agents (Silverstone & Goodall, 1992). effects. Other drugs function primarily as Several studies reported that fenfluramine anorectic agents and suppress appetite by (Guy-Grand et al., 1989; Guy-Grand, 1992; Breum increasing catecholamine or serotonin levels. et al., 1994; O’Connor et al., 1995) and fluoxetine Unlike most of the studies examined in this (currently approved for the treatment of depres- chapter, studies of this group of drugs have pre- sion) result in weight loss in obese subjects (Wise, dominantly used females as subjects. 1992; Stinson et al., 1992). Due to heart valve Several studies have reported that ephedrine is problems and cardiac disturbances in patients more effective than placebo in reducing weight taking fenfluramine, this drug was withdrawn in obese subjects (Dulloo & Miller, 1986; Astrup et from the maket in 1997 at the Food and Drug al., 1992b; Pasquali & Casimirri, 1993) and reduc- Administration’s request. ing nitrogen loss, thereby sparing protein Pharmacological agents like ephedrine that (Pasquali et al., 1987; Dulloo, 1993). Ephedrine increase energy expenditure may impair perfor- also prevents the decrease in resting metabolic mance because they act on the sympathetic rate associated with low-calorie diets (Pasquali et nervous system and can increase tremor and ner- al., 1992). To enhance its effectiveness in produc- vousness and exert effects on the cardiovascular ing weight loss, ephedrine has been coupled to system. Anorectic drugs may also result in caffeine and aspirin, which potentiate the sym- adverse symptoms that can impair ability to pathetic effects of ephedrine. A combination of accomplish optimal training and performance. ephedrine and caffeine increases energy expen- Thus, pharmacological agents are more likely to diture and enhances weight loss in obese subjects impair performance than they are to benefit per- (Astrup et al., 1991, 1992c; Astrup & Toubro, 1993; formance by inducing weight loss. It is still Breum et al., 1994). Astrup and Toubro (1993) esti- unclear how effective these drugs are in non- mated that about 80% of the weight loss was due obese subjects. Moreover, weight loss caused by to an anorectic effect and 20% to a thermogenic these drugs is regained when the diet pills are effect. The combination of ephedrine, caffeine discontinued (Munro et al., 1992) and many and aspirin is also effective in producing weight weight-loss drugs have serious side-effects. loss in obese subjects (Daly et al., 1993). The effectiveness of these drugs for those who diuretics are already relatively lean (such as athletes) has not been determined. The reason the drugs may Diuretics are used by athletes to induce rapid be effective for obese subjects is that these indi- weight loss. Many diuretics act by blocking the viduals have a lower thermogenesis and the reabsorption of electrolytes in the kidneys, thus drugs increase thermogenesis (Geissler, 1993). In facilitating water loss from the body. Wrestlers, fact, ephedrine, aspirin and caffeine were more light-weight crew, body-builders and jockeys effective in increasing the thermic response in who must make a particular weight classification obese compared with lean subjects (Horton & or who want to reduce body weight for competi- Geissler, 1991). Another reason why athletes tion have used diuretics. Diuretics can produce a should be discouraged from using these drugs is weight loss of about 3–4% within a 24-hour that they have side-effects that could hinder ath- period (Claremont et al., 1976; Caldwell et al., letic performance. 1984; Wagner, 1991). Laboratory studies have Amphetamines and the newer adrenergic found that use of diuretics can impair perfor- drugs (diethylpropion, phentermine and mazin- mance (Steen, 1991; Horswill, 1994), although dol) have been used as anorectic drugs and act as whether diuretics adversely affect performance 334 medical issues

during competition has not been determined. the side-effects. For example, ephedrine, which is However, diuretics probably do not impair per- often considered harmless by athletes, results in formance that is not metabolically stressful. augmentation of myocardial contraction and The extent of diuretic use by female athletes is cardiac output, elevated systolic blood pressure not known, but diuretics represent about 6% of and can produce dizziness, headache, irritability the drugs abused by athletes (Al-Zaki & Talbot- and anxiety. There is now a strong movement in Stern, 1996). Female athletes may be taking the USA to increase the regulation of ephedrine. diuretics in order to reduce the effect of premen- Female athletes are using drugs to induce weight strual bloating. Also, diuretic use often becomes loss, but these drugs are also contraindicated part of the behaviour of those with eating disor- because of side-effects that could impair perfor- ders. Chronic use of diuretics can lead to elec- mance. There is a lack of information to show trolyte imbalance, which can produce symptoms that these drugs are effective in relatively lean of muscle cramps, spasms and paralysis, as well individuals as studies have used obese subjects. as disturbances in cardiac function that can be Moreover, the discontinuation of drugs that life-threatening. induce weight loss results in regain of the weight. There is a paucity of research on female athletes with regard to both nutritional and Conclusion pharmacological ergogenic aids. To improve Adequate carbohydrate before, during and after performance in female athletes as well as to exercise is important in ensuring optimal perfor- safeguard their health, it is important that mance. However, there are some data to suggest future research identifies possible ergogenic and that a high-carbohydrate diet may not be as effec- ergolytic effects of these supplements specifically tive in females as it is in males, but this warrants for female subjects. further study. Amino acid supplements, MCTs, carnitine and coenzyme Q have not proved 10 References beneficial for males, and there is no reason to suspect that they would be any more effective for Ahlborg, G., Felig, P., Hagenfeldt, L., Hendler, R. & females. The most popular nutritional supple- Wahren, J. (1974) Substrate turnover during ment today is probably creatine. Several studies prolonged exercise in man. Journal of Clinical Investi- gation 53, 1080–1090. have found that creatine supplementation Alles, G.A. & Feigen, G.A. (1942) The influence of ben- enhances performance of short-term high-inten- zedrine on work-decrement and patellar reflex. sity exercise. Because many females limit their American Journal of Physiology 136, 392–400. intake of meat or are vegetarians, they may have Al-Zaki, T. & Talbot-Stern, J. (1996) A bodybuilder with lower creatine stores. Further research is needed diuretic abuse presenting with symptomatic hypotension and hyperkalemia. American Journal of to determine whether creatine may be an even Emergency Medicine 14, 96–98. more effective performance enhancer in females American College of Sports Medicine (1987) Position than males. stand on the use of anabolic–androgenic steroids in It appears that fewer females compared with sports. Medicine and Science in Sports and Exercise 19, males are taking drugs in order to improve 534–539. Anderson, O. (1993) Creatine propels British athletes to performance. However, a small percentage of Olympic gold medals: is creatine the one true females are using drugs so it is important to ergogenic aid? Running Research News 9, 1–5. determine whether these drugs are effective. Antal, L.C. & Good, C.S. (1980) Effects of oxprenolol on Because of the large interindividual variability in pistol shooting under stress. Practitioner 224, response to drugs, it is uncertain whether a given 755–760. Asmussen, E. & Bøje, O. (1948) The effect of alcohol individual will experience an enhancement of and some drugs on the capacity for work. Acta Physi- performance. Furthermore, most drugs are prob- ologica Scandinavica 15, 109–118. ably contraindicated as ergogenic aids because of Astrup, A. & Toubro, S. (1993) Thermogenic, metabolic, nutritional and pharmacological ergogenic aids 335

and cardiovascular responses to ephedrine and caf- Beyer, R.E. (1994) The role of ascorbate in antioxidant feine in man. International Journal of Obesity 17 protection of biomembranes: interaction with (Suppl. 1), S41–S43. vitamin E and coenzyme Q. Journal of Bioenergetics Astrup, A., Toubro, S., Cannon, S., Hein, P. & Madsen, and Biomembranes 26, 349–358. J. (1991) Thermogenic synergism between ephedrine Bhasin, S., Storer, T.W., Berman, N. et al. (1996) The and caffeine in healthy volunteers: a double-blind, effects of supraphysiologic doses of testosterone on placebo-controlled study. Metabolism 40, 323–329. muscle size and strength in normal men. New Astrup, A., Toubro, S., Christensen, N.J. & Quaade, F. England Journal of Medicine 335, 1–7. (1992a) Pharmacology of thermogenic drugs. Ameri- Bigard, A.X., Lavier, P., Ullmann, L., Legrand, H., can Journal of Clinical Nutrition 55, 246S–248S. Douce, P. & Guezennec, C.Y. (1996) Branched-chain Astrup, A., Breum, L., Toubro, S., Hein, P. & Quaade, F. amino acid supplementation during repeated pro- (1992b) The effect and safety of an ephedrine/caf- longed skiing exercises at altitude. International feine compound compared to ephedrine, caffeine Journal of Sports Nutrition 6, 295–306. and placebo in obese subjects on an energy restricted Birch, R., Noble, D. & Greenhaff, P.L. (1994) The influ- diet. A double blind trial. International Journal of ence of dietary creatine supplementation on perfor- Obesity 16, 269–277. mance during repeated bouts of maximal isokinetic Astrup, A., Buemann, B., Christensen, N.J. et al. (1992c) cycling in man. European Journal of Applied Physiology The effect of ephedrine/caffeine mixture on energy 69, 268–270. expenditure and body composition in obese women. Blomstrand, E., Andersson, S., Hassmen, P., Ekblom, B. Metabolism 41, 686–688. & Newsholme, E.A. (1995) Effect of branched-chain Atkinson, R.L. & Hubbard, V.S. (1994) Report on the amino acid and carbohydrate supplementation on NIH workshop on pharmacologic treatment of the exercise-induced change in plasma and muscle obesity. American Journal of Clinical Nutrition 60, concentration of amino acids in human subjects. Acta 153–156. Physiologica Scandinavica 153, 87–96. Bach, A.C. & Babayan, V.K. (1982) Medium-chain Blomstrand, E., Hassmen, P., Ek, S., Ekblom, B. & New- triglycerides: an update. American Journal of Clinical sholme, E.A. (1997) Influence of ingesting a solution Nutrition 36, 950–962. of branched-chain amino acids on perceived exertion Bahrke, M.S. & Yesalis, C.E. III (1994) Weight training: during exercise. Acta Physiologica Scandinavica 159, a potential confounding factor in examining the 41–49. psychological and behavioral effects of anabolic– Blum, B., Stern, M.H. & Melville, K.I. (1964) A com- androgenic steroids. Sports Medicine 18, 309–318. parative evaluation of the action of depressant and Bahrke, M.S., Yesalis, C.E. III & Wright, J.E. (1996) Psy- stimulant drugs on human performance. Psychophar- chological and behavioural effects of endogenous macologia 6, 173–177. testosterone and anabolic–androgenic steroids: an Blyth, C.S., Allen, E.M. & Lovingood, B.W. (1960) update. Sports Medicine 22, 367–390. Effects of amphetamines (Dexedrine) and caffeine on Balsom, P.D., Ekblom, B., Soderlund, K., Sjodin, B. & subjects exposed to heat and exercise stress. Research Hultman, E. (1993) Creatine supplementation and Quarterly 31, 553–559. dynamic high-intensity intermittent exercise. Scandi- Borghouts, L., Juekendrup, A.E., Saris, W.H.M., navian Journal of Medicine and Science in Sports 3, Brouns, F. & Wagenmakers, A.J.M. (1995) No effect of 143–149. medium chain triglyceride (MCT) ingestion during Barnett, C., Costill, D.L., Vukovich, M.D. et al. (1994) prolonged exercise on muscle glycogen utilization. Effect of L-carnitine supplementation on muscle and Medicine and Science in Sports and Exercise 27 (Suppl. blood carnitine content and lactate accumulation 5), S101. during high-intensity sprint cycling. International Brantigan, C.O., Brantigan, T.A. & Joseph, N. (1982) Journal of Sports Nutrition 4, 280–288. Effect of beta blockade and beta stimulation on stage Beckers, E.J., Jeukendrup, A.E., Brouns, F., Wagenmak- fright. American Journal of Medicine 72, 88–94. ers, A.J.M. & Saris, W.H.M. (1992) Gastric emptying Brass, E.P. & Hiatt, W.R. (1994) Minireview: carnitine of carbohydrate–medium chain triglyceride suspen- metabolism during exercise. Life Sciences 54, sions at rest. International Journal of Sports Medicine 13, 1383–1393. 581–584. Braun, B., Clarkson, P.M., Freedson, P.S. & Kohl, R.L. Bedi, J.F., Gong, H. Jr & Horvath, S.M. (1988) Enhance- (1991) Effects of coenzyme Q supplementation on · 10 ment of exercise performance with inhaled albuterol. exercise performance, VO2max, and lipid peroxidation Canadian Journal of Sport Sciences 13, 144–148. in trained cyclists. International Journal of Sports Berning, J. (1996) The role of medium-chain triglyc- Nutrition 1, 353–365. erides in exercise. International Journal of Sports Nutri- Breum, L., Pedersen, J.K., Ahlstrøm, F. & Frimodt- tion 6, 121–133. Møller, J. (1994) Comparison of an ephedrine/caf- 336 medical issues

feine combination and dexfenfluramine in the treat- lism and performance. Exercise and Sport Sciences ment of obesity. A double-blind multi-centre trial in Reviews 19, 1–40. general practice. International Journal of Obesity 18, Conlee, R.K. (1991) Amphetamine, caffeine, and 99–103. cocaine. In D.R. Lamb & M.H.Williams (eds) Perspec- Bright, T.P., Sandage, B.W. & Fletcher, H.P. (1981) tives in Exercise Science and Sports Medicine, Vol. 4. Selected cardiac and metabolic responses to pseu- Ergogenics: Enhancement of Performance in Exercise and doephedrine with exercise. Journal of Clinical Pharma- Sport, pp. 285–329. Brown and Benchmark, Carmel, cology 21, 488–492. Indiana. Broquist, H.P. (1994) Carnitine. In M.E. Shils, J.A. Olson Constantin-Teodosiu, D., Howell, S. & Greenhaff, P.L. & M. Shike (eds) Modern Nutrition in Health and (1996) Carnitine metabolism in human muscle fiber Disease, 8th edn, pp. 459–465. Lea & Febiger, types during submaximal dynamic exercise. Journal Philadelphia. of Applied Physiology 80, 1061–1064. Bucci, L.R. (1994) Nutritional ergogenic aids. In Cordova, M.L. (1996) Steroid use and the female I.Wolinsky & J.F. Hickson (eds) Nutrition in Exercise athlete. Strength and Conditioning 18, 17–19 and Sport, 2nd edn, pp. 295–346. CRC Press, Boca Costill, D.L. & Hargreaves, M. (1992) Carbohydrate Raton, Florida. nutrition and fatigue. Sports Medicine 13, 86–92. Bucci, L.R., Hickson, J.F., Wolinsky, I. & Pivarnik, J.M. Cowan, D.A. (1994) Drug abuse. In M. Harries, C. (1992) Ornithine supplementation and insulin Williams, W.D. Stanish & L.J. Micheli (eds) Oxford release in bodybuilders. International Journal of Sports Textbook of Sports Medicine, pp. 314–329. Oxford Uni- Nutrition 2, 287–291. versity Press, New York. Burke, L.M., Pyne, D.B. & Telford, R.D. (1996) Effect of Coyle, E.F. (1992) Carbohydrate supplementation oral creatine supplementation on single-effort sprint during exercise. Journal of Nutrition 122, 788–795. performance in elite swimmers. International Journal Coyle, E.F. (1995) Substrate utilization during exercise of Sports Nutrition 6, 222–233. in active people. American Journal of Clinical Nutrition Caldwell, J.E., Ahonen, E. & Nousiainen, U. (1984) Dif- 61 (Suppl.), 968S–979S. ferential effects of sauna-, diuretic-, and exercise- Cuthbertson, D.P. & Knox, J.A.C. (1947) The effects of induced hypohydration. Journal of Applied Physiology analeptics on the fatigued subject. Journal of Physiol- 57, 1018–1023. ogy 106, 42–58. Caruso, J.F., Signorile, J.F., Perry, A.C. et al. (1995) The Daly, P.R., Krieger, D.R., Dulloo, A.G., Young, J.B. & effects of albuterol and isokinetic exercise on the Landsberg, L. (1993) Ephedrine, caffeine and aspirin: quadriceps muscle group. Medicine and Science in safety and efficacy for treatment of human obesity. Sports and Exercise 27, 1471–1476. International Journal of Obesity 17 (Suppl. 1), S73–S78. Chait, L.D. (1994) Factors influencing the reinforcing Davis, J.M. (1995) Carbohydrate, branched-chain and subjective effects of ephedrine in humans. Psy- amino acids, and endurance: the central fatigue chopharmacology 113, 381–387. hypothesis. International Journal of Sports Nutrition 5, Chandler, J.V. & Blair, S.N. (1980) The effect of amphet- S29–S38. amines on selected physiological components Décombaz, J., Arnaud, M.J., Milon, H. et al. (1983) related to athletic success. Medicine and Science in Energy metabolism of medium-chain triglycerides Sports and Exercise 12, 65–69. vs. carbohydrates during exercise. European Journal of Christ, D.M., Peake, G.T., Egan, P.A. & Waters, D.L. Applied Physiology 52, 9–14. (1988) Body composition response to exogenous GH Décombaz, J., Gmuender, B., Sierro, G. & Cerretelli, P. during training in highly conditioned adults. Journal (1992) Muscle carnitine after strenuous endurance of Applied Physiology 65, 579–584. exercise. Journal of Applied Physiology 72, 423–427. Claremont, A.D., Costill, D.L., Fink, W. & Van Handel, Décombaz, J., Deriza, O., Acheson, K., Gmuender, B. & P. (1976) Heat tolerance following diuretic induced Jequier, E. (1993) Effect of L-carnitine on submaximal dehydration. Medicine and Science in Sports and Exer- exercise metabolism after depletion of muscle glyco- cise 8, 239–243. gen. Medicine and Science in Sports and Exercise 25, Clarkson, P.M. (1992) Nutritional ergogenic aids: carni- 733–740. tine. International Journal of Sports Nutrition 2, Deyssig, R., Frisch, H., Blum, W.F. & Waldhör, T. (1993) 185–190. Effect of growth hormone treatment on hormonal Clemons, J.M. & Crosby, S.L. (1993) Cardiopulmonary parameters, body composition and strength in ath- and subjective effects of a 60 mg dose of pseu- letes. Acta Endocrinologica 128, 313–318. doephedrine on graded treadmill exercise. Journal of Dodd, S.L., Herb, R.A. & Powers, S.K. (1993) Caffeine Sports Medicine and Physical Fitness 33, 405–412. and exerercise performance: an update. Sports Medi- Coggan, A.R. & Coyle, E.F. (1991) Carbohydrate inges- cine 15, 14–23. tion during prolonged exercise: effects on metabo- Dodd, S.L., Powers, S.K., Vrabas, I.S., Criswell, D., nutritional and pharmacological ergogenic aids 337

Stetson, S. & Hussain, R. (1996) Effects of clenbuterol From ancient Olympia to modern Atlanta: celebra- on contractile and biochemical properties of skeletal tion of the Olympic Centennial. Nutrition Today 31, muscle. Medicine and Science in Sports and Exercise 28, 241–249. 669–676. Guy-Grand, B. (1992) Clinical studies with d- Donelly, K. & McNaughton, L. (1992) The effects of two fenfluramine. American Journal of Clinical Nutrition levels of caffeine ingestion on excess postexercise 55, 173S–176S. oxygen consumption in untrained women. European Guy-Grand, B., Apfelbaum, M., Crepaldi, G., Gries, A., Journal of Applied Physiology 65, 459–463. Lafebvre, P. & Turner, P. (1989) International trial of Dulloo, A.G. (1993) Ephedrine, xanthines and long-term dexfenfluramine in obesity. Lancet ii, prostaglandin-inhibitors: actions and interactions 1142–1145. in the stimulation of thermogenesis. International Haldi, H. & Wynn, W. (1946) Action of drugs on effi- Journal of Obesity 17 (Suppl. 1), S35–S40. ciency of swimmers. Research Quarterly 17, 96–101. Dulloo, A.G. & Miller, D.S. (1986) The thermic proper- Hanna, J.M. (1970) The effects of coca chewing on ties of ephedrine/methylxanthine mixtures: human exercise in the Quechua of Peru. Human Biology 42, studies. International Journal of Obesity 10, 467–481. 1–11. Eston, R.G. & Thompson, M. (1997) Use of ratings of Hanna, J.M. (1971) Further studies on the effects of coca perceived exertion for predicting maximal work rate chewing on exercise. Human Biology 43, 200–209. and prescribing exercise intensity in patients taking Harris, R.C., Soderlund, K. & Hultman, E. (1992) Eleva- atenolol. British Journal of Sports Medicine 31, 114–119. tion of creatine in resting and exercised muscle of Fallowfield, J.L. & Williams, C. (1993) Carbohydrate normal subjects by creatine supplementation. Clini- intake and recovery from prolonged exercise. Inter- cal Science 83, 367–374. national Journal of Sports Nutrition 3, 150–164. Haupt, H.A. (1989) Drugs in athletics. Clinics in Sports Favier, R., Caceres, E., Koubi, H., Sempore, B., Sauvain, Medicine 8, 561–582. M. & Spielvogel, H. (1996) Effects of coca chewing Haupt, H.A. & Rovere, G.D. (1984) Anabolic steroids: a on hormonal and metabolic responses during review of the literature. American Journal of Sports prolonged submaximal exercise. Journal of Applied Medicine 12, 469–484. Physiology 80, 650–655. Heinonen, O.J. (1996) Carnitine and physical exercise. Geissler, C.A. (1993) Effects of weight loss, ephedrine Sports Medicine 22, 109–132. and aspirin on energy expenditure in obese women. Horowitz, J.F., Mora-Rodriquez, R. & Coyle, E.F. (1995) International Journal of Obesity 17 (Suppl. 1), S45–S48. The effect of pre-exercise medium-chain triglyceride Gillies, H., Derman, W.E., Noakes, T.D., Smith, P., ingestion on muscle glycogen utilization during Evans, A. & Gabriels, G. (1996) Pseudoephedrine is high-intensity exercise. Medicine and Science in Sports without ergogenic effects during prolonged exercise. and Exercise 27 (Suppl.), S203. Journal of Applied Physiology 81, 2611–2617. Horswill, C.A. (1994) Physiology and nutrition for Golding, L.A. & Barnard, J.R. (1963) The effect of d- wrestling. In D.R. Lamb, H.G. Knuttgen & R. Murray amphetamine sulfate on physical performance. (eds) Perspectives in Exercise Science and Sports Medi- Journal of Sports Medicine and Physical Fitness 3, cine, Vol. 7. Physiology and Nutrition for Competitive 221–224. Sport, pp. 131–180. Cooper Publishing Group, Green, A.L., Simpson, E.J., Littlewood, J.J., Macdonald, Carmel, Indiana. I.A. & Greenhaff, P.L. (1996) Carbohydrate ingestion Horton, T.J. & Geissler, C.A. (1991) Aspirin potentiates augments creatine retention during creatine feeding the effect of ephedrine on the thermogenic response in humans. Acta Physiologica Scandinavica 158, to a meal in obese but not lean women. International 195–202. Journal of Obesity 15, 359–366. Greenhaff, P.L. (1995) Creatine and its application as an Hough, D.O. (1990) Anabolic steroids and ergogenic ergogenic aid. International Journal of Sports Nutrition aids. American Family Physician 41, 1157–1164. 5, S100–S110. Hultman, E., Söderlund, K., Timmons, J.A., Cederblad, Greenhaff, P.L., Casey, A., Short, A.H., Harris, R., G. & Greenhaff, P.L. (1996) Muscle creatine loading Soderlund, K. & Hultman, E. (1993) Influence of oral in men. Journal of Applied Physiology 81, 232–237. creatine supplementation on muscle torque during Imhof, P.R., Blaatter., K., Fuccella, M. & Turri, M. (1969) repeated bouts of maximal voluntary exercise in Beta-blockade and emotional tachycardia; radiotele- man. Clinical Science 84, 565–571. metric investigations in ski jumpers. Journal of Greenway, F.L. (1992) Clinical studies with phenyl- Applied Physiology 27, 366–369. propanolamine: a metaanalysis. American Journal of James, I.M., Griffith, D.N.W., Pearson, R.M. & Clinical Nutrition 55, 203S–205S. Newbury, P. (1977) Effect of oxyprenolol on stage- Grivetti, L.E., Applegate, E.A., Clarkson, P.M., Grand- fright in musicians. Lancet ii, 952–954. jean, A.C., McDonald, R.B. & Tipton, C.M. (1996) Jenkins, R.R. (1993) Exercise, oxidative stress, and 338 medical issues

antioxidants: a review. International Journal of Sports Serum amino acid concentrations in nine athletes Nutrition 3, 356–375. before and after the 1993 Colmar Ultra Triathlon. Jeukendrup, A.E., Saris, W.H.M., Schrauwen, P., International Journal of Sports Medicine 16, 155–159. Brouns, F. & Wagenmarkers, A.J.M. (1995) Metabolic Lemmer, J.T., Fleck, S.J., Wallach, J.M. et al. (1995) The availability of medium-chain triglycerides coin- effects of albuterol on power output in non- gested with carbohydrate during prolonged exer- asthmatic athletes. International Journal of Sports cise. Journal of Applied Physiology 79, 756–762. Medicine 16, 243–249. Johnson, R.C., Young, S.K., Cotter, R., Lin, L. & Rowe, Lemon, P.W.R. (1995) Do athletes need more protein W.B. (1990) Medium-chain-triglyceride lipid emul- and amino acids? International Journal of Sports Nutri- sion: metabolism and tissue distribution. American tion 5, S39–S61. Journal of Clinical Nutrition 52, 502–508. Lombard, K.A., Olson, A.L., Nelson, S.E. & Rebouche, Kanter, M.M. & Williams, M.H. (1995) Antioxidants, C.J. (1989) Carnitine status of lactoovovegetarians carnitine, and choline as putative ergogenic aids. and strict vegetarian adults and children. American International Journal of Sports Nutrition 5, S120–S131. Journal of Clinical Nutrition 50, 301–306. Karlsson, J. (1997) Antioxidants and Exercise. Human Lombardo, J.A. (1986) Stimulants and athletic perfor- Kinetics Publishers, Champaign, Illinois. mance (Part 2): cocaine and nicotine. Physician and Karlsson, J., Diamant, B., Edlund, P.O., Lund, B., Sportsmedicine 14, 85–90. Folkers, K. & Theorell, H. (1992) Plasma ubiquinone, Lombardo, J.A., Hickson, R.C. & Lamb, D.R. (1991) alpha-tocopherol and cholesterol in man. Inter- Anabolic/androgenic steroids and growth hormone. national Journal for Vitamin and Nutrition Research 62, In D.R. Lamb & M.H. Williams (eds) Perspectives in 160–164. Exercise Science and Sports Medicine, Vol. 4. Ergogenics: Karlsson, J., Lin, L., Sylven, C. & Jansson, E. (1996) Enhancement of Performance in Exercise and Sport, Muscle ubiquinone in healthy physically active pp. 249–284. Wm. C. Brown Publishers, Dubuque, males. Molecular and Cellular Biochemistry 156, Iowa. 169–172. Macintyre, J.G. (1987) Growth hormone and athletes. Karpovich, P.V. (1959) Effect of amphetamine sulfate on Sports Medicine 4, 129–142. athletic performance. Journal of the American Medical McKenzie, D.C., Rhodes, E.C., Stirling, D.R. et al. (1983) Association 170, 558–561. Salbutamol and treadmill performance in non-atopic Keith, R.E., O’Keeffe, K.A., Blessing, D.L. & Wilson, athletes. Medicine and Science in Sports and Exercise 15, G.D. (1991) Alterations in dietary carbohydrate, 520–522. protein, and fat intake and mood state in trained Malm, C., Svensson, M., Sjöberg, B., Ekblom, B. & female cyclists. Medicine and Science in Sports and Sjödin, B. (1996) Supplementation with ubiquinone- Exercise 23, 212–216. 10 causes cellular damage during intense exercise. Korkia, P. (1996) Use of anabolic steroids has been Acta Physiologica Scandinavica 157, 511–512. reported by 9% of men attending gymnasiums. Maltin, C.A., Delday, M.I., Watson, J.S. et al. (1993) British Medical Journal 313, 1009. Clenbuterol, a b-adrenoceptor agonist, increases Kruse, P., Ladefoged, J., Nielsen, U., Paulev, P.-E. & relative muscle strength in orthopaedic patients. Sørensen, J.P. (1986) b-Blockade used in precision Clinical Science 84, 651–654. sports: effect on pistol shooting performance. Journal Maresh, C.M., Gabaree, C.L., Hoffman, J.R. et al. (1994) of Applied Physiology 61, 417–420. Anaerobic power responses to amino acid nutri- Laaksone, R., Fogelholm, M., Himberg, J.J., Laakso, J. & tional supplementation. International Journal of Sports Salorinne, Y. (1995) Ubiquinone supplementation Nutrition 4, 366–377. and exercise capacity in trained young and older Martineau, L., Horan, M.A., Rothwell, N.J. & Little, men. European Journal of Applied Physiology 72, R.A. (1992) Salbutamol, a b2-adrenoceptor agonist, 95–100. increases skeletal muscle strength in young men. Lamb, D.R. (1984) Anabolic steroids in athletics: how Clinical Science 83, 615–621. well do they work and how dangerous are they? Massey, L.K. & Wise, K.J. (1992) Impact of gender and American Journal of Sports Medicine 12, 31–38. age on urinary water and mineral excretion Landsberg, L. & Young, J.B. (1993) Sympathoadrenal responses to acute caffeine doses. Nutrition Research activity and obesity: physiological rationale for the 12, 605–612. use of adrenergic thermogenic drugs. International Massicotte, D., Peronnet, F., Brisson, G.R. & Hillaire- Journal of Obesity 17, S29–S34. Marcel, C. (1992) Oxidation of exogenous medium- Laties, V.G. & Weiss, B. (1981) The amphetamine chain free fatty acids during prolonged exercise: margin in sports. Federation Proceedings 40, comparison with glucose. Journal of Applied Physiol- 2689–2692. ogy 73, 1334–1339. Lehmann, M., Huonker, M., Dimeo, F. et al. (1995) Maughan, R.J. (1995) Creatine supplementation and nutritional and pharmacological ergogenic aids 339

exercise performance. International Journal of Sports ance of middle-aged, untrained men. International Nutrition 5, 94–101. Journal of Sports Medicine 16, 421–427. Meeusen, R. & De Meirleir, K. (1995) Exercise and brain Redondo, D.R., Dowling, E.A., Graham, B.L., Almada, neurotransmission. Sports Medicine 20, 160–188. A.L. & Williams, M.H. (1996) The effect of oral crea- Meeuwisse, W.H., McKenzie, D.C., Hopkins, S.R. & tine monohydrate supplementation on running Road, J.D. (1992) The effect of salbuterol on perfor- velocity. International Journal of Sports Nutrition 6, mance in elite nonasthmatic athletes. Medicine and 213–221. Science in Sports and Exercise 24, 1161–1166. Rudman, D., Feller, A.G., Nagraj, H.S. et al. (1990) Morton, A.R. & Fitch, K.D. (1992) Asthmatic drugs and Effects of human growth hormone in men over 60 competitive sport: an update. Sports Medicine 14, years old. New England Journal of Medicine 323, 1–6. 228–242. Schwenk, T.L. (1997) Psychoactive drugs and athletic Morton, A.R., Joyce, K., Papalia, S.M., Carroll, N.G. & performance. Physician and Sportsmedicine 25, 32– Fitch, K.D. (1996) Is salmeterol ergogenic? Clinics in 46. Sports Medicine 6, 220–225. Sherman, W.M. (1991) Carbohydrate feedings before Mujika, I., Chatard, J., Lacoste, L., Barale, F. & Geyssant, and after exercise. In D.R. Lamb & M.H. Williams A. (1996) Creatine supplementation does not (eds) Perspectives in Exercise Science and Sports Medi- improve sprint performance in competitive swim- cine, Vol. 4. Ergogenics: Enhancement of Performance in mers. Medicine and Science in Sports and Exercise 28, Exercise and Sport, pp. 1–27. Wm C. Brown Publish- 1435–1441. ers, Ann Arbor, Michigan. Munro, J.F., Scott, C. & Hodge, J. (1992) Appraisal of Sherman, W.M. (1995) Metabolism of sugars and physi- the clinical value of serotoninergic drugs. American cal performance. American Journal of Clinical Nutrition Journal of Clinical Nutrition 55, 189S–192S. 62 (Suppl.), 228S–241S. NCAA (1997) NCAA Study of Substance Use and Abuse Sherman, W.M. & Wimer, G.S. (1991) Insufficient Habits of College Student Athletes. National Collegiate dietary carbohydrate during training: does it impair Athletic Association. athletic performance? International Journal of Sports Nicklas, B.J., Hackney, A.C. & Sharp, R.L. (1989) The Nutrition 1, 28–44. menstrual cycle and exercise: performance, muscle Sidney, K.H. & Lefcoe, N.M. (1978) Effects of tedral glycogen, and substrate response. International upon exercise performance: a double-blind cross- Journal of Sports Medicine 10, 264–269. over study. In F. Landry & W.A.R. Organ (eds) Sports O’Connor, H.T., Richman, R.M., Steinbeck, K.S. & Medicine, pp. 297–299. Symposium Specialists, Caterson, I.D. (1995) Dexfenfluramine treatment of Miami. obesity: a double blind trial with post trial follow up. Signorile, J.F., Kaplan, T.A., Applegate, B. & Perry, A.C. International Journal of Obesity 19, 181–189. (1992) Effects of acute inhalation of the bronchodila- Odland, L.M., MacDougall, J.D., Tarnopolsky, M.A., tor, albuterol, on power output. Medicine and Science Elorriaga, A. & Borgmann, A. (1997) Effect of oral cre- in Sports and Exercise 24, 638–642. atine supplementation on muscle [Pcr] and short- Signorile, J.F., Banovac, K., Gomez, M., Flipse, D., term maximum power output. Medicine and Science Caruso, J.F. & Lowensteyn, I. (1995) Increased muscle in Sports and Exercise 29, 216–219. strength in paralyzed patients after spinal cord Pasquali, R. & Casimirri, F. (1993) Clinical aspects of injury: effect of beta-2 adrenergic agonist. Archives of ephedrine in the treatment of obesity. International Physical Medicine and Rehabilitation 76, 55–58. Journal of Obesity 17, S65–S68. Siitonen, L., Sonck, T. & Jänne, J. (1977) Effect of beta- Pasquali, R., Cesari, M.P., Melchionda, N., Stefani, C., blockade on performance: use of beta-blockade in Raitano, A. & Labo, G. (1987) Does ephedrine bowling and in shooting competitions. Journal of promote weight loss in low-energy-adapted obese International Medical Research 5, 359–366. women? International Journal of Obesity 11, 163–168. Silverstone, T. & Goodall, E. (1992) Centrally acting Pasquali, R., Casimirri, F., Melchionda, N. et al. (1992) anoretic drugs: a clinical perspective. American Effects of chronic administration of ephedrine Journal of Clinical Nutrition 55, 211S–214S. during very-low-calorie diets on energy expendi- Smith, G.M. & Beecher, H.K. (1959) Amphetamine ture, protein metabolism and hormone levels in sulfate and athletic performance. Journal of the Ameri- obese subjects. Clinical Science 82, 85–92. can Medical Association 170, 542–557. Phillips, S.M., Atkinson, S.A., Tarnopolsky, M.A. & Smith, G.M. & Beecher, H.K. (1960) Amphetamine, sec- MacDougall, J.D. (1993) Gender differences in obarbital, and athletic performance. Journal of the leucine kinetics and nitrogen balance in endurance American Medical Association 172, 1502–1514. athletes. Journal of Applied Physiology 75, 2134–2141. Snider, I.P., Bazzarre, T.L., Murdoch, S.D. & Goldfarb, Porter, D.A., Costill, D.L., Zachwieja, J.J. et al. (1995) A. (1992) Effects of coenzyme athletic performance The effect of oral coenzyme Q10 on the exercise toler- system as an ergogenic aid on endurance perfor- 340 medical issues

mance to exhaustion. International Journal of Sports Tesch, P.A. (1985) Exercise performance and b-block- Nutrition 2, 272–286. ade. Sports Medicine 2, 389–412. Spann, C. & Winter, M.E. (1995) Effect of clenbuterol on Thornton, G.R., Holck, H.G.O. & Smith, E.L. (1939) The athletic performance. Annals of Pharmacotherapy 29, effect of benzedrine and caffeine upon performance 75–77. in certain psychomotor tasks. Journal of Abnormal and Spielvogel, H., Caceres, E., Koubi, H., Sempore, B., Social Psychology 34, 96–113. Sauvain, M. & Favier, R. (1996) Effects of coca Tsintzas, K., Liu, R., Williams, C., Campbell, I. & chewing on metabolic and hormonal changes during Gaitanos, G. (1993) The effect of carbohydrate graded incremental exercise to maximum. Journal of ingestion on performance during a 30-km race. Inter- Applied Physiology 80, 643–649. national Journal of Sports Nutrition 3, 127–139. Spriet, L.L. (1995) Caffeine and performance. Interna- Van Hall, G., Raaymakers, J.S.H., Saris, W.H.M. & tional Journal of Sports Nutrition 5, S84–S99. Wagenmakers, A.J.M. (1995) Ingestion of branched- Spriet, L.L. (1997) Ergogenic aids: recent advances and chain amino acids and tryptophan during sustained retreats. In D.R. Lamb & R. Murray (eds) Perspectives exercise in man: failure to affect performance. Journal in Exercise Science and Sports Medicine, Vol. 10. Recent of Physiology 486, 789–794. Advances in the Science and Medicine of Sport, pp. Van Zyl, C.G., Lambert, E.V., Hawley, J.A., Noakes, T.D. 185–234. Cooper Publishing Group, Carmel, Indiana. & Dennis, S.C. (1996) Effects of medium-chain Steen, S.N. (1991) Nutrition considerations for the low- triglyceride ingestion on fuel metabolism and body-weight athlete. In J.R. Berning & S.N. Steen cycling performance. Journal of Applied Physiology 80, (eds) Sports Nutrition for the 90s: The Health Profes- 2217–2225. sional’s Handbook, pp. 153–174. Aspen Publishers Inc., Varnier, M., Sarto, P., Martines, D. et al. (1994) Effects of Gaithersburg, Maryland. infusing BCAA during incremental exercise with Stinson, J.C., Murphy, C.M., Andrews, J.F. & Tomkin, reduced muscle glycogen content. European Journal of G.H. (1992) An assessment of the thermogenic effects Applied Physiology 69, 26–31. of fluoxetine in obese subjects. International Journal of Videman, T., Sonck, T. & Jänne, J. (1979) The effect of Obesity 16, 391–395. beta-blockade in ski-jumpers. Medicine and Science in Strauss, R.H. & Yesalis, C.E. (1991) Anabolic steroids in Sports and Exercise 11, 266–269. the athlete. Annual Review of Medicine 42, 449–457. Vukovich, M.D., Costill, D.L. & Fink, W.J. (1994) Carni- Strauss, R.H., Liggett, M.T. & Lanese, R.R. (1985) Ana- tine supplementation: effect on muscle carnitine bolic steroid use and perceived effects in ten weight- and glycogen content during exercise. Medicine and trained women athletes. Journal of the American Science in Sports and Exercise 26, 1122–1129. Medical Association 253, 2871–2873. Wagenmaker, A.J.M. (1991) L-Carnitine supplementa- Swift, L.L., Hill, J.O., Peters, J.C. & Greene, H.L. (1990) tion and performance in man. In F. Brouns (ed.) Medium-chain fatty acids: evidence for incorpora- Advances in Nutrition and Top Sport. Medicine and tion into chylomicron triglycerides in humans. Amer- Sport Science, Vol. 32, pp. 110–127. Karger, Basel. ican Journal of Clinical Nutrition 52, 834–836. Wagner, J.C. (1989) Abuse of drugs used to enhance Taaffe, D.R., Pruitt, L., Reim, J. et al. (1994) Effect of athletic performance. American Journal of Hospital recombinant human growth hormone on the muscle Pharmacy 46, 2059–2067. strength response to resistance exercise in elderly Wagner, J.C. (1991) Enhancement of athletic perfor- men. Journal of Clinical Endocrinology and Metabolism mance with drugs. Sports Medicine 12, 250–265. 79, 1361–1366. Walberg-Rankin, J. (1995) Dietary carbohydrate as an Tarnopolsky, J.T., MacDougall, J.D., Atkinson, S.A., ergogenic aid for prolonged and brief competitions Tarnopolsky, M.A. & Sutton, J.R. (1990) Gender dif- in sport. International Journal of Sports Nutrition 5, ferences in substrate for endurance exercise. Journal S13–S28. of Applied Physiology 68, 302–308. Welle, S., Thornton, C., Statt, M. & McHenry, B. (1996) Tarnopolsky, M.A. (1994) Caffeine and endurance per- Growth hormone increases muscle mass and formance. Sports Medicine 18, 109–125. strength but does not rejuvenate myofibrillar protein Tarnopolsky, M.A., Atkinson, S.A., Phillips, S.M. & synthesis in healthy subjects over 60 years old. MacDougall, J.D. (1995) Carbohydrate loading and Journal of Clinical Endocrinology and Metabolism 81, metabolism during exercise in men and women. 3239–3243. Journal of Applied Physiology 78, 1360–1368. Williams, M.H. (1991) Alcohol, marijuana and beta Tennant, F.S. (1984) Dealing with cocaine use by ath- blockers. In D.R. Lamb and M.H. Williams (eds) Per- letes. Sport Medicine Digest 6, 1–3. spectives in Exercise Science and Sports Medicine, Vol. 4. Terney, R. & McLain, L.G. (1990) The use of anabolic Ergogenics: Enhancement of Performance in Exercise and steroids in high school students. American Journal of Sport, pp. 331–372. Brown and Benchmark, Carmel, Diseases of Children 144, 99–103. Indiana. nutritional and pharmacological ergogenic aids 341

Williams, M.H. & Thompson, J. (1973) Effect of variant Yarasheski, K.E., Campbell, J.A., Smith, K., Rennie, dosages of amphetamine upon endurance. Research M.J., Holloszy, J.O. & Bier, D.M. (1992) Effect of Quarterly 44, 417–421. growth hormone and resistance exercise on muscle Wilmore, J.H. (1988) Exercise testing, training, growth in young men. American Journal of Physiology and beta-adrenergic blockade. Physician and Sports- 262, E261–E267. medicine 16, 45–50. Yarasheski, K.E., Zachwieja, J.J., Angelopoulos, T.J. & Wirth, V.J. & Gieck, J. (1996) Growth hormone: myths Bier, D.M. (1993) Short-term growth hormone treat- and misconceptions. Journal of Sport Rehabilitation 5, ment does not increase muscle protein synthesis 244–250. in experienced weight lifters. Journal of Applied Physi- Wise, S.D. (1992) Clinical studies with fluoxetine in ology 74, 3073–3076. obesity. American Journal of Clinical Nutrition 55, Yarasheski, K.E., Zachwieja, J.J., Campbell, J.A. & 181S–184S. Bier, D.M. (1995) Effect of growth hormone and resis- Wyndham, C.H., Rogers, G.G., Benade, A.J.S. & tance exercise on muscle growth and strength in Strydom, N.B. (1971) Physiological effect of amphet- older men. American Journal of Physiology 268, E268– amine during exercise. South African Medical Journal E276. 45, 247–252. Chapter 23

Sexual Harassment and Abuse

CELIA BRACKENRIDGE

Introduction social work approaches. Risk analysis and subse- quent risk management is suggested as one prac- Women athletes will only optimize their poten- tical method for securing better personal safety tial in sport if they are able to train and compete for the female athlete. However, the limitations in conditions of complete safety. However, many of this approach are also acknowledged and a females in sport endure less than safe conditions future research agenda is set out that might gen- and, as a result, suffer pain, illness or injury. erate a better information base. This, in turn, The major focus of this chapter is on the conse- should facilitate the development and imple- quences for the female athlete when her personal mentation of more effective policy and practice safety is violated by others in the course of in protecting the athlete from sexual harassment interpersonal relations in sport, through either and abuse. harassment or abusive behaviour. Such poten- According to the National Society for the Pre- tially dangerous relationships include those vention of Cruelty to Children in the UK, abuses between the athlete and her coach (usually male) takes four major forms: sexual, physical, or other authority figures (S. Kirby & L. Greaves, emotional and neglect (Crouch, 1995). Clearly, unpublished observation), as well as those combinations of these abuses frequently between the athlete and her peers (Kane & Disch, occur, for example where an athlete suffers 1993; Pike Masteralexis, 1995). The violation of emotional blackmail or physical damage as well personal safety within such relationships has as sexual exploitation. However, the focus of the serious outcomes for mental health. However, rest of this chapter is on the psychological deter- it is clear that a medical perspective alone cannot minants and correlates of sexual harassment and resolve the multifarious issues surrounding abuse. harassment and abuse of women in sport. A more complete understanding of the social and Sexual violations against the political context in which these actions occur is female athlete necessary. This chapter sets out the current research Origins of research into sexual violations knowledge about the incidence and prevalence against women in sport of harassment and abuse of women in sport, the clinical therapy perspectives on the effects of Whilst legal and constitutional changes towards such experiences, and known risk factors for the sex equity in society at large had been secured by coach/athletic leader, athlete and sport context. the women’s movement in many western indus- A new model for risk analysis is proposed, trial nations during the 1970s (e.g. Title IX in the drawing from existing clinical, therapeutic and USA in 1972, the Sex Discrimination Act in the 342 sexual harassment and abuse 343

UK in 1975 and the Charter of Rights and observation). Specific knowledge about the Freedoms, Constitution Act 1982 in Canada), it extent and types of violations of personal and became apparent to those advocates of women’s sexual safety in sport is comparatively sparse right within the world of sport that discrimina- since systematic research into the issue began so tory behaviour was a persistent, deep-seated and late. However, literature from cognate fields such resilient male habit that would take some time to as women’s studies, the sociology of violence, change. Research mapping the extent of institu- clinical therapy, and psychiatry were available tional discrimination preceded that on personal and theories and models from these fields gave sexism and abuse (Acosta & Carpenter, 1985, sports researchers a set of tools with which to 1990; White & Brackenridge, 1985) but provided begin investigating sexual harassment and an important platform of statistical evidence abuse. The original stimulus for such work came about vertical and horizontal sex segregation on not from medicine, even though clinical symp- which later interpersonal studies subsequently toms of harassment and abuse were evident developed. amongst some female athletes, but as an exten- It is only since the late 1980s that research sion of research into discriminatory practices and studies about interpersonal harassment and equal opportunities (Lenskyj, 1986; Theberge, sexual abuse in sport have started to appear 1987; Hall, 1988). It was but a short step from the (Brackenridge, 1987, 1991, 1994, 1997a; Lackey, study of sex discrimination to the study of sexual 1990; Lenskyj, 1992a; T. Crosset, unpublished harassment (Table 23.1).

Table 23.1 The sexual violence continuum. (From Brackenridge, 1997b with permission)

Sex discrimination Sexual harassment Sexual abuse

Institutional Personal Personal ‘The chilly climate’‘Unwanted attention’‘Groomed or coerced’ Vertical and horizontal job segregation Written or verbal abuse or threats Exchange of reward or privilege for Lack of harassment policy and/or Sexually oriented comments sexual favours officer or reporting channels Jokes, lewd comments or sexual Rape Lack of counselling or mentoring innuendoes, taunts about Anal or vaginal penetration by systems body, dress, marital situation penis, fingers or objects Differential pay or rewards or or sexuality Forced sexual activity promotion prospects on the basis of Ridiculing of performance Sexual assault sex Sexual or homophobic graffiti Physical/sexual violence Poorly/unsafely designed or lit Practical jokes based on sex Groping venues Intimidating sexual remarks, Indecent exposure Absence of security propositions, invitations or Incest familiarity Domination of meetings, play space or equipment Condescending or patronizing behaviour undermining self- respect or work performance Physical contact, fondling, pinching or kissing Vandalism on the basis of sex Offensive phone calls or photos Bullying based on sex 344 medical issues

like relationship, providing a mixture of disci- Definitions of sexual harassment and abuse pline and affection upon which the athlete grad- There is no universally accepted set of definitions ually becomes reliant. Grooming is a conscious of sexual harassment or sexual abuse. Even process on the part of the abuser. The athlete, on though these behaviours may be defined objec- the other hand, is an unwitting, sometimes ner- tively it is important to recognize that they are vously accepting, other times enthusiastically experienced subjectively; thus the personal and cooperating party to the gradual erosion of psychological impact of the same behaviour may boundaries between her and the coach. be vastly different depending on the individual The power afforded the coach in his position female athlete’s background and perceptions. of authority offers an effective camouflage for However, if we accept a relativist position on grooming and abuse. Incremental shifts in the sexual abuse (i.e. what constitutes abuse is in the boundary between the coach and athlete go eye/experience of the beholder) then we are also unnoticed, unrecognized or unreported by the in danger of permitting exploitative behaviour to athlete until the point when she has become continue to undermine the sport experience for entirely trapped and is unable to resist his sexual countless millions of women. advances. Disclosure is enormously difficult for It is necessary therefore to agree on working the athlete, who risks uncertain support from definitions of abuse and harassment in order to her teammates and sport administrators and facilitate a debate in sport about safe and unsafe may even lose her athletic career by speaking interpersonal boundaries. In Table 23.1 sexual out. Any rejection of grooming by an athlete or harassment and abuse are represented as the any challenge to the authority of the perpetrator middle and extreme points along a continuum of carry the risk of sanctions such as withdrawal of sexual violence, and sets of behaviours are listed privileges or his coaching expertise, even exclu- to exemplify each term. Whilst this conceptual- sion from the team or squad. Since the raison ization of behaviours separates each type, it is d’être of the talented young athlete is to succeed important to stress again that individual victims in her chosen sport, she feels virtually powerless may experience them in an undifferentiated way; to challenge the one individual who can help her indeed, the nuances of definitional distinctions achieve that success. For this reason, the athlete are completely irrelevant to the victim at the time with potential talent is at higher risk of being tar- of her experience. However, the model does offer geted for sexual abuse than either the recre- us a means of approaching preventative work ational athlete, who can leave the sport or club to with authority figures in sport and may also find another, or the already successful athlete, facilitate variations in treatments and curative who is no longer so dependent on her coach. For work. the athlete on the brink of top level success the There is an especially important distinction stakes are highest of all and the pressures to between sexual harassment, defined as un- collude with unsafe behaviours felt most keenly. wanted behaviour or approaches on the basis of sex, and sexual abuse, defined as groomed or Recognizing the athlete at risk of coerced collaboration in sexual acts. The groom- sexual abuse ing process, long recognized within clinical liter- ature, is at the heart of the abusive relationship. General statistics for non-sport settings indicate The athlete gains trust in the coach or authority that around one in three or four girls experience figure because he offers not only tangible sexual abuse, however defined, before reaching extrinsic rewards for good performance (team adulthood (Russell, 1984). Most of these cases selection, the chance to win competitions, repre- occur within the familial setting, although extra- sentative honours and medals) but also because familial abuse comprises a small but significant he nurtures and protects the athlete in a parent- proportion of the total recorded (LaFontaine, sexual harassment and abuse 345

1990). These figures suggest therefore that large 40 numbers of girls and young women enter sports clubs and programmes already having experi- enced the stresses and trauma of sexual abuse in the family. These individuals are likely to 30 be especially vulnerable to approaches by unscrupulous coaches. Research on small popu- lations of female athlete survivors of abuse (Brackenridge, 1997a) indicates that a distant 20 relationship with the parents, especially the

father, may well be a risk factor for sexual abuse Number of events in sport. Whether having experienced sexual abuse in the home increases the susceptibility of 10 the individual to abuse in sport is not known but it seems that this is highly likely. Women athletes who present with signs of dis- ordered eating (extreme weight loss, amenor- 0 rhoea, eroded tooth enamel, etc.) may also be On team Regular Private Vehicle Other showing the symptoms of sexual abuse. Accord- trip training location or hotel public ing to the literature on eating disorders, there is a location proven link between anorexia and bulimia and Fig. 23.1 Location of incidents of sexual abuse involv- sexual victimization (Johnson, 1994). One sug- ing female athletes. n = 146. (Adapted from S. Kirby & gested explanation for this link is that the athlete L. Greaves, unpublished observations.) is trying to desexualize her body in order to take back control over the sexual advances of her abuser. Certainly, the links between disordered one being the paedophile cycle (S.C. Wolf, cited eating and sexual abuse, within both sport and in Fisher, 1994) and the other termed the ‘preda- family settings, bear further examination. Other tor’ by Brackenridge (unpublished observation) overt signs of sexual abuse and neglect include (Fig. 23.2.). These two cycles bear theoretical cuts or bruises to the body, vaginal soreness, resemblance to the child molester and rapist unusual knowledge of or interest in sexual typologies developed in clinical psychology (see, matters for a particular age, depression and for example, Knight & Prentky, 1990); however, social withdrawal, refusal to eat, or sudden the predator cycle has yet to be verified on data changes in mood or routine behaviour. from a large sample. Risk factors for sexual abuse in sport associ- Whilst it is tempting to focus analysis of risk ated with the coach, the athlete and the sport entirely on perpetrator motivations and behav- have been extrapolated from both qualitative iours, this is also a dangerous strategy. Sexual research (Brackenridge, 1997b) and quantitative abusers have proved notoriously difficult to clas- research (S. Kirby & L. Greaves, unpublished sify and evidence from social work and therapy observation) (Fig. 23.1 & Table 23.2). The risks of has repeatedly shown that they cross social sexual exploitation in sport are particularly and demographic categories (Russell, 1984; increased for young girls, for women and girls Waterhouse, 1993; Whetsell-Mitchell, 1995). suffering physical disabilities or learning diffi- No clear link with socioeconomic status, culties, and for those for whom communication ethnicity or region has been proven, although it or access to others is difficult. has been suggested that the silence veiling the Perpetrators of sexual abuse in sport appear incest taboo has been more effectively main- to demonstrate at least two cycles of behaviour, tained by those from the wealthier classes 346 medical issues

Table 23.2 Risk factors for sexual abuse in sport. (From Brackenridge, 1997b with permission)

Coach variables Athlete variables Sport variables

Sex (male) Sex (female) Amount of physical handling Age (older) Age (younger) required for coaching Size/physique (larger/stronger) Size/physique (smaller/weaker) Individual/team sport Accredited qualifications (good) Rank/status (potentially high) Location of training and Rank/reputation (high) History of sexual abuse competitions Previous record of sexual harassment (unknown/none) Opportunity for trips away (unknown/ignored) Level of awareness of sexual Dress requirements Trust of parents (strong) harassment (low) Employment/recruitment Standing in the sport/ Self-esteem (low) controls and/or vetting club/community (high) Relationship with parents (weak/none) Chances to be alone with athletes (weak) Regular evaluation, including in training, at competitions and Medical problems, especially athlete screening and cross- away on trips (frequent) disordered eating referencing to medical data Commitment to sport/national (medium/high) Education and training on coaches association codes of Devotion to coach (complete) sexual harassment and ethics and conduct (weak/none) abuse (none) Use of car to transport athletes (frequent) Use of national and sport- specific codes of ethics or sport-specific codes of ethics and conduct (weak) Existence of athlete and parent contracts (none) Climate for debating sexual harassment (poor/ nonexistent)

Comments in parentheses are based on trends from unstructured interviews with 12 survivors of sexual abuse in sport. Where there is no comment, further research is required.

Poor self-image Good self-image Increased confidence Poor personal skills Push away guilt Good personal skills Increased sense Transitory guilt Expects rejection of control Expects approval/ Outlet acceptance Withdraws Grooming Seeks public Unassertive Sexual escapism Sexual confidence profile Compensatory Assertive Assumption of fantasies superiority (a) (b)

Fig. 23.2 Two cycles of sexual abuse in sport: (a) paedophile and (b) predator. (From C. Brackenridge, unpublished observations.) sexual harassment and abuse 347

(Doyle, 1994). A singular focus on perpetrators Table 23.3 Feelings of abuse victims also distracts from other potentially useful areas Suspicious, unable to trust others of risk analysis and management, notably the Afraid, unable to stand up for own opinion athlete and the sport. Blames self for everything bad that happens Not surprisingly, known athlete risk factors in Feels guilty and ashamed even when there is no reason sport match those recognized in other, non-sport Withdraws, does not want to spend time with others settings. However, the added physical nature of Feels ‘different’ from others Feels hurt by others a lot of the time sport, coupled with the requirements for extreme Lonely, bored and empty inside dedication and social, physical and emotional Suicidal sacrifice at a relatively young age, all combine Feels like a perfectionist, cannot tolerate mistakes to increase risk. For the athlete who has low self- Constantly feels sorry for self esteem or a weak relationship with her ‘natural’ Feels angry all the time Closes off feelings, unable to tolerate emotional pain parents, especially the father, there appear to be Not caring about appearance greater risks. Susceptibility to the close attention Feels out of control of life and interest of a parent substitute, the coach, can Depressed and sad lead to close emotional attachment, infatuation Afraid of change and even love. Indeed, many survivors of sexual Feels trapped, like nobody understands Feels stupid, less capable than others abuse in sport articulate mixed emotions about Ashamed of sexual feelings their abusers, perhaps even years or decades later, and blame themselves for falling prey to sexual exploitation. The sport context represents another set of Major research contributions potential risks of sexual abuse for the female athlete (see Table 23.2). Organizations that have Researchers in several countries have taken dif- no formal policies or procedures for recruiting, ferent approaches to this topic and have built on checking, inducting or monitoring employees, different disciplinary foundations. whether paid or volunteer, are an especially easy Celia Brackenridge (UK) has used pre-existing target for the paedophile. This is particularly the models from social work and sociology in the case in the lower ranks of a sport or at the recre- USA and the UK to help analyse female athletes’ ational level, where volunteer labour is often testimonies of abuse (Brackenridge, 1997b) and welcomed with little or no screening. Whether has suggested possible descriptions of offender or not rules about requirements for dress or profiles and risk factors for sexual harassment the amount of physical touching necessary for and abuse in sport (Brackenridge, 1997a). An coaching influence the level of risk of sexual extension of her risk factor model is currently exploitation is unclear from research. However, being tested amongst a small group of sexually sports in which it is possible for individuals to be abused female athletes in The Netherlands in isolated in or from the main training venue or a study by Marian Cense commissioned by taken on trips away from home clearly have a The Netherlands Olympic Committee. The Nor- responsibility to implement rigorous safety wegian Confederation of Sport and the Norwe- procedures. gian Olympic Committee are also planning a For the female athlete the consequences of study that will explore the incidence of sexual experiencing sexual abuse are devastating and harassment and abuse among a sample of may be enduring. Many suffer psychological dis- 600 élite sportswomen and seek to test a possi- orders for years afterwards and most have great ble relationship between disordered eating and difficulty summoning up the courage to report sexual abuse. Brackenridge has also developed what has happened to them (Table 23.3). workshop materials for groups of administra- 348 medical issues

tors, coaches and policy-makers that explore policy approaches for the sports community how to maintain safe boundaries between based on the ‘duty of care’. coaches and female athletes. Helen Lenskyj (Canada) is another feminist Todd Crosset and Lisa Pike Masteralexis researcher whose research with and for women (USA) have studied the legal status of women has also been drawn from a radical critique of wishing to confront their abusers (Crosset et al., violent gender relations (Lenskyj, 1992a); she has 1995) and the extent of sexual violence to women also helped to develop practical guidelines for amongst college athletes in campus populations the prevention of harassment of women in sport (Pike Masteralexis, 1995). Crosset (unpublished (Lenskyj, 1992b). observation) has also developed awareness- Don Sabo and Carole Oglesby (USA) have led raising workshop materials for use with male a task force for the United States Women’s Sports coaches. Foundation that has developed a set of training Sandra Kirby and Lorraine Greaves (Canada) materials for administrators and sports organiza- are feminist researchers using quantitative and tions on abuse prevention and athletes’ rights qualitative social research methods to build an (Women’s Sports Foundation, 1994). Don has analysis that defines harassment and abuse in also collaborated with Mike Messner on issues sport as extensions of sexual violence towards of masculinity, violence, sexuality and sport women (S. Kirby, unpublished observation; S. (Messner & Sabo, 1990). Kirby & L. Greaves, unpublished observation). Karin Volkwein (USA) has completed a Sandra Kirby has also advised on the develop- large-scale survey of the incidence of sexual ment of an information pack on sexual harass- harassment and abuse amongst college athletes ment for the Canadian Association for the (K. Volkwein, unpublished observation). Advancement of Women and Sport (1994), con- Liv Kolnes (Norway) and Ilkay Yorganci ducted a media analysis of coverage of cases of (UK) are the first two researchers to complete sexual abuse in sport, and begun to develop doctoral theses on the topic of sexual harassment

Forces generating resistance

THE COACH THE SPORT THE ATHLETE

Sexual control Contextual restraint Athlete susceptibility

1 23

Fig. 23.3 Contingency model of Sexual motivation Contextual laxity Athlete susceptibility risk of sexual abuse in sport. 1, sexual motivation of the coach/authority figure is Forces generating risk stronger than his sexual self- control; 2, the sport’s contextual restraints are weak or absent; 3, Weak force the athlete is susceptible to a sexual approach. (From C. Strong force Brackenridge, unpublished observations.) sexual harassment and abuse 349

and abuse in sport (Kolnes, 1992; Yorganci, Higher Education, pp. 313–325. Human Kinetics Pub- 1994). lishers, Champaign, Illinois. Acosta, R.V. & Carpenter, L.J. (1990) Women in Intercolle- giate Sport: A Longitudinal Study 1977–1990. Brooklyn Recommendations for future research College, Brooklyn. Brackenridge, C.H. (1987) Ethical problems in women’s The greatest impediment to future research into sport. Coaching Focus 6, 5–7. sexual abuse of athletes is access to the commu- Brackenridge, C.H. (1991) Cross-gender coaching rela- tionships: myth, drama or crisis? Coaching Focus 16, nity of sport. Very few sport organizations are yet 12–14. persuaded of the importance of the issue or of the Brackenridge, C.H. (1994) Fair play or fair game: child need to gather more data. Even those working sexual abuse in sport organisations. International towards policies for improving athlete safety in Review for the Sociology of Sport 29, 287–299. this regard are reluctant to open themselves to Brackenridge, C.H. (1997a) ‘He owned me basi- cally . . .’ Women’s experiences of sexual abuse in the gaze of the researcher and to risk the pos- sport. International Review for the Sociology of Sport 32, sibility of uncovering ‘bad news’. However, only 115–130. with the systematic collection and analysis of Brackenridge, C.H. (1997b) Researching sexual abuse large datasets, both quantitative and qualitative, in sport. In G. Clarke & B. Humberstone (eds) and comparison with data outside the sport Researching Women in Sport, pp. 126–141. Macmillan, London. setting will the scale and dynamics of this issue Canadian Association for the Advancement of Women become known. In the mean time, researchers and Sport (1994) What Sport Organisations Need to continue to piece together data from purposive Know about Sexual Harassment. Canadian Association samples and from small surveys. The develop- for the Advancement of Women and Sport, Ottawa. ment of a contingency theory of sexual abuse Crosset, T., Benedict, J. & McDonald, M. (1995) Male student-athletes reported for sexual assault: a survey in sport, which combines the perspectives of the of campus police departments and judicial affairs athlete, the coach/abuser and the sport context, offices. Journal of Sport and Social Issues May, 126– should enable sport organizations to assess risk 140. in a given setting (Fig. 23.3). The most valuable Crouch, M. (1995) Protecting Children: A Guide for research will identify the causes rather than just Sportspeople. National Society for the Prevention of Cruelty to Children/National Coaching Foundation, the symptoms of sexual abuse and therefore Leeds. assist us in making sport a safer place for women. Doyle, C. (1994) Child Sexual Abuse: A Guide for Health Professionals. Chapman & Hall, London. Fisher, D. (1994) Adult sex offenders: Who are they? Acknowledgements Why and how do they do it? In T. Morrison, M. Erooga & R.C. Beckett (eds) Sexual Offending Against Thanks are due to Dr Sandra Kirby, University Children: Assessment and Treatment of Male Abusers, of Winnipeg, and Lorraine Greaves, Centre for p. 19. Sage, London. Research on Violence Against Women and Chil- Hall, M.A. (1988) The discourse of gender and sport: dren, University of Western Ontario, for giving from femininity to feminism. Sociology of Sport permission for their data to be quoted. Marian Journal 5, 330–340. Johnson, M. (1994) Disordered eating. In R. Agostini Cense of Transact, employed as a researcher by (ed.) Medical and Orthopaedic Issues of Active and Ath- The Netherlands Olympic Committee to investi- letic Women, pp. 143–151. Mosby, St Louis. gate sexual abuse in sport, has been especially Kane, M.J. & Disch, L.J. (1993) Sexual violence and the supportive and is developing and extending the reproduction of male power in the locker room: ‘The previous work on risk factors. Lisa Olsen incident’. Sociology of Sport Journal 10, 331–352. Kolnes, L. (1992) Coaches, athletes and gender rela- References tions: questions of power control and self-identity. Paper presented to the Pre-Olympic Scientific Con- Acosta, R.V. & Carpenter, L.J. (1985) Women in sport. In gress on Sport and Quality of Life, Malaga, Spain, D. Chu, J.O. Segrave & B.J. Becker (eds) Sport and July 1992. 350 medical issues

Knight, R.A. & Prentky, R.A. (1990) Classifying sexual departments. Journal of Sport and Social Issues May, offenders: the development and corroboration of 141–156. taxonomic models. In W.L. Marshall, D.R. Laws & Russell, D.E.H. (1984) Sexual Exploitation: Rape, Child H.E. Barbaree (eds) Handbook of Sexual Assault: Issues, Sexual Abuse and Workplace Harassment. Sage, Theories and Treatment of the Offender, pp. 23–49. London. Plenum Press, New York. Theberge, N. (1987) Sport and women’s empower- Lackey, D. (1990) Sexual harassment in sports. Physical ment. Women’s Studies International Forum 10, Educator 47, 22–26. 387–393. LaFontaine, J. (1990) Child Sexual Abuse. Polity, London. Waterhouse, L. (1993) Child Abuse and Child Abusers: Lenskyj, H. (1986) Out of Bounds: Women, Sport and Protection and Prevention. Jessica Kingsley, London. Sexuality. Women’s Press, Toronto. Whetsell-Mitchell, J. (1995) Rape of the Innocent: Under- Lenskyj, H. (1992a) Unsafe at home base: women’s standing and Preventing Child Sexual Assault. Taylor & experiences of sexual harassment in university sport Francis, London. and physical education. Women in Sport and Physical White, A.C. & Brackenridge, C.H. (1985) Who rules Activity Journal 1, 19–34. sport? Gender divisions in the power structure of Lenskyj, H. (1992b) Sexual harassment: female athletes’ British sporting organisations from 1960. Inter- experiences and coaches’ responsibilities. Sport national Review for the Sociology of Sport 20/21, 95– Science Periodical on Research and Technology in Sport 107. 12, 6, Special Topics B-1. Women’s Sports Foundation (1994) Prevention of Sexual Messner, M. & Sabo, D. (eds) (1990) Sport, Men and the Harassment in Athletic Settings: An Educational Gender Order. Human Kinetics Publishers, Cham- Resource Kit for Athletic Administrators. Women’s paign, Illinois. Sports Foundation, New York. Pike Masteralexis, L. (1995) Sexual harassment and Yorganci, I. (1994) Gender, sport and sexual harassment. athletics: legal and policy implications for athletic PhD Thesis, University of Brighton. PART 6

THE FEMALE ATHLETE TRIAD

Chapter 24

Body Composition

WENDY M. KOHRT

Introduction ideal body composition for optimal athletic performance is probably the principal driving In a global context, body composition undoubt- force behind the development of the female edly has a strong bearing on the performance of athlete triad. Several issues regarding the role of many physical activities. Aesthetics aside, the body composition in the female athlete triad are performance of skills that are the essence of such addressed. activities as gymnastics, figure skating and ballet dancing requires considerable muscle mass and Body composition and strength. A high lean to fat mass ratio is obvi- sports performance ously desirable for athletes who participate in these activities, as well as in others that involve Cross-sectional comparisons of non-athletes lifting, or moving the body mass. It is not surpris- and athletes of different calibres ing, therefore, that reducing fat mass to improve performance can often lead to success in such Comparisons of physiological profiles of élite sports. However, weight loss does not necessar- and non-élite athletes often reveal characteristics ily result in improved sports performance that are related to superior performance. Table and may, in fact, lead to worsened perfor- 24.1 summarizes results from some of the mance and/or adverse health outcomes. The studies that have measured body composition of latter concern has emerged in recent years as élite sportswomen. In many cases, comparison the number of girls and women taking part groups of competitive or recreational athletes in competitive sports has grown and as health or non-athletic controls were included. This is professionals have become increasingly aware important not only for comparing groups within of the pernicious nature of the female athlete a study but also for making relative comparisons triad. across studies, since different methods of assess- The term ‘triad’ refers to the clustering of ing body composition may not yield equivalent disordered eating, amenorrhoea and premature results. Across sports, it is obvious that body osteoporosis that tends to occur in female ath- composition is an important determinant of letes participating in sports where successful successful sports performance. Relative body performance is dependent on, physiologically fat levels tend to be lower among athletes partici- and/or aesthetically, a low body fat content pating in individual rather than team sports, and (Yeager et al., 1993). Each of these disorders is dis- lowest in sports that require moving or lifting cussed in greater detail in subsequent chapters. the body mass (e.g. running, jumping, gymnas- However, a separate discussion of body compo- tics, etc.). Within a sport, élite sportswomen tend sition is warranted, as the desire to attain the to have lower relative body fat levels than non- 353 354 the female athlete triad

Table 24.1 Examples of body composition of young female athletes

Reference (method of determination No. of Height Weight Fat Fat-free mass of body composition) Activity Level athletes (cm) (kg) (%) (kg)

Fleck (1983) Swimming E´lite 41 62.0 19.5 49.9 (hydrodensitometry) Handball E´lite 17 68.8 19.0 55.7 Rowing E´lite 19 67.4 18.4 55.0 Speed E´lite 20 56.3 17.8 46.3 skating Volleyball E´lite 36 69.4 15.8 58.4 Running E´lite 28 50.5 13.8 43.5 Sprinting E´lite 21 56.7 13.7 48.9 Jumping E´lite 22 60.3 13.2 52.3 Graves et al. (1987) Running E´lite 15 161 47.2 14.3 40.4 (hydrodensitometry) Competitive 12 162 49.4 16.8 41.1 Alway et al. (1990) Weight- E´lite 5 167 62.2 18.0 51.0 (total body volume) lifting Recreational 8 167 58.8 21.6 46.1 Schulz et al. (1992) Running E´lite 9 163 52.4 12.0 46.1 (hydrodensitometry) Slemenda & Figure E´lite 22 158 50.3 18.7 40.9 Johnston (1993) skating Control 22 160 53.1 24.3 40.2 (dual-energy X-ray absorptiometry) Koutedakis et al. Rowing E´lite 6 58.4 11.5 51.7 (1994) (total body potassium) Creagh & Reilly Orienteering E´lite 12 168 56.3 20.4 44.8 (1995) (skinfold Competitive 11 170 57.7 21.8 45.1 thickness) Control 20 167 63.4 26.6 46.5 Evans et al. (1995) Running Competitive 10 165 53.1 15.0 45.1 (hydrodensitometry) Fehling et al. (1995) Volleyball Collegiate 8 182 76.3 24.2 57.8 (hydrodensitometry) Swimming Collegiate 7 171 65.6 23.9 49.9 Gymnastics Collegiate 13 161 55.6 19.0 45.0 Control Collegiate 17 163 58.6 27.5 42.1 Hetland et al. (1995) Running E´lite 28 57.2 13.3 49.6 (dual-energy X-ray Competitive 89 62.1 20.8 49.2 absorptiometry) Recreational 88 62.2 24.1 47.2 Nichols et al. (1995) Basketball Collegiate 14 172 66.4 29.0 47.1 (dual-energy X-ray Volleyball Collegiate 13 176 69.5 27.1 50.7 absorptiometry) Gymnastics Collegiate 13 160 53.9 22.6 41.7 Tennis Collegiate 6 166 59.8 30.2 41.7 Control Collegiate 12 165 60.6 30.6 42.1 Pacy et al. (1995) Rowing E´lite 15 178 72.6 20.7 57.6 (hydrodensitometry)

élite competitors, and athletes tend to have less et al., 1995; Hetland et al., 1995; Nichols et al., fat than non-athletes regardless of the activity 1995). Although these cross-sectional com- (Graves et al., 1987; Alway et al., 1990; Slemenda parisons provide useful descriptions of élite & Johnston, 1993; Creagh & Reilly, 1995; Fehling sportswomen, they do not provide information body composition 355

regarding the extent to which changes in body induced increase in maximal aerobic power · composition affect performance level. (VO2max) that occurred in weight-stable athletes did not occur in athletes who reduced their body weight by 9% over 9 weeks; 26% of Effects of weight loss on performance the weight loss was lean mass. Koutedakis et al. The observation of lower body fat levels in élite (1994) studied a group of élite oarswomen who compared with non-élite athletes within a sport underwent two different periods of weight raises the question of the extent to which body reduction while continuing their usual exercise composition can be manipulated to enhance per- training. They reduced their body weight by formance. Could competitive runners who have 3.8kg (6.0%) over 2 months and by 4.7kg (7.4%) a body fat content of 17–21% of body weight over 4 months; in both cases, approximately (Graves et al., 1987; Hetland et al., 1995) become 50% of the reduction was lean mass. The 2-month élite runners if they reduced their fat content weight-reduction period was associated with to the level characteristic of élite runners, i.e. significant decreases in knee flexion peak torque 12–14% (Fleck, 1983; Graves et al., 1987; Schulz and ventilatory threshold during a maximal et al., 1992; Hetland et al., 1995)? This is a difficult rowing ergometer test, and non-significant · question to answer and one that does not have a decreases in VO2max, knee extension peak torque definitive answer. There is a considerable body of and power output during an anaerobic power literature on the effects of rapid weight loss test. Conversely, in response to the 4-month (i.e. to make a weight requirement for competi- weight-reduction period, there were significant · tion) on measures of physiological function in increases in VO2max, ventilatory threshold, knee male wrestlers (Fogelholm, 1994; American flexion peak torque and peak power during the College of Sports Medicine, 1996). In general, anaerobic power test. The investigators specu- rapid weight loss does not appear to have benefi- lated that the longer weight-reduction period cial effects and may in fact have adverse effects allowed more time for the biochemical and bio- on muscle strength, anaerobic power and mechanical adaptations to weight loss to occur, endurance capacity. leading to improvements in measures of perfor- There is a paucity of data on the effects of mance. What the investigators did not address, gradual weight loss on physiological function however, was the possibility that the 2-month and performance in athletes who are already weight-reduction period could have led to the relatively lean, particularly women (Fogelholm, same improvements in performance as the 4- 1994). From the few controlled studies that have month weight-reduction period if the athletes been conducted, it appears that the protective had been assessed after 4 months of training, i.e. effect of exercise on the maintenance of lean body 2 months after the weight-reduction period. mass that occurs during diet-induced weight In such sports as running and gymnastics, ath- loss in overweight people (Ballor & Poehlman, letes are often strongly encouraged by coaches 1994) does not occur in athletes who are rela- and/or parents to attain very low body fat levels. tively lean. In male and female athletes who lost The justification for this practice most likely weight at rates of 0.3–0.8kg·week–1 over 7–16 stems from the theoretical benefit of a low body weeks, 26–58% of the reduction was lean tissue fat content on performance, coupled with the (Widerman & Hagan, 1982; Horswill et al., 1990; observation that élite performers tend to be very Inger & Sundgot-Borgen, 1991; Manore et al., lean. From a scientific perspective, however, 1993; Koutedakis et al., 1994). Whether the reduc- there is little or no evidence that weight reduc- tion in lean mass counteracts any potential tion will enhance performance in already lean benefits of reduced fat mass on performance is athletes. In fact, weight reduction in relatively equivocal. In élite female skiers, Inger and lean athletes can result in a significant loss of lean Sundgot-Borger (1991) found that the training- mass and have an adverse effect on performance. 356 the female athlete triad

Body composition and health normal menstrual function but that it varies widely among individuals. Careful monitoring It would be unethical to consider the effects of of changes in body composition and changes in weight loss on the performance of competitive menstrual function in individual athletes is sportswomen without also considering the necessary to determine whether such thresholds potential concomitant effects on health. It is exist. common knowledge that being overweight increases the risk for many diseases, including regional adiposity coronary artery disease, diabetes mellitus and hypertension, and that weight loss is generally It has been suggested that critical levels of associated with improved health. However, regional, rather than total, adiposity may be nec- being markedly underweight can also be un- essary for normal menstrual function (Brownell healthy, and weight loss in an already lean indi- et al., 1987). The notion that regional differences vidual may result in adverse health outcomes. in fat deposition can influence metabolism is Because a comprehensive overview of the effects indeed plausible. There is overwhelming evi- on health of being underweight are beyond the dence that accumulation of fat in the intra- scope of this chapter, discussion focuses on those abdominal region is more closely associated with aspects of health that are relevant to the female the development of coronary artery disease, athlete triad. adult-onset diabetes mellitus and hypertension than is total degree of adiposity (Björntorp, 1992). Brownell et al. (1987) speculate that amenorrhoea Body composition and amenorrhoea may be triggered by depletion below a certain total body adiposity threshold of fat in the femoral region because of the importance of that site in providing energy An important question with regard to body com- for lactation and pregnancy. position and the female athlete triad is whether Unfortunately, few studies have assessed reducing fat mass below a certain level leads to regional fat distribution in athletes who differ in amenorrhoea. It was once proposed that mainte- menstrual function. One comparison of amenor- nance of normal menstrual function required a rhoeic and eumenorrhoeic runners found no body fat content of at least 22% of body weight significant differences in abdominal or leg fat (Frisch & McArthur, 1974). This notion has been content (i.e. percentage of total regional mass) effectively dispelled, as many eumenorrhoeic measured by dual-energy X-ray absorptiometry athletes have been shown to have body fat levels (DXA) (Hetland et al., 1995). In another study, less than 22% of body weight (Fisher et al., 1986; magnetic resonance imaging (MRI) was used Kaiserauer et al., 1989; Crist & Hill, 1990; Snead to assess the total and regional fat content of 20 et al., 1992; Wilmore et al., 1992; Myburgh et al., rowers, 12 of whom were anovulatory, and four 1993; Rutherford, 1993). Moreover, no clear amenorrhoeic runners (Frisch et al., 1993). There association between either relative or absolute were no significant differences between eumen- body fat content and menstrual function of ath- orrhoeic athletes and those with menstrual letes has emerged (Table 24.2). Thus, there does dysfunction in any of the fat regions that were not appear to be a critical level of adiposity, either assessed. Thus, there appears to be no evidence absolute mass or relative fraction of body that regional adiposity plays a role in the devel- weight, below which menstrual irregularities opment of amenorrhoea. However, these nega- occur. However, this does not rule out the possi- tive findings should be interpreted cautiously bility that amenorrhoea occurs as a result of because of the small number of subjects that were changes in body composition. It is possible that assessed (Frisch et al., 1993) and the inability of there is a critical level of adiposity necessary for DXA (Hetland et al., 1995) to distinguish between body composition 357

Table 24.2 Body composition and/or lumbar spine bone mineral density of eumenorrhoeic and amenorrhoeic or oligomenorrhoeic athletes

Bone Reference (method of Fat Fat-free mineral determination of No. of Weight Fat mass mass density body composition) Subjects Status athletes (kg) (%) (kg) (kg) (g·cm-2)

Snead et al. (1992) Runners E 24 58.7 21.4 12.8 46.0 1.15 (hydrodensitometry) A 11 59.6 19.8 12.1 47.5 1.02 Wilmore et al. (1992) Runners E 5 52.0 10.3 5.4 46.6 1.17 (hydrodensitometry) A 8 51.4 10.8 5.6 45.8 1.16 Myburgh et al. (1993) Athletes E 9 53.2 20.3 10.8 42.4 1.05 (dual-energy X-ray A 12 52.9 16.7 8.8 44.1 0.93 absorptiometry) Rutherford (1993) Runners E 16 60.1 14.7 8.8 51.3 1.18 (dual-energy X-ray and A 15 55.3 10.9 6.0 49.3 1.07 absorptiometry) triathletes Micklesfield et al. Runners E 15 58.3 28.5 16.6 41.7 1.09 (1995) (skinfold O/A 10 57.2 29.0 16.6 40.6 0.95 thickness) Fisher et al. (1986) Runners E 24 56.3 21.3 12.0 44.3 (hydrodensitometry) A 11 58.0 22.1 12.8 45.2 Kaiserauer et al. (1989) Runners E 9 54.2 10.7 5.8 48.4 (hydrodensitometry) A 8 49.3 11.8 5.8 43.5 Crist & Hill (1990) Runners E 5 54.7 10.2 5.6 49.1 (hydrodensitometry) A 6 55.2 17.4 9.6 45.6 Hetland et al. (1995) Runners E 93 61.6 22.2 13.7 47.9 (dual-energy X-ray A 13 59.7 18.9 11.3 48.4 absorptiometry) Rencken et al. (1996) Athletes E 20 56.1 1.07 (dual-energy X-ray A 29 55.3 0.95 absorptiometry) Robinson et al. (1995) Runners E 14 0.89 (dual-energy X-ray O/A 6 0.86 absorptiometry) Gymnasts E 11 1.12 O/A 10 1.05

A, amenorrhoeic; E, eumenorrhoeic; O/A, oligomenorrhoeic/amenorrhoeic. subcutaneous fat and fat stores in intra- mineral density. Theoretically, each may have an abdominal or intramuscular regions. The ques- independent effect on skeletal integrity. For most tion of whether the relative depletion of specific people, the majority of the loading forces acting fat depots triggers amenorrhoea should continue on the skeleton on a day-to-day basis are intro- to be explored. duced through ground reaction forces. Body weight is an important determinant of the mag- nitude of these forces, and peak loading forces Body composition and osteoporosis are thought to play an important role in the Low body weight is a risk factor for osteoporosis, bone modelling/remodelling process (Lanyon, while being overweight provides a degree of 1992). Lean body mass, as a surrogate measure of protection against osteoporosis (Lindsay, 1996). muscle mass, may reflect the structural and func- Total body weight, lean body mass and body fat tional link between muscle strength and bone content have been shown to be related to bone strength. Men and women with a large muscle 358 the female athlete triad

mass generally also have a large bone mass Assessment of body composition (Heinrich et al., 1990; Karlsson et al., 1993), and muscle strength has been shown to be a determi- Methodological considerations nant of bone mineral density in the skeletal regions on which the muscles act (Bevier et al., All the issues discussed thus far regarding the 1989; Pocock et al., 1989). Finally, because andro- effects of body composition on performance and gens can be converted to oestrogen in adipose health of young female athletes must be inter- tissue, this source of oestrogen may provide preted cautiously as there is no guarantee, even protection against bone mineral loss when in the most carefully conducted studies, that ovarian oestrogen production diminishes (Perel measures of body composition are accurate. All & Killinger, 1979). methods for assessing body composition The relative influence of fat and lean mass on of humans are indirect and are therefore reliant bone mineral density was evaluated in 246 on certain assumptions. Error within a method healthy women, aged 20–40 years, who were occurs when the underlying assumptions are grouped into nine cells by tertiles of fat mass violated, and it is usually possible to make only (low, <10.7kg; high, >21.1kg) and tertiles of theoretical estimates of the degree of error that lean mass (low, <42.5kg; high, >47.4kg) (Sowers may occur. et al., 1992). Having a high lean body mass was For example, the principal assumption of the associated with high bone mineral density at the reference method for assessing body composi- femoral neck and trochanter sites, regardless of tion, hydrostatic weighing (Fig. 24.1), is that the the body fat content. The bone mineral densities density of the fat-free mass is constant. This at these sites were similar in women in the high implies that the constituents of fat-free mass (i.e. lean/low fat and high lean/high fat cate- water, protein and minerals) are present in the gories, despite a large difference in the average same proportion in all individuals. With respect body weights of the two groups (67 and 91kg to the female athlete triad, a specific reduction in respectively). Women in the low lean/low fat only the bone mineral fraction of fat-free mass in category (average body weight 49kg) had the amenorrhoeic athletes would theoretically result lowest bone mineral density values, 15–20% in a systematic overestimation of body fat lower than those of women in the high lean/high content by hydrodensitometry. Based on hypo- fat group. Aloia et al. (1995a) also found that lean thetical calculations, a 15% reduction in osseous mass was a stronger determinant of bone mass mineral mass in an athlete with a body fat than was fat mass among 164 women aged 24–79 content of 12.0% of body weight, independent of years. any other changes in body composition, would It would seem therefore that the relatively high result in the body fat level being erroneously esti- lean body mass levels of athletes (see Tables mated as 14.3% rather than 12.1%. Thus, if amen- 24.1 & 24.2) are protective against osteoporosis orrhoea causes a disproportionate loss of bone even when body fat levels are low. Given that mineral, it is possible that all comparisons of lumbar spine bone mineral density is often lower densitometrically determined body composition in amenorrhoeic compared with eumenorrhoeic of eumenorrhoeic and amenorrhoeic athletes are athletes matched for body composition (see inherently flawed. Alternatively, it is possible Table 24.2), it is likely that hormonal status, that reductions in bone mineral in response to rather than body composition, plays a primary oestrogen deficiency do not occur independently role in the premature osteoporosis characteristic but rather that proportional reductions occur in of the female athlete triad. However, the low lean other constituents of fat-free mass (Aloia et al., body mass of athletes who maintain a very low 1991, 1995b; Poehlman et al., 1995), resulting in body weight may contribute to their risk for little or no error in estimating body composition osteoporosis. from body density. body composition 359

Fig. 24.1 Hydrostatic weighing: the gold standard for estimation of body fat.

Another concern regarding the assessment of mates of fatness ranged from 11.3% to 24.0% of body composition is that different methods can body weight. Even when the estimates from BMI yield highly variable results. In nine élite female were disregarded, the differences between the distance runners (Schulz et al., 1992), body fat highest and lowest values ranged from 4.0% to content assessed by hydrodensitometry, total 20.7% of body weight. Importantly, it cannot be body water and bioelectrical impedance aver- determined which of the methods, if any, yielded aged 12±3%, 11±4% and 17±3% of body weight, an accurate estimate of body composition. respectively. Pacy et al. (1995) evaluated body Is there a valid method of assessing body com- composition of 15 élite heavyweight oarswomen position in humans? Computed tomography by hydrodensitometry, total body potassium (CT) provides objective measures of adipose- counting, two commercially available bioelec- tissue and lean-tissue areas in cross-sectional trical impedance analysers, two equations to images of body regions. Serial CT images of the predict body fat content from skinfold thick- entire body should therefore yield accurate mea- nesses and three equations to predict fatness sures of adipose-tissue and lean-tissue volumes. from body mass index (BMI, i.e. weight in kilo- However, CT is not a feasible method for total grams divided by height in metres). The average body assessments because it involves expo- body fat levels as a percentage of body weight sure to ionizing radiation. Even if technological ranged from 15.7% (total body potassium) to advances should make it possible to reduce the 28.5% (BMI); the average using hydrodensitome- radiation exposure to acceptable levels, the con- try was 20.7%. Although using BMI to estimate version of adipose-tissue and lean-tissue areas fatness was the simplest of the methods, requir- to fat and fat-free masses would require certain ing measurements only of weight and height, assumptions that could introduce error. the three BMI equations yielded the highest esti- Although Frisch et al. (1993) have suggested mates (26.8–28.5% of body weight). There was that valid measures of fat and lean masses can be considerable variability even for a given method. obtained by MRI, a soft-tissue imaging proce- For example, the two bioelectrical impedance dure that does not involve radiation exposure, analysers measured body fat as 16.7% and 20.9% this is not the case. MRI is subject to the same of body weight. For individual athletes, the dif- errors as CT that result when fat and fat-free ferences between the highest and lowest esti- masses are estimated from adipose-tissue and 360 the female athlete triad

lean-tissue areas. Furthermore, unlike CT, the estimated to be only 55% fat. Similar results were MRI signal intensity for adipose tissue is not obtained by Milliken et al. (1996) using a Lunar homogeneous within a cross-section or between DPX-L instrument and software version 1.3y. It serial cross-sectional images. The quantification is likely that the source of the error lies in the of adipose-tissue and lean-tissue areas therefore method of data analysis rather than acquisi- requires subjective input from the person tion. In fact, an updated version of the analysing the image, which is an obvious source Hologic enhanced whole body software program of variability. (version 5.64) now appears to assess exoge- Another procedure that has received consider- nous fat accurately when it is positioned over able attention as a possible reference method central or peripheral regions of the body (Kohrt, for the assessment of body composition is DXA 1998). (Roubenoff et al., 1993; Kohrt, 1995). DXA pro- As with other methods of assessing body com- vides a precise measure of bone mineral content position, DXA is dependent on some assump- and can further distinguish non-bone tissue into tions that will always make it vulnerable to a fat and lean components. Although some investi- certain degree of error. However, if that degree of gators have already endorsed DXA as a valid error can be quantified and is found to be within means of assessing body composition (Formica acceptable limits, there would be advantages to et al., 1993), this is premature for two reasons. using DXA to assess body composition in sports- First, it is inappropriate to speak in general terms women susceptible to the female athlete triad of the validity of DXA per se, as there is incon- of disorders. The most obvious advantage, gruity among the different manufacturers of which is important because of the risk for prema- DXA instruments with regard to methods of cali- ture osteoporosis, is that changes in total bone bration, data acquisition and data analysis. The mineral content and density can be monitored issue of the validity of body composition assess- simultaneously with changes in fat and fat-free ment by DXA must therefore be specific to the mass. Another advantage is that relatively large manufacturer of the instrument, the instrument fluctuations in hydration status, which are not model, the mode of operation and the version of uncommon in athletes who train vigorously or the software analysis program. restrict their energy intake, have a negligible The second reason it is premature to endorse effect on the assessment of fat mass by DXA DXAas a valid method of assessing body compo- (Horber et al., 1992; Formica et al., 1993; Going sition is that there is convincing evidence that it et al., 1993; Kohrt, 1995). is not accurate in some circumstances. Because the X-ray attenuation properties of lard are such Assessment of body composition to establish that it appears to be 98% fat by DXA analysis, this weight goals material can be used to manipulate fat mass experimentally and determine whether DXA Given the methodological problems associated accurately assesses such manipulations. Snead with the assessment of body composition, the et al. (1993) assessed body composition with a judiciousness of using such information to Hologic QDR-1000/W instrument and version establish body weight goals for the purpose of 5.5 of the enhanced whole body software when optimizing sports performance is highly ques- packets of lard were positioned over central tionable. It is not difficult to imagine how an regions of the body or over the thighs. Com- overestimation of fatness could lead coaches, pared to the control condition, DXA accurately parents and/or athletes to set unrealistic goals assessed the composition of the added mass as for weight loss and initiate behavioural changes 96% fat when it was positioned over the thighs. that could have adverse effects on physical However, when it was positioned over the and/or psychological health. The suggestion to abdomen and chest, the additional mass was establish an acceptable range of values, rather body composition 361

than a specific degree of fatness, for athletes in a to maintain a low body weight for a prolonged particular sport is certainly a more conservative period of time. To learn more about the potential approach (Brownell et al., 1987). However, given effects of weight loss on the health and perfor- that some of the common methods of assessing mance of athletes and to better understand the body composition yield estimates of fatness that role that body composition plays in the develop- vary within an individual by 20% of body weight ment of the female athlete triad, the following or more (Pacy et al., 1995), the range of values are some of the issues that must continue to be would have to be generous indeed to encompass explored. this degree of methodological variability. • Does weight loss in already lean athletes result Because body composition is an important in a disproportionate loss of lean mass? Is the loss determinant of performance in many sports, the of lean mass affected by the method of achieving assessment of body composition for the purpose weight loss (e.g. fast vs. slow, increased energy of determining ideal weight is a practice that will expenditure vs. reduced energy intake)? undoubtedly continue whether or not there are • In relatively lean athletes, what is the effect of established guidelines. It is important therefore weight loss on physiological measures of perfor- that acceptable ranges of body fat levels, based mance? Does the method of achieving weight on sound scientific principles, be established loss affect the changes in performance? within given sports and that the ranges be spe- • Within individual athletes, is there a critical cific to the method of assessment of body compo- body fat level necessary for maintaining normal sition. Furthermore, there should be an ongoing menstrual function? effort to evaluate the appropriateness of such • In eumenorrhoeic and amenorrhoeic athletes guidelines, with the principal focus being the matched for body composition and performance overall health of the athlete. At a minimum, it is level, are there differences in the regional accu- recommended that records of body weight, men- mulation of fat? strual function and training level be maintained • Is there a negative effect of weight loss, inde- to assist individual athletes in finding the ideal pendent of menstrual dysfunction, on bone body weight for health and performance. Raising mineral density in athletes? Is a reduction in non- the level of consciousness of athletes and their bone lean mass accompanied by a proportional coaches, parents and physicians with regard to reduction in bone mass? the disorders that comprise the female athlete triad, and the role that striving to achieve a low References body weight may play in its development, is cer- tainly paramount to the prevention and treat- Aloia, J.F., McGowan, D.M., Vaswani, A.N., Ross, P. & ment of the disorders. Cohn, S.H. (1991) Relationship of menopause to skeletal and muscle mass. American Journal of Clinical Nutrition 53, 1378–1383. Recommendations for future research Aloia, J.F., Vaswani, A., Ma, R. & Flaster, E. (1995a) To what extent is bone mass determined by fat-free or For such sports as wrestling, where athletes often fat mass? American Journal of Clinical Nutrition 61, repeatedly strive to achieve a certain weight 1110–1114. limit for competition, there has been consider- Aloia, J.F., Vaswani, A., Russo, L., Sheehan, M. & Flaster, E. (1995b) The influence of menopause and able research on the effects of weight loss on phy- hormonal replacement therapy on body cell mass siological measures of performance and health and body fat mass. American Journal of Obstetrics and (American College of Sports Medicine, 1996). Gynecology 172, 896–900. However, since weight loss for such sports is typ- Alway, S.E., Stray-Gundersen, J., Grumbt, W.H. & ically accomplished rapidly and is transient, it Gonyea, W.J. (1990) Muscle cross-sectional area and torque in resistance trained subjects. European Journal is unlikely that findings are applicable to athletes of Applied Physiology 60, 86–90. such as gymnasts or distance runners, who strive American College of Sports Medicine (1996) Position 362 the female athlete triad

stand: weight loss in wrestlers. Medicine and Science Frisch, R.E., Snow, R.C., Johnson, L.A., Gerard, B., in Sports and Exercise 28, ix–xii. Barbieri, R. & Rosen, B. (1993) Magnetic resonance Ballor, D.L. & Poehlman, E.T. (1994) Exercise-training imaging of overall and regional body fat, estrogen enhances fat-free mass preservation during diet- metabolism, and ovulation of athletes compared to induced weight loss: a meta-analytical finding. Inter- controls. Journal of Clinical Endocrinology and Metabo- national Journal of Obesity and Related Metabolic lism 77, 471–477. Disorders 18, 35–40. Going, S.B., Massett, M.P., Hall, M.C. et al. (1993) Detec- Bevier, W.C., Wiswell, R.A., Pyka, G., Kozak, K.C., tion of small changes in body composition by dual- Newhall, K.M. & Marcus, R. (1989) Relationship of energy X-ray absorptiometry. American Journal of body composition, muscle strength, and aerobic Clinical Nutrition 57, 845–850. capacity to bone mineral density in older men and Graves, J.E., Pollock, M.L. & Sparling, P.B. (1987) Body women. Journal of Bone and Mineral Research 4, composition of elite female distance runners. Interna- 421–432. tional Journal of Sports Medicine 8, 96–102. Björntorp, P. (1992) Abdominal fat distribution and Heinrich, C.H., Going, S.B., Pamenter, R.W., Perry, disease: an overview of epidemiologic data. Annals of C.D., Boyden, T.W. & Lohman, T.G. (1990) Bone Medicine 24, 15–18. mineral content of cyclically menstruating female Brownell, K.D., Nelson Steen, S. & Wilmore, J.H. (1987) resistance and endurance trained athletes. Medicine Weight regulation practices in athletes: analysis of and Science in Sports and Exercise 22, 558–563. metabolic and health effects. Medicine and Science in Hetland, M.L., Haarbo, J. & Christiansen, C. (1995) Sports and Exercise 19, 546–556. Body composition and serum lipids in female Creagh, U. & Reilly, T. (1995) A multivariate analysis of runners: influence of exercise level and menstrual kinanthropometric profiles of elite female orienteers. bleeding pattern. European Journal of Clinical Investi- Journal of Sports Medicine and Physical Fitness 35, gation 25, 553–558. 59–66. Horber, F.F., Thomi, F., Casez, J.P., Fonteille, J. & Jaeger, Crist, D.M. & Hill, J.M. (1990) Diet and insulinlike P. (1992) Impact of hydration status on body compo- growth factor I in relation to body composition in sition as measured by dual energy X-ray absorptiom- women with exercise-induced hypothalamic amen- etry in normal volunteers and patients on orrhea. Journal of the American College of Nutrition 9, haemodialysis. British Journal of Radiology 65, 200–204. 895–900. Evans, S.L., Davy, K.P., Stevenson, E.T. & Seals, D.R. Horswill, C.A., Park, S.H. & Roemmich, J.N. (1990) (1995) Physiological determinants of 10-km perfor- Changes in the protein nutritional status of adoles- mance in highly trained female runners of different cent wrestlers. Medicine and Science in Sports and Exer- ages. Journal of Applied Physiology 78, 1931–1941. cise 22, 599–604. Fehling, P.C., Alekel, L., Clasey, J., Rector, A. & Stillman, Inger, F. & Sundgot-Borgen, J. (1991) Influence of body R.J. (1995) A comparison of bone mineral densities weight regulation on maximal oxygen uptake in among female athletes in impact loading and active female elite athletes. Scandinavian Journal of Medicine loading sports. Bone 17, 205–210. and Science in Sports 1, 141–146. Fisher, E.C., Nelson, M.E., Frontera, W.R., Turksoy, R.N. Kaiserauer, S., Snyder, A.C., Sleeper, M. & Zierath, J. & Evans, W.J. (1986) Bone mineral content and levels (1989) Nutritional, physiological, and menstrual of gonadotropins and estrogens in amenorrheic status of distance runners. Medicine and Science in running women. Journal of Clinical Endocrinology and Sports and Exercise 21, 120–125. Metabolism 62, 1232–1236. Karlsson, M.K., Johnell, O. & Obrant, K.J. (1993) Bone Fleck, S.J. (1983) Body composition of elite American mineral density in weight lifters. Calcified Tissue athletes. American Journal of Sports Medicine 11, International 52, 212–215. 398–403. Kohrt, W.M. (1995) Body composition by DXA: tried Fogelholm, M. (1994) Effects of bodyweight reduction and true? Medicine and Science in Sports and Exercise on sports performance. Sports Medicine 18, 249–267. 27, 1349–1353. Formica, C., Atkinson, M.G., Nyulasi, I., McKay, J., Kohrt, W.M. (1998) Preliminary evidence that DEXA Heale, W. & Seeman, E. (1993) Body composition provides an accurate assessment of body composi- following hemodialysis: studies using dual-energy tion. Journal of Applied Physiology 84, 372–377. X-ray absorptiometry and bioelectrical impedance Koutedakis, Y., Pacy, P.J., Quevedo, R.M. et al. (1994) analysis. Osteoporosis International 3, 192–197. The effects of two different periods of weight- Frisch, R.E. & McArthur, J.W. (1974) Menstrual cycles: reduction on selected performance parameters in fatness as a determinant for minimum weight or elite lightweight oarswomen. International Journal height necessary for their maintenance or onset. of Sports Medicine 15, 472–477. Science 185, 949–951. Lanyon, L.E. (1992) The success and failure of the adap- body composition 363

tive response to functional load-bearing in averting Robinson, T.L., Snow-Harter, C., Taaffe, D.R., Gillis, D., bone fracture. Bone 13, S17–S21. Shaw, J. & Marcus, R. (1995) Gymnasts exhibit higher Lindsay, R. (1996) Prevention of osteoporosis. In M.J. bone mass than runners despite similar prevalence Favus (ed.) Primer on the Metabolic Bone Diseases and of amenorrhea and oligomenorrhea. Journal of Bone Disorders of Mineral Metabolism, 3rd edn, pp. 256–261. and Mineral Research 10, 26–35. Lippincott–Raven Publishers, Philadelphia. Roubenoff, R., Kehayias, J.J., Dawson-Hughes, B. & Manore, M.M., Thompson, J. & Russo, M. (1993) Diet Heymsfield, S.B. (1993) Use of dual-energy X-ray and exercise strategies of a world-class bodybuilder. absorptiometry in body composition studies: not International Journal of Sports Nutrition 3, 76–86. yet a ‘gold standard’. American Journal of Clinical Micklesfield, L.K., Lambert, E.V., Fataar, A.B., Noakes, Nutrition 58, 589–591. T.D. & Myburgh, K.H. (1995) Bone mineral density Rutherford, O.M. (1993) Spine and total body bone in mature, premenopausal ultramarathon runners. mineral density in amenorrheic endurance athletes. Medicine and Science in Sports and Exercise 27, 688–696. Journal of Applied Physiology 74, 2904–2908. Milliken, L.A., Going, S.B. & Lohman, T.G. (1996) Schulz, L.O., Alger, S., Harper, I., Wilmore, J.H. & Effects of variations in regional composition on soft Ravussin, E. (1992) Energy expenditure of elite tissue measurements by dual-energy X-ray absorp- female runners measured by respiratory chamber tiometry. International Journal of Obesity and Related and doubly labeled water. Journal of Applied Physiol- Metabolic Disorders 20, 677–682. ogy 72, 23–28. Myburgh, K.H., Bachrach, L.K., Lewis, B., Kent, K. & Slemenda, C.W. & Johnston, C.C. (1993) High intensity Marcus, R. (1993) Low bone mineral density at axial activities in young women: site specific bone mass and appendicular sites in amenorrheic athletes. Med- effects among female figure skaters. Bone and Mineral icine and Science in Sports and Exercise 25, 1197–1202. 20, 125–132. Nichols, D.L., Sanborn, C.F., Bonnick, S.L., Gench, B. & Snead, D.B., Weltman, A., Weltman, J.Y. et al. (1992) DiMarco, N. (1995) Relationship of regional body Reproductive hormones and bone mineral density composition to bone mineral density in college in women runners. Journal of Applied Physiology 72, females. Medicine and Science in Sports and Exercise 27, 2149–2156. 178–182. Snead, D.B., Birge, S.J. & Kohrt, W.M. (1993) Age- Pacy, P.J., Quevedo, M., Gibson, N.R., Cox, M., related differences in body composition by Koutedakis, Y. & Millward, J. (1995) Body composi- hydrodensitometry and dual-energy X-ray absorp- tion measurement in elite heavyweight oarswomen: tiometry. Journal of Applied Physiology 74, 770–775. a comparison of five methods. Journal of Sports Medi- Sowers, M.F., Kshirsagar, A., Crutchfield, M.M. & cine and Physical Fitness 35, 67–74. Updike, S. (1992) Joint influence of fat and lean body Perel, E. & Killinger, D.W. (1979) The interconversion composition compartments on femoral bone mineral and aromatization of androgens by human adipose density in premenopausal women. American Journal tissue. Journal of Steroid Biochemistry 10, 623–627. of Epidemiology 136, 257–265. Pocock, N., Eisman, J., Gwinn, T. et al. (1989) Muscle Widerman, P.M. & Hagan, R.D. (1982) Body weight strength, physical fitness, and weight but not age loss in a wrestler preparing for competition: a case predict femoral neck bone mass. Journal of Bone and report. Medicine and Science in Sports and Exercise 14, Mineral Research 4, 441–448. 413–418. Poehlman, E.T., Toth, M.J. & Gardner, A.W. (1995) Wilmore, J.H., Wambsgans, K.C., Brenner, M. et al. Changes in energy balance and body composition at (1992) Is there energy conservation in amenorrheic menopause: a controlled longitudinal study. Annals compared with eumenorrheic distance runners? of Internal Medicine 123, 673–675. Journal of Applied Physiology 72, 15–22. Rencken, M.L., Chesnut, C.H. III. & Drinkwater, B.L. Yeager, K.K., Agostini, R., Nattiv, A. & Drinkwater, B. (1996) Bone density at multiple skeletal sites in (1993) The female athlete triad: disordered eating, amenorrheic athletes. Journal of the American Medical amenorrhea, osteoporosis. Medicine and Science in Association 276, 238–240. Sports and Exercise 25, 775–777. Chapter 25

Eating Disorders

JORUNN SUNDGOT-BORGEN

Introduction Definitions and diagnostic criteria Disordered eating comprises a wide spectrum of According to the third edition of the Diagnostic harmful and often ineffective eating behaviours and Statistical Manual of Mental Disorders (Ameri- used in attempts to lose weight. These behav- can Psychiatric Association, 1987), eating disor- iours range from mild caloric restriction to the ders are characterized by gross disturbances in clinical disorders of anorexia nervosa and eating behaviour. However, athletes constitute a bulimia nervosa. Symptoms of both disordered unique population and special diagnostic con- eating and eating disorders are more prevalent siderations should be taken into account when among female athletes than non-athletes. Spe- working with this group (Szmuckler et al., 1985; cific risk factors for the development of eating Sundgot-Borgen, 1993; Thompson & Trattner- disorders occur in some sport settings. For Sherman, 1993). An attempt has been made to example, athletes competing in sports where describe athletes who show significant symp- leanness or a specific weight are considered toms of eating disorders but who do not meet all important for performance are at increased risk the criteria for anorexia nervosa or bulimia of developing eating disorders. nervosa. The term anorexia athletica has been sug- Psychological, biological and social factors gested for athletes who have a subclinical eating interrelate to produce the clinical picture of disorder (Sundgot-Borgen, 1994). As many cases eating disorders. The diagnosis of an eating dis- of anorexia nervosa and bulimia nervosa may order in female athletes can easily be missed begin as subclinical variants of these disorders, unless coaches, trainers and team physicians are early identification and treatment may prevent aware of the problem and alert to the symptoms. development of the full disorder (Bassoe, 1990). For a number of reasons, there is a strong pattern Finally, subclinical cases are more prevalent of denial and a standardized scale or a diagnostic among athletes than those meeting the formal interview specific for female athletes must be diagnostic criteria for anorexia nervosa and used to identify those at risk. If left untreated, bulimia nervosa (Grange et al., 1994). eating disorders can have long-lasting physio- logical and psychological effects and may even Diagnosis be fatal. This chapter reviews the definitions, diagnostic criteria, prevalence and risk factors Tables 25.1 and 25.2 summarize the diagnostic for the development of eating disorders in sport. criteria for anorexia nervosa and bulimia nervosa The identification and treatment of eating- specified in the fourth edition of the Diagnostic disordered athletes and the need for future and Statistical Manual of Mental Disorders (Ameri- research are also discussed. can Psychiatric Association, 1994). These new cri- 364 eating disorders 365

Table 25.1 Diagnostic criteria for anorexia nervosa. Table 25.2 Diagnostic criteria for bulimia nervosa. (Reprinted with permission from the Diagnostic and (Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn. © 1994 Statistical Manual of Mental Disorders, 4th edn. © 1994 American Psychiatric Association) American Psychiatric Association)

A Refusal to maintain body weight at or above a A Recurrent episodes of binge-eating. An episode of minimally normal weight for age and height (e.g. binge-eating is characterized by both of the weight loss leading to maintenance of body weight following: (i) eating, in a discrete period of time (e.g. less than 85% of that expected; or failure to make within any 2-hour period), an amount of food that is expected weight gain during period of growth, definitely larger than most people would eat during leading to body weight less than 85% of that a similar period of time in similar circumstances; expected) and (ii) a sense of lack of control over eating during B Intense fear of gaining weight or becoming fat, even the episode (e.g. a feeling that one cannot stop though underweight eating or control what or how much one is eating) C Disturbance in the way in which one’s body weight B Recurrent inappropriate compensatory behaviour or shape is experienced, undue influence of body in order to prevent weight gain, such as self- weight or shape on self-evaluation, or denial of the induced vomiting, misuse of laxatives, diuretics or seriousness of the current low body weight other medications, fasting or excessive exercise D In postmenarcheal females, amenorrhoea, i.e. the C The binge-eating and inappropriate compensatory absence of at least three consecutive menstrual behaviours both occur, on average, at least twice a cycles (a woman is considered to have amenorrhoea week for 3 months if her periods occur only following hormone, e.g. D Self-evaluation is unduly influenced by body shape oestrogen, administration) and weight E The disturbance does not occur exclusively during Specify type episodes of anorexia nervosa Restricting type: during the episode of anorexia nervosa, the person has not regularly engaged in Specify type binge-eating or purging behaviour (i.e. self-induced Purging type: the person regularly engages in self- vomiting or the misuse of laxatives, diuretics or induced vomiting or the misuse of laxatives, enemas) diuretics or enemas Binge-eating/purging type: during the current Non-purging type: the person uses other episode of anorexia nervosa, the person has inappropriate compensatory behaviours, such as regularly engaged in binge-eating or purging fasting or excessive exercise, but does not regularly behaviour (i.e. self-induced vomiting or the misuse engage in self-induced vomiting or the misuse of of laxatives, diuretics or enemas) laxatives, diuretics or enemas

teria formalize overlapping conventions for acknowledges the existence and importance of a subtyping anorexia nervosa into restricting variety of eating disturbances. and binge-eating/purging types based on the The term ‘anorexia athletica’ was first intro- presence or absence of binge-eating and/or duced by Pugliese et al. (1983). The main feature purging (i.e. self-induced vomiting or the misuse of anorexia athletica is an intense fear of gaining of laxatives or diuretics). Most athletes, depend- weight or becoming fat even though an individ- ing on the sport they represent, move between ual is already lean (at least 5% less than expected these two subtypes of eating disorders. However, normal weight for age and height for the general it is the author’s experience that chronicity leads female population). Weight loss is accomplished to an accumulation of eating-disordered athletes by a reduction in energy intake, often com- in the binge-eating/purging subgroup. The cate- bined with extensive or compulsive exercise. gory ‘eating disorder not otherwise specified’ is Restrictive eaters have an energy intake below for disorders of eating that do not meet the crite- that required to maintain the energy require- ria for any specific eating disorder. This category ments of the high training volume (Sundgot- 366 the female athlete triad

Table 25.3 Diagnostic criteria for anorexia athletica. Table 25.4 Athletes competing in five endurance (From Sundgot-Borgen, 1994 with permission) events who met the eating disorder criteria

Weight loss > 5% of expected body weight + Percentage Delayed puberty (no menstrual bleeding (+) No. of with eating at age 16, i.e. primary amenorrhoea) athletes disorders (CI) Menstrual dysfunction (primary (+) amenorrhoea, secondary amenorrhoea Cross-country skiing 22 33.3 (31.4–34.5) and oligomenorrhoea) Middle- and long- 15 27.2 (26.1–28.1) Gastrointestinal complaints (+) distance running Absence of medical illness or affective + Cycling 10 20.0 (17.5–22.5) disorder explaining the weight Swimming 20 15.0 (14.2–15.7) reduction Orienteering 13 0 Distorted body image (+) Average 80 20.0 (19.9–20.1) Excessive fear of becoming obese + Restriction of food [< 5040kJ (1200kcal) + CI, confidence interval. daily] Use of purging methods (self-induced (+) vomiting, laxatives and diuretics Binge-eating (+) et al., 1987; Warren et al., 1990; Sundgot-Borgen, + Compulsive exercise ( ) 1994). +, Absolute criteria; (+), relative criteria. Methodological weaknesses, such as small sample size, failure to define the competitive level and type of sport(s) and the method of data collection, characterize most of the studies Borgen, 1993). In addition to normal training that have attempted to investigate the prevalence to enhance performance in sport, athletes with of eating disorders (Sundgot-Borgen, 1994). In anorexia athletica exercise excessively or com- addition, eating disorders are known to be secre- pulsively in order to purge their bodies of the tive activities and many athletes do not admit effect of eating. These athletes frequently report they have a problem. Only one study has used binge-eating and the use of vomiting, laxatives a clinical evaluation and applied the criteria or diuretics. The binge-eating is usually planned specified in the Diagnostic and Statistical Manual and included in a strict training and study of Mental Disorders (1987) to both athletes and schedule. The criteria for anorexia athletica controls (Sundgot-Borgen, 1994). The prevalence listed in Table 25.3 include a modification of the of anorexia nervosa (1.3%) appeared to be within original criteria introduced by Pugliese et al. the same range as that reported in non-athletes (1983). (Andersen, 1990), whereas bulimia nervosa (8.2%) and subclinical eating disorders (8%) appeared to be more prevalent among athletes Prevalence of eating disorders than non-athletes (Sundgot-Borgen, 1994). Fur- in athletes thermore, the prevalence of eating disorders was Data on the prevalence of eating disorders in ath- significantly higher among athletes competing letic populations are limited and equivocal. Most in aesthetic and weight-dependent sports com- studies have looked at the symptoms of eating pared with athletes competing in sports where disorders, such as preoccupation with food and leanness is considered less important (Fig. 25.1). weight, disturbed body image or the use of path- Further analysis revealed a significant difference ogenic methods for weight control. Estimates of in the prevalence of eating disorders between the the prevalence of the symptoms of eating disor- sports included in the endurance group (Table ders and true eating disorders among female ath- 25.4 & Fig. 25.2). letes range from <1% to as high as 75% (Gadpalle The frequency of eating disorder problems eating disorders 367

50

40

30

20

10

0 G1 G2 G3 G4 G5 G6 Number of subjects with eating disorders (%) Sports groups Non-athletes

Fig. 25.1 Prevalence of eating disorders in female élite athletes representing technical sports (G1; n = 98), endurance sports (G2; n = 119), aesthetic sports (G3; n = 64), weight-dependent sports (G4; n = 41), ball games (G5; n = 183), power sports (G6; n = 17) and non- athletes (n = 522). The data are shown as mean and 95% confidence intervals. The shaded area is the 95% CI for the control group of non-athletes. (From Sundgot- Bergen, 1993 with permission.)

when determined by questionnaire is much Fig. 25.2 This endurance athlete reduced her weight higher than the frequency reported when ath- by a few kilograms and felt that she had enhanced letes have been evaluated clinically (Rosen & her performance level. Those few kilograms were the beginning of years of anorexia nervosa. Hough, 1988; Rucinski, 1989). Despite the methodological weaknesses, existing studies are consistent in showing that symptoms of eating ence of an eating disorder and over-report the disorders and pathogenic methods of weight use of binge-eating (Sundgot-Borgen & Larsen, control are more prevalent in female athletes 1993). In spite of the high sensitivity observed compared with non-athletes and more prevalent in the subtests of the Eating Disorder Inventory in sports in which leanness or a specific weight as a predictor of eating disorders (Sundgot- are considered important compared with sports Borgen, 1994), it is the author’s opinion that where these factors are considered less important determining whether an athlete actually suffers (Rosen et al., 1986; Dummer et al., 1987; Sundgot- from any of the eating disorders described above Borgen & Corbin, 1987; Hamilton et al., 1988; requires an interview with a clinician in order to Rosen & Hough, 1988; Wilmore, 1991; Sundgot- assess the athlete’s physical and emotional con- Borgen, 1993; O’Connor et al., 1995). dition and whether this interferes with everyday functioning. Self-report vs. clinical interview Effect of skill level In questionnaires, élite athletes have been found to under-report the use of purging methods (e.g. It is assumed that some risk factors (e.g. intense laxatives, diuretics and vomiting) and the pres- pressure to be lean, increased training volume 368 the female athlete triad

and perfectionism) are more pronounced in élite anorexia nervosa has been proposed in a series of athletes. However, Hamilton et al. (1988) found studies (Epling et al., 1983; Epling & Pierce, 1988). that in the USA less-skilled dancers reported Indeed, there are some studies indicating that significantly more eating problems than more an increased training load may induce caloric skilful dancers. On the other hand, Garner et al. deprivation in endurance athletes, which in turn (1987) found that dancers at the highest perfor- may elicit biological and social reinforcements mance level had a higher prevalence of eating leading to the development of eating disorders disorders than dancers at a lower level. Thus, (Sundgot-Borgen, 1994). Longitudinal studies in firm conclusions about the prevalence at differ- athletes representing different sports with close ent skill levels cannot be drawn without long- monitoring of a number of sport-specific factors, itudinal studies with careful classification such as volume, type and intensity of training, and description of the calibre of the athletes are needed before the the role played by different investigated. sports in the development of eating disorders can be determined. • Starting sport-specific training at a prepuber- Risk factors for the development of tal age may prevent athletes from choosing the eating disorders sport most suitable for their adult body type. Psychological, biological and social factors are Athletes with eating disorders have been shown implicated in the development of eating disor- to start sport-specific training at an earlier age ders (Katz, 1985; Garfinkel et al., 1987). It has than athletes who do not meet the criteria for been claimed that female athletes appear to be eating disorders (Sundgot-Borgen, 1994). more vulnerable to eating disorders than the • In addition to the pressure to reduce weight, general female population because of additional athletes are often pressed for time: they have stresses associated with the athletic environment to lose weight rapidly to make or stay on the (Wilmore, 1991). Other factors specific to sport team. As a result they often experience frequent may also play a role, as listed below. periods of restrictive dieting or weight cycling • It has been suggested that sport attracts indi- (Sundgot-Borgen, 1994). Such periods have been viduals who are anorectic, at least in attitude if suggested as important risk or trigger factors for not in behaviour or weight, before they start the development of eating disorders in athletes participating in sport ( Sacks, 1990; Thompson & (Brownell et al., 1987; Sundgot-Borgen, 1994) Trattner-Sherman, 1993). (Fig. 25.3). • A biobehavioural model of activity-based • The characteristics of a sport (e.g. emphasis on

Fig. 25.3 Periods of restrictive dieting and weight cycling are risk factors for the development of eating disorders. eating disorders 369

leanness or individual competition) may interact vulnerable individuals through inappropriate with the personality traits of the athlete to initiate coaching (Wilmore, 1991). In most cases the role and perpetuate an eating disorder (Wilson & of coaches in the development of eating disor- Eldredge, 1992). ders in athletes should be seen as part of a Athletes have reported that they developed complex interplay of factors. eating disorders as a result of an injury or illness that left them temporarily unable to continue Medical issues their normal level of exercise (Katz, 1985; Sundgot-Borgen, 1994). An injury can curtail Eating disorders can result in serious medical the athlete’s exercise and training habits. As a problems and can even be fatal. It is the author’s result of weight gain due to less energy expendi- experience that signs and symptoms of eating ture, the athlete may develop an irrational fear disorders in competitive athletes are often of weight gain and begin to diet as a means of ignored or trivialized. Whereas most complica- compensating (Thompson & Trattner-Sherman, tions of anorexia nervosa occur as a direct or in- 1993). Thus, the loss of a coach or unexpected direct result of starvation, the complications of illness or injury can be regarded as traumatic bulimia nervosa occur as a result of binge-eating events similar to those described as trigger mech- and purging (Thompson & Trattner-Sherman, anisms for eating disorders in non-athletes 1993). Johnson and Connor (1987), Hsu (1990) (Bassoe, 1990). and Mitchell (1990) all provide information on Pressure to reduce weight has been the general the medical problems encountered in eating- explanation for the increased prevalence of disordered patients. eating-related problems among athletes. It is not Studies have reported mortality rates of <1% necessarily dieting per se but the situation in to as high as 18% in patients with anorexia which the athlete is told to lose weight, the words nervosa in the general population (Thompson & used and whether the athlete receives guidance Trattner-Sherman, 1993). Death is usually attrib- or not is important. The different reasons for utable to fluid and electrolyte abnormalities or the development of eating disorders reported suicide (Brownell & Rodin, 1992). Mortality in by high-level athletes are presented in Table 25.5. bulimia nervosa is less well studied but deaths Most researchers agree that coaches do not do occur, usually secondary to the complica- cause eating disorders in athletes, although the tions of the bingeing–purging cycle or suicide. problem may be triggered or exacerbated in Mortality rates of eating disorders among ath- letes are not known. However, a number of deaths of top-level athletes, representing gym- Table 25.5 The different reasons for the development nastics, running, cross-country, alpine skiing and of eating disorders reported by eating-disordered cycling, have been reported in the media. Of athletes. (From Sundgot-Borgen, 1994 with permission) those diagnosed in the Norwegian study (Sundgot-Borgen, 1994), five (5.4%) reported that Prolonged periods of dieting 37% they had tried to commit suicide. New coach 30% For years, athletes have used and abused Injury/illness 23% drugs in order to control weight (Thompson Casual comments 19% Leaving home/failure at school/work 10% & Trattner-Sherman, 1993). Some athletes use Problem in relationship 10% dieting, bingeing, vomiting, sweating and fluid Family problems 7% restriction for weight control. It is clear that many Illness/injury to family members 7% of these behaviours represent health hazards for Death of significant others 4% the athlete. Laxatives, diet pills and diuretics Sexual abuse (by coach) 4% are probably the type of drugs most commonly Multiple answers were allowed; 15% did not give any abused by athletes, while eating-disordered specific reason. dancers also report the use of marijuana, cocaine, 370 the female athlete triad

tranquillizers and amphetamines (Holderness Table 25.6 Physical symptoms of athletes with et al., 1994). Of the Norwegian élite athletes suf- anorexia nervosa or anorexia athletica. (Modified from Thompson & Trattner-Sherman, 1993) fering from eating disorders, 8% reported use of diuretics (Sundgot-Borgen, 1994). It should be Significant weight loss beyond that necessary for noted that diet pills often contain drugs in the adequate sport performance stimulant class and that both these and diuretics Amenorrhoea or menstrual dysfunction are banned by the International Olympic Dehydration Fatigue beyond that normally expected in training or Committee. competition Gastrointestinal problems (i.e. constipation, diarrhoea, Long-term health effects bloating, postprandial distress) Hyperactivity The long-term effects of body weight cycling Hypothermia Bradycardia and eating disorders in athletes are not clear. Bio- Lanugo logical maturation and growth have been inves- Muscle weakness tigated in girl gymnasts before and during Overuse injuries puberty; these studies provide sufficient data Reduced bone mineral density to conclude that young female gymnasts are Stress fractures smaller and mature later than females compet- ing in sports that do not require extreme lean- ness, e.g. swimming (Mansfield & Emans, 1993; Table 25.7 Psychological and behavioural Theintz et al., 1993). However, it is difficult to characteristics of athletes with anorexia nervosa and anorexia athletica. (From Thompson & Trattner- separate the effects of physical strain, energy re- Sherman, 1993; Sundgot-Borgen, 1994 with striction and genetic predisposition on delayed permission) puberty. Athletes with frequent or long periods of amenorrhoea fail to achieve normal peak bone Anxiety, both related and unrelated to sport mass and may be at risk for premature osteo- performance Avoidance of eating and eating situations porosis (see Chapter 27). More longitudinal data Claims of ‘feeling fat’ despite being thin on rapid and gradual body weight reduction and Resistance to weight gain or maintenance cycling in relation to health and performance recommended by sport support staff parameters in different groups of athletes are Unusual weighing behaviour (i.e. excessive weighing, clearly needed. refusal to weigh, negative reaction to being weighed) Compulsiveness and rigidity, especially regarding Identifying athletes with eating disorders eating and exercise Excessive or obligatory exercise beyond that required Most individuals with anorexia athletica do not for a particular sport realize that they have a problem and therefore Exercising while injured despite prohibitions by medical and training staff do not seek treatment on their own. Only if Restlessness: relaxing is difficult or impossible these athletes see that their performance level is Social withdrawal from team-mates and sport support impaired might they consider seeking help. The staff, as well as from people outside sports physical and psychological characteristics listed Depression in Tables 25.6 and 25.7 may indicate the presence Insomnia of anorexia nervosa or anorexia athletica. Most athletes suffering from bulimia nervosa are at, or near, normal weight. Bulimic athletes negatively. Therefore, the team staff must be able usually try to hide their disorder until they feel to recognize the physical symptoms and psycho- that they are out of control or when they realize logical characteristics listed in Tables 25.8 and that the disorder is affecting sport performance 25.9. It should be noted that the presence of some eating disorders 371

Table 25.8 Physical symptoms of athletes with Table 25.9 Psychological and behavioural bulimia nervosa. (From Thompson & Trattner- characteristics of athletes with bulimia nervosa. (From Sherman, 1993 with permission) Thompson & Trattner Sherman, 1993 with permission)

Callus or abrasion on back of hand from inducing Binge-eating vomiting Agitation when bingeing is interrupted Dehydration, especially in the absence of training or Depression competition Dieting that is unnecessary for appearance, health or Dental and gum problems sport performance Oedema, complaints of bloating, or both Evidence of vomiting unrelated to illness Electrolyte abnormalities Excessive exercise beyond that required for the Frequent and often extreme weight fluctuations (i.e. athlete’s sport mood worsens as weight goes up) Excessive use of the rest room Gastrointestinal problems Going to the rest room or ‘disappearing’ after eating Low weight despite eating large volumes Self-critical, especially concerning body, weight and Menstrual irregularity sport performance Muscle cramps, weakness, or both Secretive eating Swollen parotid glands Substance abuse: legal, illegal, prescribed or over-the- counter drugs, medications or other substances Use of laxatives, diuretics (or both) that is unsanctioned by medical or training staff of the characteristics listed in Tables 25.6–25.9 do not necessarily indicate the presence of the disorder. However, the likelihood of the disorder endurance work, especially after rapid weight being present increases as the number of char- reduction (Fogelholm, 1994). Absolute maximal acteristics increases (Thompson & Trattner- oxygen uptake (litres per minute) may be un- Sherman, 1993). The laboratory investigations changed or decreased after rapid body weight recommended for all eating-disordered patients, loss, although maximal oxygen uptake ex- those indicated for particular patients and those pressed in relation to body weight may increase of academic interest with expected findings are after gradual body weight reduction (Ingjer & discussed by Beumont et al. (1993). Sundgot-Borgen, 1991; Fogelholm, 1994).

Effect of eating disorders on Anaerobic performance, muscle strength sports performance and coordination The nature and the magnitude of the effect of Anaerobic performance and muscle strength are eating disorders on sports performance are influ- typically decreased after rapid weight reduction enced by the severity and chronicity of the eating with or without 1–3 hours of rehydration. When disorder and the physical and psychological tested after 5–24 hours of rehydration, perfor- demands of the sport. mance is maintained at euhydrated levels (Klinz- ing & Karpowicz, 1986; Fogelholm et al., 1993). Loss of coordination due to dehydration Aerobic endurance is also reported to impair exercise performance Loss of endurance due to dehydration im- (Fogelholm, 1994). pairs exercise performance (Fogelholm, 1994). Reduced plasma volume, impaired thermoregu- Psychological effects lation and nutrient exchange, decreased glyco- gen availability and decreased buffer capacity in Studies on the psychological effect of dieting the blood are plausible explanations for reduced and weight cycling are lacking in female athletes; performance in aerobic, anaerobic and muscle however, it is reported that many young 372 the female athlete triad

wrestlers experience mood alterations (increased the family’s involvement is recommended. For fatigue, anger or anxiety) when attempting to the athlete who agrees to participate, treatment lose body weight rapidly (Brownell et al., 1987). can involve a variety of types and modes and may vary with regard to goals, duration and intensity. Treatment of eating disorders Few authors have discussed the specific issue Training and competition of the treatment of eating disorders in athletes. Therefore, the comments here rely primarily on Once an athlete has begun treatment, an impor- the experiences described by Thompson and tant question is whether she should be allowed to Trattner-Sherman (1993) and Clark (1993), and continue to train and compete while recovering the author’s own experiences in treating élite from the disorder. Generally, it is not recom- athletes suffering from eating disorders. mended that athletes compete during treatment. • Admitting to an eating disorder is more threat- However, in some cases it may be permissible for ening for the athlete with bulimia nervosa or the athlete to continue competing before success- bulimic symptoms than for those suffering from fully completing treatment. However, several anorexia nervosa or anorexia athletica. important issues must be considered, the most • Eating-disordered athletes seem more likely important of which include diagnosis, the sever- to accept the idea of a consultation than the ity of the disorder, the type of sport and competi- prospect of prolonged treatment. Persuading the tive level. In addition, allowing an athlete to athlete to accept a referral for evaluation is some- compete while affected by an eating disorder times a significant accomplishment in itself; per- may give her the message that sport performance suading her to participate in formal treatment is more important than her health. may be another challenge entirely. For an anorectic athlete the medical risks of • The formal treatment of athletes with eating competition are considerable; this is usually also disorders should be undertaken only by quali- true for athletes suffering from bulimia nervosa. fied healthcare professionals. Ideally, these indi- In certain circumstances it may be acceptable viduals should also be familiar with, and have for some athletes with milder symptoms, such as an appreciation for, the sport environment anorexia athletica or eating disorder not other- (Clark, 1993; Thompson & Trattner-Sherman, wise specified, to compete before they have 1993). completed treatment. The athlete who is being • The success of the treatment plan must be considered for competition while in treatment based on establishing a trusting relationship must undergo extensive medical and psycholog- between the athlete and the care providers. This ical evaluations. These must indicate that the includes respecting the athlete’s desire to be lean athlete is not at risk medically and that competi- for athletic performance and expressing a will- tion will not increase her risk either medically ingness to work together to help the eating- or psychologically (Thompson & Trattner- disordered athlete be lean and healthy. Sherman, 1993). • The treatment team needs to listen to the If the athlete is allowed to continue competing athlete’s fears and irrational thoughts about food and training, Thompson and Trattner-Sherman and weight and then present a rational approach (1993) believe minimal criteria must be set. for achieving self-management of a healthy diet, • The athlete must agree to comply with all weight and training programme (Clark, 1993). treatment strategies as best she can. The athlete’s family may be involved in the • She must genuinely want to compete. process of persuading the athlete to begin treat- • She must be closely monitored on an ongoing ment. One factor affecting this involvement is the basis by the medical and psychological health- athlete’s age: the younger the athlete, the more care professionals handling her treatment and by eating disorders 373

the sport-related personnel who are working nervosa require at least some inpatient treat- with her in her sport. ment, although the healthcare provider may try • The treatment must always take precedence outpatient treatment if the individual’s weight over the sport. is stable and not extremely low and if she is not • If any question arises at any time regarding purging (Hsu, 1990). Conversely, most athletes whether the athlete is meeting, or is able to meet, with anorexia athletica or bulimia nervosa can the preceding criteria, competition is not to be and should be treated on an outpatient basis. considered a viable option while the athlete is in treatment. Types of treatment Some athletes should be allowed to compete while in aftercare, if not medically or psychologi- Whether the athlete is in inpatient or outpatient cally contraindicated. However, it is extremely treatment, she is likely to be involved in several important to examine whether the athlete really modes of treatment. Typically these include indi- wants to go back to competitive sport. If so and vidual, group and family therapy. Nutritional if she is in good health, she should be allowed to counselling and pharmacotherapy may also be return as soon as she feels ready after finish- included as adjuncts to the treatment regimen. ing treatment (Thompson & Trattner-Sherman, The different types of treatment strategies have 1993). been described in detail by Thompson and Trat- tner-Sherman (1993). Limited training while in treatment Treatment goals and expectations If the above-mentioned criteria for returning to competition cannot be met, or if competition The primary focus of treatment is normalizing rather than physical exertion is a problem, some weight, eating behaviour and exercise behaviour, athletes may still be allowed to engage in limited modifying unhealthy thought processes that training. The same criteria that are used to assess maintain the disorder and dealing with the emo- the safety of competition apply here as well (i.e. tional issues in the individual’s life. Athletes diagnosis, severity of problem, type of sport, have the same general concerns as non-athletes competitive level and health maintenance) about gaining weight, but they also have con- (Thompson & Trattner-Sherman, 1993). Some cerns from a sporting point of view. What they athletes in treatment will be encouraged by the think is an ideal competitive weight, one that opportunity to continue training; thus if the they believe helps them to be successful in their athlete is recovering from her disorder and if sport, may be significantly lower than their treat- she is determined to continue competing in her ment goal weight. As a result, athletes may have sport after treatment, allowing her to continue concerns about their ability to perform in their with her sport can increase her motivation and sport following treatment. It is the author’s expe- enhance the effect of treatment. It is the author’s rience that most athletes are willing to allow a experience that a total suspension is not a good coach or other support staff only minimal contact solution. Therefore, if no medical complications with the therapist, while some athletes want the are present, she should be allowed to train but at coach involved and view this as evidence of a lower volume and at a decreased intensity. caring and concern on the part of the coach.

Inpatient vs. outpatient Health maintenance standards

Treatment for an eating disorder can involve If the athlete is permitted to train or compete either inpatient or outpatient treatment, or both. during treatment, ‘bottom-line’ standards re- Generally, most individuals with anorexia garding health maintenance must be imposed to 374 the female athlete triad

protect the athlete. The treatment staff determine tic and based on body composition rather than these and individually tailor them according to weight-for-height standards. the athlete’s particular condition. These stan- • The weight loss programme should start well dards may vary between individual athletes or before the season begins. by sport. At a minimum, athletes should main- • Athletes must consume regular meals with tain a weight of no less than 90% of ‘ideal’ sufficient calories and nutrients to avoid men- weight, not sport related but health related. The strual irregularities, loss of bone mass, loss of athlete should eat at least three balanced meals a muscle tissue and the experience of compro- day, consisting of enough calories to sustain the mised performance. pre-established weight standard the dietitian has • The healthcare personnel should set realistic proposed. Athletes who have been amenorrhoeic goals that address methods of dieting, rate of for 6 months or more should undergo a gynaeco- weight change and a reasonable target range of logical examination in order to consider hor- weight and body fat. mone replacement therapy. In addition, bone • Change in body composition should be moni- mineral density should be assessed and results tored on a regular basis to detect any continued should be within the normal range. or unwarranted losses or fluctuations in weight. • Measurements of body composition should be made in private in order to reduce the Prevention of eating disorders stress, anxiety and embarrassment of public in athletes assessment. Since the exact causes of eating disorders are • A registered dietitian who knows the unknown, it is difficult to draw up preventive demands of the specific sport should be involved strategies. Coaches should realize that they can in the planning of individual nutritionally ade- greatly influence their athletes. Coaches or quate diets. Throughout this process, the role of others involved with young athletes should overall good nutrition practices in optimizing not comment on an individual’s body size or performance should be emphasized. demand weight loss in young and still growing • If the athlete exhibits symptoms of an eating athletes. Without nutritional guidance, dieting disorder, the athlete should be counselled about may result in unhealthy eating behaviour or the possible problem. eating disorders in highly motivated and unin- • Coaches should not try to diagnose or treat formed athletes (Eisenman et al., 1990). Early eating disorders but should be specific about intervention is also important, since eating disor- their suspicions and talk with the athlete about ders are more difficult to treat the longer they the fears or anxieties she may be having progress. However, most important of all is the about food and performance. They should prevention of circumstances or factors that could encourage medical evaluation and support the lead to an eating disorder. Therefore, profession- athlete. als working with athletes should be informed • The coach should assist and support the about the possible risk factors for the develop- athlete during treatment. ment, early signs and symptoms of eating disorders, the medical, psychological and Conclusion and recommendations for social consequences of these disorders, how to future research approach the problem if it occurs, and what treatment options are available. • The prevalence of eating disorders is higher among female athletes than non-athletes, but the relationship to performance or training level Weight loss recommendations is unknown. Additionally, athletes competing in A change in body composition and weight loss sports where leanness or a specific weight are can be achieved safely if the goal weight is realis- considered important are more prone to eating eating disorders 375

disorders than athletes competing in sports Andersen, A.E. (1990) Diagnosis and treatment of where these factors are considered less males with eating disorders. In A.E. Andersen (ed.) Males With Eating Disorders, pp. 133–162. Brunner/ important. Mazel, New York. • It is not known whether eating disorders are Bassoe, H.H. (1990) Anorexia/bulimia nervosa: the more common among élite athletes than among development of anorexia nervosa and of mental less-successful athletes. Therefore, it is necessary symptoms. Treatment and the outcome of the to examine anorexia nervosa, bulimia nervosa disease. Acta Psychiatrica Scandinavica 82, 7–13. Beumont, P.J., Russell, J.D. & Touyz, S.W. (1993) Treat- and subclinical eating disorders, and the range of ment of anorexia nervosa. Lancet 341, 1635–1640. behaviours and attitudes associated with eating Brownell, K.D. & Rodin, J. (1992) Prevalence of eating disturbances, in athletes representing different disorders in athletes. In K.D. Brownell, J. Rodin & sports and competitive levels in order to learn J.H. Wilmore (eds) Eating, Body Weight and Perfor- how these clinical and subclinical disorders are mance in Athletes, pp. 128–143. Lea and Febiger, Philadelphia. related. Brownell, K.D., Steen, S.N. & Wilmore, J.H. (1987) • Clinical interview seems to be superior to self- Weight regulation practices in athletes: analysis of report for determining the prevalence of eating metabolic and health effects. Medicine and Science in disorders. However, because of methodological Sports and Exercise 19, 546–560. weaknesses in the existing studies (e.g. deficient Clark, N. (1993) How to help the athlete with bulimia: practical tips and case study. International Journal of description of the populations investigated and Sports Nutrition 3, 450–460. procedures of data collection) the best instru- Dummer, G.M., Rosen, L.W. & Heusner, W.W. (1987) ment or interview method is not known. There- Pathogenic weight-control behaviors of young com- fore, there is a need to validate self-report and petitive swimmers. Physician and Sportsmedicine 5, interview methods with athletes and identify the 75–86. Eisenman, P.A., Johnson, S.C. & Benson, J.E. (1990) conditions under which self-reporting of eating Coaches Guide to Nutrition and Weight Control, 2nd disturbances is most likely to be accurate. edn. Leisure Press, Champaign, Illinois. • Interesting suggestions have been made about Epling, W.F. & Pierce, W.D. (1988) Activity based possible sport-specific risk factors for the devel- anorexia nervosa. International Journal of Eating Disor- opment of eating disorders in athletes, but large- ders 7, 475–485. scale longitudinal studies are needed in order to Epling, W.F., Pierce, W.D. & Stefan, L. (1983) Atheory of activity based anorexia. International Journal of Eating learn more about risk factors and the aetiology of Disorders 3, 27–46. eating disorders in athletes at different competi- Fogelholm, M. (1994) Effects of bodyweight reduction tive levels and within different sports. on sports performance. Sports Medicine 4, 249–267. • The formal treatment of athletes with eating Fogelholm, G.M., Koskinen, R. & Laakso, J. (1993) disorders should be undertaken only by quali- Gradual and rapid weight loss: effects on nutrition and performance in male athletes. Medicine and fied healthcare professionals. Ideally, these indi- Science in Sports and Exercise 25, 371–377. viduals should also be familiar with, and have an Gadpalle, W.J., Sandborn, C.F. & Wagner, W.W. (1987) appreciation for, the sport environment. Athletic amenorrhea, major affective disorders and • More knowledge is needed about the short- eating disorders. American Journal of Psychiatry 144, term and long-term effects of weight cycling and 9399–9443. Garfinkel, P.E., Garner, D.M. & Goldbloom, D.S. (1987) eating disorders on the health and performance Eating disorders: implications for the 1990’s. Cana- of athletes. dian Journal of Psychiatry 32, 624–631. Garner, M.D., Garfinkel, P.E., Rockert, W. & Olmsted, M.P. (1987) A prospective study of eating distur- References bances in the ballet. Psychotherapy and Psychosomatics 48, 170–175. American Psychiatric Association (1987) Diagnostic Grange, D.L., Tibbs, J. & Noakes, T. (1994) Implications and Statistical Manual of Mental Disorders, 3rd edn, of a diagnosis of anorexia nervosa in a ballet school. pp. 65–69. APA, Washington, DC. International Journal of Eating Disorders 4, 369–376. American Psychiatric Association (1994) Diagnostic Hamilton, L.H., Brocks-Gunn, J., Warren, M.P. & and Statistical Manual of Mental Disorders, 4th edn, Hamilton, W.G. (1988) The role of selectivity in the pp. 1–2. APA, Washington, DC. 376 the female athlete triad

pathogenesis of eating problems in ballet dancers. dietary intake of competitive ice skaters. Journal of the Medicine and Science in Sports and Exercise 20, 560–565. American Dietetic Association 89, 98–100. Holderness, C.C., Brooks-Gunn, J. & Warren, M.P. Sacks, M.H. (1990) Psychiatry and sports. Annals of (1994) Eating disorders and substance use: a dancing Sports Medicine 5, 47–52. vs. nondancing population. Medicine and Science in Sundgot-Borgen, J. (1993) Prevalence of eating disor- Sports and Exercise 26, 297–302. ders in female elite athletes. International Journal of Hsu, L.K.G. (1990) Eating Disorders. Guilford Press. Sports Nutrition 3, 29–40. New York. Sundgot-Borgen, J. (1994) Risk and trigger factors for Ingjer, F. & Sundgot-Borgen, J. (1991) Influence of body the development of eating disorders in female elite weight reduction on maximal oxygen uptake in athletes. Medicine and Science in Sports and Exercise female elite athletes. Scandinavian Journal of Medicine 26(4), 414–419. and Science in Sports 1, 141–146. Sundgot-Borgen, J. & Corbin, C.B. (1987) Eating disor- Johnson, C. & Connor, S.M. (1987) The Etiology and ders among female athletes. Physician and Sportsmed- Treatment of Bulimia Nervosa. New York Basic Books, icine 2(15), 89–95. New York. Sundgot-Borgen, J. & Larsen, S. (1993) Nutrient intake Katz, J.L. (1985) Some reflections on the nature of the and eating behavior of female elite athletes suffer- eating disorders. International Journal of Eating Disor- ing from anorexia nervosa, anorexia athletica and ders 4, 617–626. bulimia nervosa. International Journal of Sports Nutri- Klinzing, J.E. & Karpowicz, W. (1986) The effect of tion 3, 431–442. rapid weight loss and rehydration on a wrestling Szmuckler, G.I., Eisler, I., Gillies, C. & Hayward, M.E. performance test. Journal of Sports Medicine and Physi- (1985) The implications of anorexia nervosa in a cal Fitness 26, 149–156. ballet school. Journal of Psychiatric Research 19, Mansfield, M.J. & Emans, S.J. (1993) Growth in female 177–181. gymnasts: should training decrease during puberty? Theintz, M.J., Howald, H. & Weiss, U. (1993) Evidence Pediatrics 122, 237–240. of a reduction of growth potential in adolescent Mitchell, J.E. (1990) Bulimia Nervosa. University of Min- female gymnasts. Journal of Pediatrics 122, 306–313. nesota Press, Minneapolis. Thompson, R.A. & Trattner-Sherman, R. (1993) Helping O’Connor, P.J., Lewis, R.D. & Kirchner, E.M. (1995) Athletes with Eating Disorders. Human Kinetics Pub- Eating disorder symptoms in female college gym- lishers, Champaign, Illinois. nasts. Medicine and Science in Sports and Exercise 27(4), Warren, B.J., Stanton, A.L. & Blessing, D.L. (1990) Dis- 550–555. ordered eating patterns in competitive female ath- Pugliese, M.T., Lifshitz, F., Grad, G., Fort, P. & Marks- letes. International Journal of Eating Disorders 5, Katz, M. (1983) Fear of obesity. A cause of short 565–569. stature and delayed puberty. New England Journal of Wilmore, J.H. (1991) Eating and weight disorders in Medicine 309, 513–518. female athletes. International Journal of Sports Nutri- Rosen, L.W. & Hough, D.O. (1988) Pathogenic weight- tion 1, 104–117. control behaviors of female college gymnasts. Physi- Wilson, T. & Eldredge, K.L. (1992) Pathology and cian and Sportsmedicine 16(9), 141–144. development of eating disorders: implications for Rosen, L.W., McKeag, D.B. & Hough, D.O. (1986) Path- athletes. In K.D. Brownell, J. Rodin & J.H. Wilmore ogenic weight-control behaviors in female athletes. (eds) Eating, Body Weight and Performance in Athletes: Physician and Sportsmedicine 14, 79–86. Disorders of Modern Society, pp. 115–127. Lea & Rucinski, A. (1989) Relationship of body image and Febiger, Philadelphia. Chapter 26

Amenorrhoea

LORNA A. MARSHALL

Introduction in female athletes has been difficult to determine, with estimates based on descriptive cross- Of the three disorders in the female athlete triad, sectional studies. In addition, the definition of amenorrhoea, or the absence of menstrual bleed- amenorrhoea has varied between investigations. ing, was the first to be recognized. Several Glass et al. (1987) showed that 19% of women in reports in the 1970s suggested an association Olympic marathon trials were amenorrhoeic. In between exercise and delayed puberty or sec- various studies 3.4–66% of certain groups of the ondary amenorrhoea (Feicht et al., 1978; Malina et athletic population have been estimated to be al., 1978). By the 1980s, the association of exercise amenorrhoeic (Feicht et al., 1978; Frisch et al., with amenorrhoea was well recognized, espe- 1981; Warren, 1992). cially in ballet dancers (Frisch et al., 1980; Warren et al., 1986) and long-distance runners. Shangold Physiology of the menstrual cycle and Levine (1982) showed an increased inci- dence of oligomenorrhoea and amenorrhoea A basic understanding of the physiology of the with the onset of marathon training, suggesting normal menstrual cycle will help the clinician a causal relationship between exercise and evaluate the athlete with amenorrhoea or other amenorrhoea. menstrual cycle abnormalities. In the absence of Initially, many individuals viewed menstrual pregnancy and lactation, a menstrual period dysfunction as a benign consequence of strenu- should occur every 21–35 days from menarche to ous exercise. Gradually, the association of amen- menopause. To achieve this, the hypothalamus, orrhoea with osteoporosis and disordered eating pituitary gland and ovaries must function in a was recognized, and the concept of the female coordinated manner to allow the normal produc- athlete triad was formulated (Yeager et al., 1993). tion of female reproductive hormones. In addi- Amenorrhoea continues to be the problem that tion, a uterus and vagina must be present to first brings a female athlete to medical attention. allow the endometrial growth and vaginal bleed- Its presence should prompt the physician or ing that occurs in the course of a menstrual cycle. trainer to search for underlying disordered eating and consider the possibility of Hypothalamic production of gonadotrophin- osteoporosis. releasing hormone Amenorrhoea is a relatively common disorder, with an estimated prevalence of 2–5% in the Gonadotrophin-releasing hormone (GnRH) general female population and as high as 8.5% in must be produced by the hypothalamus in suffi- an unselected adolescent population (Johnson & cient quantity and must be secreted in a regular Whitaker, 1992). The prevalence of amenorrhoea pulsatile pattern. GnRH is released into the 377 378 the female athlete triad

portal vessels, through which it travels down esterone (as in chronic anovulation or poly- the pituitary stalk to affect the cells in the pitu- cystic ovarian syndrome), the endometrium itary gland that produce luteinizing hormone develops but will usually bleed erratically and (LH) and follicle-stimulating hormone (FSH). infrequently. Amenorrhoea results when the GnRH pulses that reach the pituitary gland decrease below Genital outflow tract a critical frequency or concentration, or are disordered (Liu, 1990). There are many neuro- A uterus, a normal endometrial lining and a tract hormones, including endorphins and catechola- connecting the uterine cavity with the external mines, that modulate GnRH production (Plosker genitalia must be present for menstrual bleed- et al., 1990). Physical and emotional stresses are ing to be observed. A normal uterus with an believed to result in ‘hypothalamic amenor- obstructed outflow tract may result in the uterus, rhoea’ by affecting such neurohormones. In vagina and peritoneal cavity distended with addition, the GnRH-producing cells in the hypo- menstrual blood, and amenorrhoea will be thalamus can be damaged or congenitally defi- reported. cient, or the pituitary stalk can be traumatized, resulting in amenorrhoea. Overview of menstrual dysfunction

Pituitary production of LH and FSH Amenorrhoea

The cells in the pituitary gland that produce LH Amenorrhoea usually refers to the absence of and FSH must be intact and functional. LH and menstrual bleeding for 6months or for a length FSH are necessary to initiate the maturation of of time equal to the sum of three previous men- the egg, stimulate ovulation and support the strual cycles. Women who have not had any corpus luteum after ovulation. Large pituitary menstrual bleeding by 16 years of age, or by 14 tumours or ischaemia may compromise or years of age in the absence of sexual develop- destroy these cells. Prolactin is also secreted by ment, are also considered to be amenorrhoeic. the pituitary gland; when prolactin levels are Definitions of amenorrhoea vary greatly from high from any cause, LH and FSH secretion falls study to study and should be noted when com- and amenorrhoea may follow. paring findings in athletes with amenorrhoea. To standardize future reports, the International Olympic Committee has defined amenorrhoea as Ovarian production of oestrogen one period or less in a year. and progesterone Primary amenorrhoea refers to women who The ovaries must produce oestrogen and proges- have never had menstrual bleeding; secondary terone in a sequential manner. This depends on amenorrhoea refers to those who have had at the presence of oocytes (eggs), their maturation least one episode of menstrual bleeding before and the appropriate development of a corpus amenorrhoea. Many reproductive disorders can luteum after ovulation. Oestrogen stimulates the result in either primary or secondary amenor- endometrium to develop, and the withdrawal rhoea, so their evaluation is almost identical. of both oestrogen and progesterone results in menstrual shedding. ‘Ovarian failure’ or ‘meno- Delayed menarche pause’ means that there are few or no func- tional oocytes remaining, and despite normal Delayed menarche refers to the onset of menses pituitary and hypothalamic function the ovary after the age of 16. For practical purposes this is cannot produce significant oestrogen or proges- a retrospective diagnosis used, for example, to terone. When oestrogen is present but not prog- profile the athlete with secondary amenorrhoea. amenorrhoea 379

The young female athlete who presents with phase defect. Multiple measurements of proges- primary amenorrhoea may eventually be diag- terone in one menstrual cycle, with determina- nosed with delayed menarche, but should be tion of the area under the curve or measurement evaluated and treated like any other woman with of progesterone in a pooled sample, are much primary amenorrhoea. more accurate determinants of a luteal phase defect. Oligomenorrhoea Causes of amenorrhoea and other There is a spectrum of menstrual dysfunction menstrual dysfunctions that seems to occur with greater frequency in the female athlete, including oligomenorrhoea When an athlete presents with amenorrhoea, the and luteal phase defect as well as amenorrhoea clinician should not assume that the causative (Shangold et al., 1990). Oligomenorrhoea refers to factor is exercise; ‘exercise-associated’ or ‘ath- menstrual cycles longer than 35 days and is letic’ amenorrhoea is a diagnosis of exclusion. All usually, but not always, associated with anovula- other causes of amenorrhoea should be consid- tion. Oligomenorrhoea can be associated with ered and an appropriate evaluation initiated. normal or high levels of oestrogen but no proges- terone. Alternatively, both oestrogen and proges- Pregnancy terone levels may be low. Pregnancy is the most common cause of amenor- rhoea and must be considered first in all women. Luteal phase defect It should even be considered in sexually active The luteal phase is the period from ovulation to women recovering from long-standing amenor- the first day of the next menses, usually about rhoea; the first ovulation can occur before the 12–14 days. A luteal phase defect or inadequate first menses. It can sometimes be devastating for luteal phase is defined as a lag of more than the athlete to delay the diagnosis of pregnancy. 2 days in histological development of the endometrium. It is difficult to diagnose since Hypothalamic dysfunction menstrual periods may occur regularly. The diagnosis requires two abnormal endometrial Except for pregnancy, hypothalamic dysfunction biopsies for its strict definition (Speroff et al., is the most common cause of secondary amenor- 1994). A luteal phase of less than 10 days is rhoea. Hypothalamic amenorrhoea is also associ- usually associated with an inadequate luteal ated with primary amenorrhoea or delayed phase. It is very difficult to identify women with menarche (Liu, 1990). Exercise-associated amen- luteal phase defects when large numbers of orrhoea is generally considered to be a subset of women are being studied. The prevalence of hypothalamic amenorrhoea. In hypothalamic luteal phase defects in the general female popu- amenorrhoea, pulsatile GnRH is deficient, absent lation or in athletes is unknown. Shangold et al. or inappropriately secreted by the hypothala- (1979) have shown that runners with regular mus. Psychological/physical stress may affect menstrual cycles have decreased peak proges- the neurohormones that modulate GnRH and is terone levels during training periods compared most commonly implicated as a cause of hypo- with control periods. Salivary progesterone thalamic amenorrhoea. Rarely, congenital abnor- levels have also been used to suggest a luteal malities or destructive processes such as trauma phase defect in runners (Ellison & Lager, 1986). or a tumour, may affect GnRH secretion. However, a single progesterone measurement in Several subtypes of hypothalamic amenor- the luteal phase is an inaccurate method for rhoea have been characterized. Isolated gonado- determining the presence or absence of a luteal trophin deficiency refers to a developmental 380 the female athlete triad

defect in the GnRH-producing centres and often most likely have exercise-associated amenor- in the hypothalamic olfactory centres as well. rhoea, other diagnoses must first be considered. Acute weight loss has been associated with Abnormalities of menstrual function can result amenorrhoea. Frisch and McArthur (1974) pro- from dysfunction at all levels of the reproductive posed that a critical percentage of body fat is system. necessary for the initiation and maintenance of reproductive function, although others (Bronson Pituitary causes of amenorrhoea & Manning, 1991) have argued strongly against this theory. Anorexia nervosa is invariably asso- The most common pituitary abnormality that ciated with amenorrhoea, presumably from the can result in amenorrhoea is a prolactin-secreting profound weight loss. Marked weight fluctua- adenoma. Galactorrhoea occurs in only one-third tions and binge–purge behaviour, especially of women who present with these tumours, so in adolescents, have been associated with a its absence does not exclude the diagnosis. higher incidence of amenorrhoea (Johnson & However, a normal prolactin level does exclude Whitaker, 1992). Stressful life events, such as the diagnosis. The measurement of serum pro- divorce or the death of a family member, lactin levels should be part of every evaluation have been associated with a variable period of for amenorrhoea. ‘psychogenic amenorrhoea’. An individual’s perception of such events, her coping skills Ovarian causes of amenorrhoea and perhaps the resiliency of her individual reproductive system may determine whether or Ovarian failure can occur at any time during the not menstrual dysfunction will occur. Exercise- reproductive years, or even before the first men- associated amenorrhoea is generally discussed strual period is expected. The average age of separately from psychogenic or weight-loss ovarian failure, or menopause, is 51, although it amenorrhoea. is normal for a woman to undergo menopause The onset of hypothalamic amenorrhoea may any time after the age of 40. Most women whose be abrupt or gradual. If gradual, a luteal phase ovaries fail after normal menses have been estab- defect and then oligomenorrhoea may precede lished experience vasomotor symptoms or hot amenorrhoea. Often, the recovery from amenor- flashes. A high FSH (>40IU·l–1) is diagnostic. rhoea is much more prolonged than its onset: it Women aged less than 40 with amenorrhoea may be months or years after the causative stress and elevated FSH levels should be referred to a is relieved before normal menses resume. gynaecologist or reproductive endocrinologist However, some athletes have reported resump- for further evaluation. Oestrogen replacement tion of menses within 1 or 2months of an injury therapy or oral contraceptive pills are recom- or period of reduced activity (Warren, 1980). mended for treating vasomotor symptoms and Women with hypothalamic amenorrhoea may preventing osteoporosis. have symptoms of vaginal atrophy but do not Polycystic ovarian disease refers to women usually have vasomotor symptoms. They have who have chronic anovulation associated with normal prolactin levels, normal or low LH and excessive androgen secretion. Most of these FSH levels, low oestrogen levels and no with- women present with irregular or infrequent drawal bleeding after a progestin challenge. menses since menarche, and menstruate after Peripheral blood GnRH determinations do not the administration of progestins. Occasionally, reflect hypothalamic secretion and serve no clini- androgen levels are high enough to result in cal purpose. A pituitary tumour should be con- endometrial atrophy and failure to bleed after a sidered and excluded to confirm the diagnosis progestin challenge. Similarly, athletes who self- of hypothalamic amenorrhoea. Although the administer androgenic hormones may become athlete who presents with amenorrhoea will oligomenorrhoeic or amenorrhoeic. amenorrhoea 381

et al., 1987), although some studies have demon- Outflow tract abnormalities strated that amenorrhoeic athletes have the same Abnormalities of the reproductive tract may percentage body fat as athletes with normal occasionally result in amenorrhoea. Congenital cycles (Sanborn et al., 1987). If her weight has discontinuities of the reproductive tract should been stable, total calorie intake may be less than be considered when an athlete presents with that of eumenorrhoeic athletes and inadequate to primary amenorrhoea and normal sexual meet energy demands (Frisch & McArthur, 1974; development. Marcus et al., 1985); however, Baer and Taper (1992) could not find any differences in energy intake between amenorrhoeic and eumenor- Pathophysiology of exercise- rhoeic runners. Frequently, the percentage of associated amenorrhoea protein in her diet is low. Vegetarian athletes Exercise is generally considered to be one cause have a higher incidence of amenorrhoea (Slavin of hypothalamic amenorrhoea. Whether exer- et al., 1984). cise-associated amenorrhoea is a disorder True eating disorders are common with delib- separate from weight-loss or psychogenic amen- erate attempts to decrease weight (see Chapter orrhoea is controversial (Schwartz et al., 1981). In 25). Eating disorders are especially common in fact, the recognition of the female athlete triad adolescents (Johnson & Whitaker, 1992) and has revived this controversy. The strong associa- highly competitive athletes (Weight & Noakes, tion of eating disorders with amenorrhoea in the 1987). Major affective disorders are occasionally athlete suggests that weight loss or marked fluc- associated with eating disorders in athletes tuations in weight may explain many cases of (Gadpaille et al., 1987). amenorrhoea, and exercise per se may not be a In some studies athletes with secondary amen- significant causative factor. orrhoea have a higher incidence of delayed Numerous studies on exercise-associated menarche or other menstrual abnormalities prior amenorrhoea provide a profile of the athlete at to vigorous training (Shangold & Levine, 1982). highest risk and afford clues to the pathophysiol- In other studies the age of menarche was the ogy. The athlete may present with primary or sec- same in eumenorrhoeic runners as in those with ondary amenorrhoea. Competitive long-distance secondary amenorrhoea (Glass et al., 1987). In runners, gymnasts and professional ballet addition, athletes who began training before dancers seem to be at highest risk (Feicht et al., menarche have been reported to have a higher 1978; Frisch et al., 1980; Glass et al., 1987). incidence of amenorrhoea than those who began Cyclists, rowers and swimmers also seem to be at training after menarche. risk. Walberg and Johnston (1991) found that 30% Exercise intensity is high in amenorrhoeic ath- of recreational weight-lifters and 86% of com- letes and is more likely to have been increased petitive body-builders were amenorrhoeic or rapidly (Bullen et al., 1985). Feicht et al. (1978) oligomenorrhoeic. Other groups of athletes may found a direct correlation between training also be at risk for menstrual dysfunction but mileage in runners and the prevalence of have not been subjected to systematic study. amenorrhoea. In addition, these athletes tend to The athlete with exercise-associated amenor- associate training with a higher level of stress rhoea often has an inadequate nutritional status. compared with eumenorrhoeic athletes Compared with athletes with normal menses, (Schwartz et al., 1981). The return of menses she is likely to weigh less and to have lost more during intervals of rest even without weight gain weight after the onset of vigorous physical activ- or increase in body fat has been reported, sug- ity (Schwartz et al., 1981). Most studies have gesting that low body fat or weight is probably shown that amenorrhoeic athletes have a lower not the single cause of amenorrhoea (Warren, percentage body fat (Schwartz et al., 1981; Glass 1980). 382 the female athlete triad

Assuming that exercise-associated amenor- with ‘overreached’ athletes is responsible for rhoea is a distinct entity, its pathophysiology is exercise-associated amenorrhoea. Athletes who probably complex. Most likely the aetiology is are amenorrhoeic are more likely to take part in heterogeneous, with weight loss, lowered body performance sports and associate training with a fat, emotional stress and physical stress all con- high level of stress. Many studies have shown tributing differently in individual athletes. Not that exercise induces the release of cortisol; all thin, competitive runners become amenor- however, Loucks and Horvath (1984) found that rhoeic, suggesting that there are individual acute exercise in amenorrhoeic runners released variations in the resiliency of the reproductive less stress hormones such as cortisol compared system. Some researchers have even postulated with eumenorrhoeic runners. Other mediators that those thin women who may be genetically at of this stress response have been proposed, risk for delayed maturation or secondary amen- including corticotrophin-releasing hormone and orrhoea may be attracted to sports such as catecholoestrogens. In the latter theory, cate- running or gymnastics. Most theories agree that cholamines released by the adrenal glands in exercise somehow results in hypothalamic dys- response to the stress of exercise are converted function. By some mechanism, hypothalamic to catecholoestrogens, which are thought to be secretion of GnRH is diminished, resulting in inhibitors of GnRH secretion (Russell et al., decreased pulsatile LH and FSH (Cumming et al., 1984). 1985; Veldhuis et al., 1985; Loucks et al., 1989). Another hypothesis states that increased endo- Egg development and ovulation are not appro- genous opioids directly suppress the frequency priately stimulated and the ovaries secrete inade- and amplitude of GnRH pulses, resulting in exer- quate oestrogen and progesterone. Reproductive cise-associated amenorrhoea (Carr et al., 1981). potential is therefore suspended, perhaps to Exercise appears to stimulate endogenous opioid prevent an individual with inadequate energy secretion more than any single stimulus. stores from undergoing the additional stress of However, endogenous opioids apparently sup- pregnancy. press GnRH secretion most effectively in an envi- A currently popular theory is that the athletes ronment of high oestrogen and/or progesterone most likely to become amenorrhoeic consume (Plosker et al., 1990). This does not support a inadequate calories for their apparent levels of prominent role of opioids in the hypo- energy use (Nelson, 1990). The high incidence of oestrogenic amenorrhoeic athlete. Furthermore, eating disorders in exercise-associated amenor- opioid blockade with naloxone does not increase rhoea supports this theory as a major mecha- GnRH release in amenorrhoeic athletes (Samuels nism. Multiple studies have shown daily caloric et al., 1991). Other changes in neurohormones intakes of 5250–9030kJ (1250–2150kcal) in amen- have been noted in various studies (Botticelli et orrhoeic athletes with expected daily caloric al., 1992). expenditures of 9660–12600kJ (2300–3000kcal) (Wilmore et al., 1992). In some way the hypothal- Evaluation of the amus senses the energy drain, output of GnRH is amenorrhoeic athlete reduced and amenorrhoea results. The mecha- nism by which this occurs is unclear, but interest All women need a complete evaluation to deter- has centred on insulin as a mediator of fuel avail- mine the cause of amenorrhoea, no matter how ability. One recently proposed metabolic signal clearly the history seems to indicate exercise as is insulin-like growth factor-binding protein 1, the causative factor. which was reported to be higher in those Olympic athletes and professional ballet dancers Medical interview who were amenorrhoeic (Crist & Hill, 1990; Jenkins et al., 1993). Areview of pubertal milestones is essential when It has been proposed that the stress associated evaluating the athlete with primary amenor- amenorrhoea 383

rhoea. Normal breast and pubic hair develop- An attempt should be made to assess the ment for age not followed by menarche suggests athlete’s association of training and competition a structural abnormality of the reproductive with stress. In addition, inquiries into stresses at organs. Lack of any pubertal development may home, work, school and in social situations occur with hypothalamic dysfunction, pituitary should be made. Her support systems and abnormalities or primary ovarian failure. methods of coping with stress should be noted. A thorough history of previous menstrual pat- A history of athletic injuries should be taken. terns should be elicited from any athlete who The degree of trauma that resulted in a fractured presents with secondary amenorrhoea. It is par- bone should be elicited. A general review of ticularly useful to elicit a detailed history of the systems should be completed with particular athlete’s menses in the year prior to the onset of attention paid to symptoms that might suggest amenorrhoea. If the onset was abrupt, the rela- a cause for amenorrhoea. Vaginal dryness and tionship between stresses such as weight loss dyspareunia suggest oestrogen deficiency. Vaso- and amenorrhoea may be drawn more readily. motor symptoms or hot flushes are specific for A history of sexual activity, contraception and ovarian failure. Symptoms of androgen excess previous pregnancies should be taken. Women include a history of coarse facial, chest or ab- on birth control pills may stop having monthly dominal hair, or acne. Virilization, including withdrawal bleeding and do not need to be eval- temporal balding or deepening of the voice, may uated for amenorrhoea if pregnancy is excluded. occur with exposure to very high levels of andro- If menses do not resume within 6months of stop- gens. A history of galactorrhoea (spontaneous ping oral contraceptives, an evaluation should be secretion of milk) should be elicited. initiated. ‘Postpill amenorrhoea’ is no longer felt The athlete should be questioned carefully to be a valid diagnosis. about the use of medications and other drugs. An attempt should be made to quantify physi- The administration of anabolic steroids may cal activity. The type, frequency and intensity of result in amenorrhoea and signs of androgen exercise needs to be documented, with particular excess. attention paid to changes in activity that may have occurred near the onset of amenorrhoea. It Physical examination is important to note the duration of training, since athletes who have trained hard for many The physical examination of the amenorrhoeic years have been reported to be at greater risk of athlete should include blood pressure, pulse, amenorrhoea (Frisch et al., 1981). height and weight. Skeletal proportions should A careful nutritional history is very important be determined in women with primary amenor- in evaluating the amenorrhoeic athlete. Weight rhoea; arm span is greater than height in gain or loss in the year prior to amenorrhoea eunuchoid individuals. should be recorded. Determination of fluctua- Determination of hair distribution is an impor- tions in weight over shorter intervals of time is tant part of the examination. For the young also important. Recording the athlete’s nutri- woman with primary amenorrhoea, pubic hair tional intake over the past 2–3 days helps the should be staged according to Marshall and clinician quantify the caloric intake. The percent- Tanner (1969). The absence of axillary and pubic age of protein, fat and carbohydrate should also hair in the presence of breast development sug- be estimated. It is especially important to elicit gests complete androgen sensitivity, a cause any history suggestive of an eating disorder, of primary amenorrhoea. Androgen excess or such as self-induced vomiting, use of laxatives or administration is suggested by coarse facial or diet pills, or periods of fasting. If an eating disor- chest hair or hair along the linea alba or above the der is suspected from the initial history, it is inverse triangle. Acne may also suggest andro- useful to arrange a consultation with a nutrition- gen excess. ist and psychologist or psychiatrist. The clinician should search for signs of disor- 384 the female athlete triad

dered eating. Signs of bulimia include parotid roidism as a cause of amenorrhoea. A prolactin swelling (‘chipmunk cheeks’), erosion of tooth level should be determined in order to exclude a enamel and Russell’s sign (finger and nail prolactin-secreting pituitary adenoma. Measure- changes on the first and second digits of the dom- ment of FSH is recommended in all women with inant hand). Some athletes with anorexia have amenorrhoea in order to exclude ovarian failure. yellowing of the skin secondary to hypercaro- Other laboratory tests may be used selectively taemia. in evaluating the amenorrhoeic athlete. A kary- The thyroid should be palpated and the breast otype should be performed on all women examined for Tanner staging and galactorrhoea. under 30 with an elevated FSH and on all women Galactorrhoea should be excluded by gently with an absent uterus. Measurement of serum compressing the nipples during breast examina- oestradiol is rarely helpful in managing the tion. White secretions appear as fat globules amenorrhoeic athlete. The androgenic hormones microscopically. Pigmented abdominal striae testosterone and dehydroepiandrosterone in nulliparous women suggest Cushing’s should be measured in women with signs of syndrome. androgen excess. A careful pelvic examination should be done. Hormonal challenges are sometimes useful for A normal clitoris should measure less than 1cm. indirectly assessing the adequacy of oestrogen The vagina should be moist and greyish pink, production or the normalcy of the genital with a rugose surface. In women with atrophic outflow tract. However, many clinicians feel that vaginitis, the vagina is dry and thin with the need for these tests is limited when a thor- decreased or flattened rugae. Abundant cervical ough history and physical examination have mucus is associated with oestrogen production. been performed along with a selective hormonal Abnormalities of the cervix and vagina, such as a evaluation. In a progestin challenge, medroxy- vaginal septum, may suggest a structural cause progesterone acetate 10mg is administered for primary amenorrhoea. The uterus and orally for 5 days; alternatively, another oral prog- ovaries should be palpated using a bimanual estin or a single intramuscular injection of prog- technique. An apparently normal uterus does not esterone-in-oil 100–200mg may be given. A exclude an early pregnancy. Rarely, ovarian pregnancy test must be confirmed as negative tumours are associated with amenorrhoea. prior to progestin administration. Any vaginal bleeding within 10 days of the injection or the last pill is considered a positive response to a prog- Laboratory evaluation and other testing estin challenge and suggests that the uterine Pregnancy testing should be ordered liberally in lining is sufficiently prepared by endogenous the amenorrhoeic athlete. Studies on the impact oestrogens (equivalent to 40–50pg·ml–1). A of high-intensity training on thyroid hormone negative response is usually consistent with an secretion have yielded conflicting results. Loucks abnormal or obstructed outflow tract, severe et al. (1992) have shown normal thyroid-stimulat- hypo-oestrogenaemia from any cause, preg- ing hormone (TSH) measurements but a slight nancy or, occasionally, an excessive androgen reduction in all circulating thyroid hormones effect on the endometrium. in female athletes with amenorrhoea compared If the FSH level is low and no withdrawal with those having normal menses. However, bleeding occurs after a progestin challenge test, other studies have shown no significant thyroid pituitary imaging should be carefully consid- hormone changes, and it is unlikely that mea- ered. It may not always be necessary when the surement of thyroid hormones helps make the relationship between onset of amenorrhoea and diagnosis of exercise-associated amenorrhoea. A a marked increase in exercise intensity or weight TSH measurement is recommended for identify- loss is obvious. When the prolactin level is ing the occasional athlete with overt hypothy- elevated, the pituitary is best evaluated with amenorrhoea 385

magnetic resonance imaging (MRI). Pituitary Treatment of the amenorrhoeic athlete tumours that cause amenorrhoea but do not secrete prolactin are often large and can usually The treatment guidelines for diagnoses other be excluded using imaging tests that are less than athletic amenorrhoea are beyond the scope expensive than MRI, such as computed of this chapter. If appropriate, referral to a gynae- tomography. cologist or reproductive endocrinologist should Bone mineral density determinations are be initiated. sometimes helpful in the management of the amenorrhoeic athlete. Dual-energy X-ray General principles of treatment absorptiometry (DXA) can accurately measure bone mineral density at several sites in a very Management decisions should depend on the short period of time. It can be used to determine currently recognized short-term and long-term how much bone has been lost when hypo-oestro- consequences of the disorder. The athlete may genic amenorrhoea has been prolonged. The find the absence of menstrual bleeding desirable success of therapy can be determined with serial in the short term and may resist any recommen- measurements. When an amenorrhoeic woman dations for treatment that will result in the return is resisting oestrogen therapy, an abnormal bone of menstrual bleeding. In one study, exercise mineral density may help convince her of the performance, as measured by oxygen uptake, need for therapy. However, there are many limi- minute ventilation, heart rate, respiratory tations of the clinical use of bone density deter- exchange ratio, rating of perceived exertion and minations. Oestrogen therapy is intended to time to fatigue, was identical for amenorrhoeic prevent not treat osteoporosis. A normal bone and eumenorrhoeic runners (DeSouza et al., density may give false reassurance that therapy 1990). Kanaley et al. (1992) showed that energy is not needed. This test has limited use in the ado- substrate utilization is the same in amenorrhoeic lescent age group, where normal values are not and eumenorrhoeic athletes. According to these well established. results, amenorrhoeic athletes do not experience Body fat measurements may be helpful in any disadvantages or advantages in perfor- assessing nutritional status. Body fat can be mance because of their menstrual function. determined with one of the many simple However, musculoskeletal injuries have been methods, such as calipers or underwater weigh- shown to be increased in athletes with menstrual ing. However, body fat determinations in the irregularities (Lloyd et al., 1986), in part because amenorrhoeic patient may be overestimated of osteopenia. As detailed in Chapter 27, bone with underwater weighing if she is osteopenic. mineral content is decreased (Drinkwater et al., DXA can accurately measure body fat and lean 1984) and the incidence of stress fractures body mass, as well as bone density, but its clinical increased in amenorrhoeic athletes as a conse- utility is limited by its higher cost. MRI can quence of long-term oestrogen deprivation. measure overall and regional body fat directly, The long-term consequences of untreated although its use is still considered investigational exercise-associated amenorrhoea are less clear. (Frisch et al., 1993). When there is no other underlying menstrual Other imaging tests are occasionally useful. dysfunction, exercise-associated amenorrhoea Sonography is a good screening test to confirm seems to be reversible. Reproductive function is the presence or absence of a uterus and ovaries. usually re-established with the onset of normal MRI can often clearly identify a reproductive menses. An individual’s peak bone mass is tract abnormality. Bone age determinations nearly attained as early as mid-adolescence and should be made when pubertal development as is fully attained by the end of an individual’s well as menarche are delayed. third decade. It is unknown whether maximal bone mass can be achieved after this time period 386 the female athlete triad

or whether women who are amenorrhoeic in be optimized and hormone replacement recom- mid-adolescence can later ‘make up’ for bone not mended. A dietitian may be useful in evaluating gained during those years. Drinkwater et al. and counselling about dietary intake. Caloric (1986) showed that, in spite of lifestyle changes intake should approximately equal expenditure. that restored normal menses, previously amen- If the woman is sexually active, she should be orrhoeic athletes could not regain bone density to counselled about contraceptive options. The first the level seen in control eumenorrhoeic athletes. ovulation after amenorrhoea often occurs prior Exercise-associated amenorrhoea may diminish to the first episode of menstrual bleeding. A peak bone mass, possibly increasing the risk of decrease in exercise intensity or a 2–3% increase osteoporosis in the postmenopausal years. in weight should be encouraged. Weight as well Rencken et al. (1996) have shown that multiple as menstrual history is important in determining sites of bone loss occur in amenorrhoeic athletes, bone mineral density. including sites with maximum weight-bearing. The clinician should recommend that oestro- There is no evidence that these athletes with gen replacement therapy be initiated soon after a history of amenorrhoea have an increased risk the diagnosis of amenorrhoea is made. Whether of heart disease, despite data showing that the or not the athlete is sexually active, oral contra- associated oestrogen deficiency has an adverse ceptive pills are probably the best source of effect on the lipid profile (Lamon-Fava et al., oestrogen. Hormone replacement therapy, using 1989). a combination of 625µg conjugated oestrogens or Several other considerations are important its equivalent and a progestin, has been shown to when treating the athlete with exercise- prevent bone loss and reduce fractures in post- associated amenorrhoea. Usually, the recre- menopausal women. The same regimens have ational athlete will consider a reduction in exer- been shown not to preserve or improve bone cise intensity if appropriate, but the élite density in premenopausal women with hypo- competitive athlete often will not. The antici- oestrogenic amenorrhoea. In one randomized pated time span of intense exercise may influence trial, this dose of oestrogen plus 10mg medroxy- the clinician’s recommendations concerning progesterone acetate administered for 10days hormone replacement therapy. An athlete plan- every month was equivalent to 1200mg calcium ning to retire from competitive sports within a in its ability to preserve bone density for 2years few months may be treated less aggressively than (Emans et al., 1990). Such regimens should be one who expects many more years of intensive used only when women have significant side- conditioning. An athlete’s sexual activity and effects or contraindications to oral contraceptive current desire for pregnancy clearly influence the pills. treatment plan. Most clinicians manage the ado- Oral contraceptives are usually better accepted lescent athlete differently from the adult, espe- than postmenopausal hormone replacement. cially if adult height has not yet been attained. However, amenorrhoeic women who have been All amenorrhoeic athletes need additional accustomed to the hypo-oestrogenic state often calcium intake and supplementation to reach a have marked symptoms, such as breast tender- target of 1500mg daily is recommended. Vitamin ness and bloating, as they readjust to a normal D intake should be approximately 400–600IU oestrogenic state. The clinician should reassure daily. the athlete that these symptoms are expected and transitory. The athlete should be advised that oral contraceptives do not correct the underlying Recommendations for the adult with problem even though they may result in cyclic exercise-associated amenorrhoea bleeding. Amenorrhoea usually resumes after For the woman who does not desire conception, the drugs are discontinued. For athletes who find nutrition, weight and exercise intensity should it desirable to avoid menses, monophasic oral amenorrhoea 387

contraceptives can sometimes be given without clinicians recommending a more aggressive the usual placebo week. approach than the American Academy of Pedi- Reassessment of the athlete every 3–6 months atrics. In order to prevent premature closure of is recommended in order to follow dietary the epiphyses, linear growth should be com- intake, weight and body fat, exercise intensity pleted before initiation of therapy. Hormone and menstrual pattern. If the amenorrhoeic replacement should be prescribed in the form athlete has refused hormone replacement of oral contraceptives because of their greater therapy, is taking less than an optimal dose of protection against bone loss, even when contra- oestrogen or if abnormal bone density has been ception is not necessary. No studies have shown documented, follow-up bone density examina- that hormone replacement therapy is effective tions are recommended at intervals of 1–2 years. in the standard postmenopausal protocols as protection against osteoporosis. Careful follow-up is very important in this age group, Recommendations for the adolescent with with visits at least every 3–6 months to ensure exercise-associated amenorrhoea that training and dietary modifications are being The appropriate management of exercise- followed. associated amenorrhoea in the adolescent female is more controversial. Delayed menarche or Recommendations for the athlete amenorrhoea after one or more menstrual desiring conception periods may occur in the adolescent athlete. The long-term consequences of untreated amenor- When a female athlete wishes to conceive, the rhoea are very poorly understood in this group. clinician’s approach is very different. The athlete Eating disorders are particularly prevalent in the should be strongly advised to decrease her exer- adolescent athlete with amenorrhoea, and cise intensity in an attempt to allow spontaneous dietary patterns need to be carefully followed. restoration of ovulation and menses. Nutritional Nutritional intake, including calcium supple- intake, including calcium, should be optimized. mentation, should be optimized. A decrease in Women attempting pregnancy should take a exercise intensity or modification of the exercise standard prenatal vitamin with folic acid. programme should be strongly encouraged, A variety of medications are available for the especially for the adolescent athlete anticipating induction of ovulation in this group of women. many years of vigorous athletic participation. However, when an underlying eating disorder is The American Academy of Pediatrics (1989) not treated or a compulsive exercise programme has recommended that amenorrhoeic athletes is not modified, these women have been shown within 3 years of menarche should be counselled to have a higher risk of delivering low-birth- to decrease the intensity of exercise and improve weight babies (Abraham et al., 1990). The clini- nutritional intake. The Academy has not recom- cian must be very certain that nutritional intake mended hormonal therapy for younger girls. is optimized and any disordered eating is However, oestrogen supplementation is sug- addressed prior to prescribing medications to gested, possibly in the form of oral contracep- induce ovulation. tion, for the amenorrhoeic athlete more than 3 When a decrease in exercise intensity does not years past menarche or over the age of 16. In result in restoration of normal menses, and the addition, this treatment is recommended for the clinician is satisfied that nutrition has been opti- younger athlete with a history of stress fractures. mized, induction of ovulation is offered. First, Dietary supplements should be given to ensure a other causes of infertility should be excluded. A calcium intake of at least 1200–1500mg daily. semen analysis should be performed on the The appropriate time to initiate oestrogen sexual partner, and evaluation of tubal function replacement remains controversial, with many with a hysterosalpingogram should be consid- 388 the female athlete triad

ered. If any bleeding occurs after a progestin challenge, clomiphene citrate may be successful; Recommendations for future research 25–50mg clomiphene citrate should be given There is an immediate need for more research for 5 days to initiate oocyte development. If concerning exercise-associated amenorrhoea in clomiphene citrate is unsuccessful, pulsatile order to make appropriate treatment recommen- GnRH administered via an infusion pump dations. results in ovulation in more than 90% of women • The short-term, mid-term and long-term with hypothalamic amenorrhoea (Leyendecker effects of athletic amenorrhoea in adolescence et al., 1980). Alternatively, gonadotrophin prepa- clearly need further research. The possibility rations with both LH and FSH are also very suc- that peak bone density is nearly attained in cessful in achieving ovulation but are associated mid-adolescence suggests that more aggressive with a higher chance of multiple pregnancies treatment of young women with athletic amen- than the GnRH pump. orrhoea may be indicated. Current studies are small and cross-sectional. Larger, longitudinal studies are clearly needed. Recommendations for the athlete with • The role of nutritional intervention and behav- oligomenorrhoea or luteal phase defect ioural modification in reversing amenorrhoea It remains speculative whether athletes with needs to be evaluated. Whether or not these other degrees of menstrual dysfunction need to interventions can act quickly enough to restore be treated. The female athlete with infrequent reproductive function before irreversible bone menses may be hypo-oestrogenic and at risk for loss occurs needs to be established. bone loss. Certainly, a careful medical interview • The long-term consequences of other types of should be taken. Early modifications of diet or menstrual dysfunction, such as oligomenorrhoea training programme may reverse these changes and luteal phase defect, need to be studied or prevent progression to amenorrhoea. Birth further in order to allow appropriate recommen- control pills should be recommended liberally dations to be given to these athletes. for contraception, dysmenorrhoea and other • The mechanism by which the hypothalamus is gynaecological disorders since they may also signalled to decrease GnRH secretion needs to be provide some protection against bone loss. It is established. impractical to screen athletes for a luteal phase defect in any clinical practice. Recommendations for any treatment of this group of patients must References await further studies in which the diagnosis is Abraham, S., Mira, M. & Llewellyn-Jones, D. (1990) made rigorously and long-term follow-up is Should ovulation be induced in women recovering available. from an eating disorder or who are compulsive exer- Prevention is the best approach to any disor- cisers? Fertility and Sterility 53, 566–568. American Academy of Pediatrics (1989) Amenorrhea in der. Preparticipation evaluation for female com- adolescent athletes. Pediatrics 84, 394–395. petitive athletes should include an assessment of Baer, J. & Taper, L. (1992) Amenorrheic and eumenor- menstrual pattern and diet. Athletes, coaches, rheic adolescent runners: dietary intake and exercise athletic trainers and parents should be coun- training status. Journal of the American Dietetic Associ- selled about the possible consequences of over- ation 92, 89–91. Botticelli, G., Bacchi Modena, A., Bresciani, D. et al. training and poor nutritional habits. They should (1992) Effect of naltrexone treatment on the treadmill be educated to recognize and discourage exercise-induced hormone release in amenorrheic binge–purge behaviour and other disordered women. Journal of Endocrinological Investigation 15, eating. Athletes should learn to develop healthy 839–847. attitudes towards nutrition and weight while Bronson, F. & Manning, J. (1991) The energetic regula- tion of ovulation: a realistic role for body fat. Biology realizing their athletic potential. of Reproduction 44, 945–950. amenorrhoea 389

Bullen, B., Skrinar, G., Beitins, I., Von Mering, G., Turn- Journal of Clinical Endocrinology and Metabolism 77, bull, B. & McArthur, J. (1985) Induction of menstrual 471–477. disorders by strenuous exercise in untrained women. Gadpaille, W., Sanborn, C. & Wagner, W. (1987) Athletic New England Journal of Medicine 312, 1349–1353. amenorrhea, major affective disorders, and eating Carr, D., Bullen, B., Skrinar, G. et al. (1981) Physical con- disorders. American Journal of Psychiatry 144, 939–942. ditioning facilitates the exercise-induced secretion of Glass, A., Deuster, P., Kyle, S., Yahiro, J., Vigersky, R. & beta-endorphin and beta-lipotropin in women. New Schoomaker, E. (1987) Amenorrhea in Olympic England Journal of Medicine 305, 560–563. marathon runners. Fertility and Sterility 48, 740–745. Crist, D. & Hill, J. (1990) Diet and insulinlike growth Jenkins, P., Ibanez-Santos, X., Holly, J. et al. (1993) factor I in relation to body composition in women IGFBP-1: a metabolic signal associated with exercise- with exercise-induced hypothalamic amenorrhea. induced amenorrhoea. Neuroendocrinology 57, Journal of the American College of Nutrition 9, 200– 600–604. 204. Johnson, J. & Whitaker, A. (1992) Adolescent smoking, Cumming, D., Vickovic, M., Wall, S. & Fluker, M. (1985) weight changes, binge–purge behavior: associations Defects in pulsatile LH release in normally menstru- with secondary amenorrhea. American Journal of ating runners. Journal of Clinical Endocrinology and Public Health 82, 47–54. Metabolism 60, 810–812. Kanaley, J., Boileau, A., Bahr, A., Misner, J. & Nelson, R. DeSouza, M., Maguire, M., Rubin, K. & Maresh, C. (1992) Substrate oxidation and GH responses to exer- (1990) Effects of menstrual phase and amenorrhea on cise are independent of menstrual phase and status. exercise performance in runners. Medicine and Science Medicine and Science in Sports and Exercise 24, 873–880. in Sports and Exercise 22, 575–580. Lamon-Fava, S., Fisher, E. & Nelson, M. (1989) Effect Drinkwater, B., Nilson, K., Chesnut, C., Bremner, W., of exercise and menstrual cycle status on plasma Shainholtz, S. & Southworth, M. (1984) Bone mineral lipids, low density lipoprotein particle size, and content of amenorrheic and eumenorrheic athletes. apolipoproteins. Journal of Clinical Endocrinology and New England Journal of Medicine 311, 277–281. Metabolism 68, 17–21. Drinkwater, B., Nilson, K., Ott, S. & Chesnut, C. (1986) Leyendecker, G., Wildt, L. & Hansmann, M. (1980) Bone mineral density after resumption of menses in Pregnancies following chronic intermittent (pul- amenorrheic women. Journal of the American Medical satile) administration of GnRH by means of a Association 256, 380–382. portable pump (Zyklomat): a new approach in the Ellison, P. & Lager, C. (1986) Moderate recreational treatment of infertility in hypothalamic amenorrhea. running is associated with lowered salivary pro- Journal of Clinical Endocrinology and Metabolism 51, gesterone profiles in women. American Journal of 1214–1216. Obstetrics and Gynecology 154, 1000–1003. Liu, J. (1990) Hypothalamic amenorrhea: clinical per- Emans, S., Grace, E., Hoffer, F., Gundberg, C., Ravnikar, spectives, pathophysiology, and management. V. & Woods, E. (1990) Estrogen deficiency in adoles- American Journal of Obstetrics and Gynecology 163, cent young adults: impact on bone mineral content 1732–1736. and effects of estrogen replacement therapy. Obstet- Lloyd, T., Triantafyllou, S., Baker, E. et al. (1986) Women rics and Gynecology 76, 585–592. athletes with menstrual irregularity have increased Feicht, C., Johnson, T., Martin, B., Sparkes, K. & musculoskeletal injuries. Medicine and Science in Wagner, W. (1978) Secondary amenorrhoea in ath- Sports and Exercise 18, 374–379. letes. Lancet ii, 1145–1146. Loucks, A. & Horvath, S. (1984) Exercise-induced stress Frisch, R. & McArthur, J. (1974) Menstrual cycles: responses of amenorrheic and eumenorrheic fatness as a determinant of minimum weight for runners. Journal of Clinical Endocrinology and Metabo- height necessary for their maintenance or onset. lism 59, 1109–1120. Science 185, 949–951. Loucks, A., Mortola, J., Girton, L. & Yen, S. (1989) Frisch, R., Wyshak, G. & Vincent, L. (1980) Delayed Alterations in the hypothalamic–pituitary–ovarian menarche and amenorrhea in ballet dancers. New and hypothalamic–pituitary–adrenal axes in athletic England Journal of Medicine 303, 17–19. women. Journal of Clinical Endocrinology and Metabo- Frisch, R., Gotz-Welbergen, A. & McArthur, J. (1981) lism 68, 402–411. Delayed menarche and amenorrhea of college ath- Loucks, A., Laughlin, G., Mortola, J., Girton, L., Nelson, letes in relation to age of onset of training. Journal of J. & Yen, S. (1992) Hypothalamic–pituitary–thyroidal the American Medical Association 246, 1559–1563. function in eumenorrheic and amenorrheic athletes. Frisch, R., Snow, R., Johnson, L., Gerard, B., Barbieri, R. Journal of Clinical Endocrinology and Metabolism 75, & Rosen, B. (1993) Magnetic resonance imaging of 514–518. overall and regional body fat, estrogen metabolism, Malina, R., Spirduso, W., Tate, C. & Baylor, A. (1978) and ovulation of athletes compared to controls. Age at menarche and selected menstrual characteris- 390 the female athlete triad

tics in athletes at different competitive levels and in Evaluation and management of menstrual dysfunc- different sports. Medicine and Science in Sports and tion in athletes. Journal of the American Medical Associ- Exercise 10, 218–222. ation 263, 1665–1669. Marcus, R., Cann, C., Madvig, P. et al. (1985) Menstrual Slavin, J., Lutter, J. & Cushman, S. (1984) Amenorrhoea function and bone mass in elite women distance in vegetarian athletes (letter). Lancet i, 474. runners. Annals of Internal Medicine 102, 158–163. Speroff, L., Glass, R. & Kase, N. (1994) Clinical Gyneco- Marshall, W.A. & Tanner, J.M. (1969) Variations in logic Endocrinology and Infertility, 5th edn. Williams & pattern of pubertal changes in girls. Archives of Wilkins, Baltimore. Disease in Childhood 44, 291–296. Veldhuis, J., Evans, W., Demers, L., Thorner, M., Wakat, Nelson, M., Fisher, E., Catsos, P. et al. (1990) Diet and D. & Rogol, A. (1985) Altered neuroendocrine regula- bone status in amenorrheic runners. American Journal tion of gonadotropin secretion in women distance of Clinical Nutrition 43, 910–916. runners. Journal of Clinical Endocrinology and Metabo- Plosker, S., Marshall, L., Martin, M. & Jaffe, R. (1990) lism 61, 557–563. Opioid, catecholamine, and steroid interactions in Walberg, J. & Johnston, C. (1991) Menstrual function prolactin and gonadotropin regulation. Obstetrical and eating behavior in female recreational and Gynecological Survey 45, 441–453. weightlifters and competitive body builders. Medi- Rencken, M., Chesnut, C. & Drinkwater, B. (1996) Bone cine and Science in Sports and Exercise 23, 30–36. density at multiple skeletal sites in amenorrheic ath- Warren, M. (1980) The effect of exercise on pubertal letes. Journal of the American Medical Association 276, progression and reproductive function in girls. 238–240. Journal of Clinical Endocrinology and Metabolism 51, Russell, J., Mitchell, D. & Musey, P. (1984) The role of b- 1150–1156. endorphins and catechol estrogens on the hypothala- Warren, M. (1992) Amenorrhea in endurance runners. mic–pituitary axis in female athletes. Fertility and Journal of Clinical Endocrinology and Metabolism 75, Sterility 42, 690–695. 1393–1397. Samuels, M., Sanborn, C., Hofeldt, F. & Robbins, R. Warren, M., Brooks-Gunn, J., Hamilton, L., Warren, L. (1991) The role of endogenous opiates in athletic & Hamilton, W. (1986) Scoliosis and fractures in amenorrhea. Fertility and Sterility 55, 507–512. young ballet dancers: relation to delayed menarche Sanborn, C., Albrecht, B. & Wagner, W. (1987) Athletic and secondary amenorrhea. New England Journal of amenorrhea: lack of association with body fat. Medi- Medicine 314, 1348–1353. cine and Science in Sports and Exercise 19, 207–211. Weight, L. & Noakes, T. (1987) Is running an analog of Schwartz, B., Cumming, D., Riordan, E., Selye, M., Yen, anorexia? A survey of the incidence of eating disor- S. & Rebar, R. (1981) Exercise-associated amenor- ders in female distance runners. Medicine and Science rhea: a distinct entity? American Journal of Obstetrics in Sports and Exercise 18, 213–217. and Gynecology 141, 662–670. Wilmore, J., Wambsgans, K., Brenner, C., Paijmans, I., Shangold, M. & Levine, H. (1982) The effect of Volpe, J. & Wilmore, K. (1992) Is there energy conser- marathon training upon menstrual function. Ameri- vation in amenorrheic compared with eumenorrheic can Journal of Obstetrics and Gynecology 143, 862–869. distance runners? Journal of Applied Physiology 72, Shangold, M., Freeman, R., Thysen, B. & Gatz, M. 15–22. (1979) The relationship between long-distance Yeager, K., Agostini, R., Nattiv, A. & Drinkwater, B. running, plasma progesterone, and luteal phase (1993) The female athlete triad: disordered eating, length. Fertility and Sterility 31, 130–133. amenorrhea, osteoporosis. Medicine and Science in Shangold, M., Rebar, R., Wentz, A. & Schiff, I. (1990) Sports and Exercise 25, 775–777. Chapter 27

Osteoporosis

JANE GIBSON

Introduction a reduction in viable osteocytes to the levels seen in elderly women has been noted in The relationship between exercise and bone the hypo-oestrogenic state associated with mineral density (BMD) is marked in athletes gonadotrophin-releasing hormone (GnRH) (Heinrich et al., 1990; Risser et al., 1990; Wolman et agonist treatment for endometriosis in young al., 1991; Slemenda & Johnston, 1993) and at one women (Tomkinson et al., 1997). These non- time it was assumed that the more intense the viable osteocytes appear to have undergone exercise, the greater the skeletal response. apoptosis, although whether this is a direct or However, during the last 10 years it has become indirect effect of oestrogen suppression is not clear that in some young women intensive ath- clear. The reduction in the number of live osteo- leticism is associated with amenorrhoea (see cytes may increase bone fragility or impair the Chapter 26) and low BMD. In some regions of the ability of bone to adapt to mechanical loading. In skeleton, for instance the vertebral bodies, BMD paediatric calvarial bone, there appears to be may be as much as 25% lower in amenorrhoeic preferential bone remodelling in areas high in women compared with their eumenorrhoeic apoptotic osteocytes, possibly due to the release peers. In the short term, musculoskeletal injuries of local signals during apoptosis (Noble et al., are more common and concern has arisen that in 1997), and this is a putative mechanism by which the long term there may be a risk of clinical osteo- bone fragility is increased in the hypo- porosis and fracture. oestrogenic state. There is less direct evidence that low proges- Effects of menstrual irregularity on terone levels can lead to bone loss, although it is bone metabolism known that progesterone can directly stimulate osteoblast proliferation in vitro (Tremollieres et In the normal hormonal milieu, bone resorp- al., 1992). It has been suggested that even asymp- tion and formation are ‘coupled’ so that appro- tomatic disturbances of ovulation such as anovu- priate remodelling can occur as required. In the lation or short luteal phase, which are associated presence of low levels of oestrogen and proges- with low progesterone levels, can lead to bone terone bone resorption increases and, since bone mineral losses of up to 4% per year (Prior et al., formation is insufficiently augmented to com- 1990), although this finding has not been con- pensate, there is a net loss of bone mineral. Not firmed by De Souza et al. (1997). In this recent only is the rate of resorption altered when oestro- study, menstrual function was assessed by daily gen levels are low, but the ratio of live to dead measurement of urinary sex steroid hormones cells may be reduced and this may influence the and their metabolites over three consecutive integrity of bone in other ways. For instance, menstrual cycles. Urinary markers of bone 391 392 the female athlete triad

turnover such as collagen cross-links and Menstrual irregularity and bone osteocalcin were measured weekly; bone density density in athletes of total body, lumbar spine and proximal femur was assessed using dual-energy X-ray absorp- Bone density of non-weight-bearing bones tiometry (DXA). Comparison was made between ovulatory sedentary women, ovulatory exercis- During the last decade several studies have ing women and exercising women with luteal examined the effect of menstrual irregularity on phase defects. There were no statistical dif- BMD in athletes. Studies on amenorrhoeic ferences between the groups at any site. runners compared with either eumenorrhoeic Additionally, there were no differences in levels runners or sedentary controls have been consis- of urinary markers reflecting bone turnover. As tent in showing lumbar BMD to be 10–20% lower De Souza et al. (1997) suggest, the conflict in find- in those with amenorrhoea (Cann et al., 1984; ings may be due to flaws in the determination Drinkwater et al., 1984; Lindberg et al., 1984; of the ovulatory state made in the study by Prior Marcus et al., 1985; Nelson et al., 1986; Wolman et et al. (1990). al., 1990). In the largest study of its kind, Many female athletes have more severe dis- Drinkwater et al. (1990) demonstrated a linear ruption of their menstrual cycle, sometimes relationship between vertebral BMD and lifetime resulting in complete amenorrhoea, and this menstrual history in 97 active women. Those has now been recognized to have profound who had a long history of amenorrhoea/ effects on bone mineral content. Trabecular oligomenorrhoea had a mean BMD 17% lower bone has a higher rate of turnover than cortical than those who had always had regular periods bone and losses in bone mineral are first (Fig. 27.1). The linear relationship between observed in skeletal areas with a high percentage degree of menstrual dysfunction and vertebral of trabecular bone, such as the vertebral bodies, bone density has also been shown in British distal radius, neck of femur and neck of humerus. Few athletes are willing to undergo bone

) 1.3 biopsy and so the changes in bone occurring at –2 cm the microscopic level in amenorrhoeic athletes . are little studied. However, Warren et al. (1990) 1.2 performed a bone biopsy on a 20-year-old dancer with longstanding anorexia and primary 1.1 amenorrhoea who suffered collapse of a femoral head. She was known to have lumbar BMD 1.0 that was more than two standard deviations below the normal mean for her age. On Bone mineral density (g 0.9 microscopy, femoral cortical bone was markedly 0 1 23 45 6 7 8 9 Menstrual groups reduced in thickness and increased in porosity. At the trabecular level, the resorption sur- Fig. 27.1 Regression of vertebral (L1–L4) bone density faces were greatly increased, although the on menstrual history for 97 active women. The mean ± formation surface was normal. It is unknown SE is shown for each of the following groups: 1, R (n = whether such changes occur in all amenor- 21); 2, R/O (n = 7); 3, O/R (n = 2); 4, O/O (n = 5); 5, R/A rhoeic athletes, at what rate they might occur, (n = 22); 6, A/R (n = 9); 7, O/A (n = 10); 8, A/O (n = 10); 9, A/A (n = 11). A, amenorrhoeic; O, oligomenorrhoeic; R, or whether they are reversible with resump- regular menstruation; the terminology (e.g. A/A) tion of menses or treatment with appropriate describes current status/history. (From Drinkwater hormones. et al., 1990 with permission.) osteoporosis 393

national and international standard endurance or controls and it is possible that the greater mus- runners. Wilson et al. (1994a) analysed the BMD cular stresses applied to the spine in gymnasts of 50 runners, of whom 24 were amenorrhoeic and dancers help to offset any reduction in bone (zero to three cycles per year), 9 oligomenor- mineral due to menstrual dysfunction. Certainly rhoeic (four to nine menses per year) and 17 in rowers this seems to be the case. Wolman et al. eumenorrhoeic. Bone density of the lumbar (1990) found that, in a group of élite athletes, spine was 15.6% lower in amenorrhoeic and rowers with prolonged amenorrhoea had higher 10.1% lower in oligomenorrhoeic runners com- lumbar bone density than non-rowers, and pared with eumenorrhoeic peers. rowers with or without menstrual dysfunction In most studies no relationship has been found had significantly greater back strength than between levels of oestradiol and lumbar BMD, amenorrhoeic runners. although Nelson et al. (1986) did demonstrate a positive correlation between these two measure- Bone density of weight-bearing bones ments in small groups of amenorrhoeic and eumenorrhoeic runners. They measured oestra- It has been proposed that muscular stresses and diol levels in eumenorrhoeic runners between ground reaction forces in the weight-bearing days 5 and 7 of the menstrual cycle (the early fol- bones may offset any effect of hypo-oestroge- licular phase), whereas other workers have not naemia and indeed it has been shown that amen- specified menstrual phase. This difference in pro- orrhoeic athletes have higher BMD than tocol may explain the contrast in findings. sedentary amenorrhoeic anorexic women Much of the work on BMD in athletes has con- (Young et al., 1994). Until recently there have centrated on distance runners. This group of ath- been conflicting reports on the effect of amenor- letes have a fairly defined type of training that is rhoea on weight-bearing bones in athletes com- usually at least 90% running, an activity which pared with eumenorrhoeic athletes and places little direct muscular stress on the verte- sedentary controls. Reduction in femoral shaft bral bodies. The stimulus for bone remodelling BMD in amenorrhoeic active women has been and subsequent increases in bone density in the noted by one study (Drinkwater et al., 1990), spine is probably less than in other sports and it although Wolman et al. (1991) found no differ- is therefore unsurprising that BMD is low at this ence in femoral shaft BMD between amenor- site in amenorrhoeic runners. Additionally, the rhoeic and eumenorrhoeic runners, rowers and vertebral bodies have a high percentage of tra- dancers. Femoral neck, calcaneal and total leg becular bone and might be expected to show BMD have also been shown to be well main- changes in bone mineral early in low-oestrogen tained despite amenorrhoea (Drinkwater et al., states. The effect of hypo-oestrogenism may not 1990; Harber et al., 1991; Myerson et al., 1992; be as marked in other athletes as in runners. Snead et al., 1992; Young et al., 1994). Young et al. (1994) found a small but significant One of the problems encountered in many reduction of only 3.5% in the lumbar spine of studies is the scarcity of athletes who are truly ballet dancers, with slightly greater reductions of amenorrhoeic, defined by most authors as fewer 5–6% in ribs, arms and skull compared with non- than three menstrual cycles in 12months or no dancers with regular menstrual cycles. Robinson menstrual cycles in the last 6months. Therefore et al. (1995) showed that runners had lumbar some authors have combined athletes with BMD values 12% lower than controls, whereas oligomenorrhoea and amenorrhoea in order to values in gymnasts were 5.5% higher than con- achieve reasonable numbers. If trabecular bone trols despite a similar prevalence of oligomenor- in the femur is affected by hypo-oestrogenaemia rhoea in the two athletic groups. The gymnasts in a similar manner to the spine, then combining were much stronger generally than the runners different menstrual groups will obscure any 394 the female athlete triad

linear relationship between degree of menstrual runners with no more than two menstrual cycles irregularity and BMD. For instance, Robinson et in the previous 12 months) was performed by al. (1995) found lower femoral neck BMD in a Rencken et al. (1996). Bone density of lumbar group of 20 runners, of whom 30% were spine, proximal femur (neck, trochanteric regions oligomenorrhoeic, compared with eumenor- and Ward’s triangle), femoral shaft, tibia and rhoeic sedentary controls. When analysed fibula was measured by DXA, with significantly according to more detailed menstrual history, lower BMD noted in amenorrhoeic athletes com- there was a 17% difference between those pared with eumenorrhoeic peers at all sites runners who had always had regular menstrual except the fibula (Fig. 27.2), refuting findings cycles and those who had had prolonged amen- from their earlier study (Drinkwater et al., 1990) orrhoea, a percentage difference very similar to when BMD was assessed by the less precise dual that found in the spine by other studies; unfortu- photon absorptiometry (DPA). nately, numbers in each group were too small for In the study of runners by Wilson et al. (1994b), more elaborate analysis. BMD was 16.5% and 19.5% lower in the femoral However, there is further support for low BMD neck and trochanteric regions, respectively, in the in the femur of amenorrhoeic athletes. Despite amenorrhoeic group compared with the eumen- small numbers, Myburgh et al. (1993) found sig- orrhoeic group. Results also suggested a linear nificantly lower bone density in all areas of the relationship between menstrual group and bone proximal femur as well as the femoral mid-shaft density, similar to that seen in the spine, with in 12 amenorrhoeic athletes compared with nine BMD in the oligomenorrhoeic athletes lying eumenorrhoeic peers. A study with relatively midway between that of the amenorrhoeic and large numbers of amenorrhoeic athletes (29 eumenorrhoeic groups (Fig. 27.3).

1.9 * 1.7 * ) 2 – 1.5 cm .

1.3 * 1.1 * * 0.9 * * Bone mineral density (g 0.7

0.5 Lumbar Femoral Trochanter Ward Inter- Femoral Tibia Fibula neck triangle trochanteric shaft region

Fig. 27.2 Bone mineral density of the lumbar spine and lower limb in amenorrhoeic athletes ( ; n = 29) and eumen- orrhoeic athletes (; n = 20). Athletes were required to exercise for 45 min four times per week for enrolment in the study. The majority were runners and average age was 26.3 years. *, P < 0.01; error bars indicate SE. (From Rencken et al., 1996 with permission.) osteoporosis 395

1.5 **

1.0

0.5

0.0 Z-score (SD) –0.5 ** –1.0 * * –1.5 *** Femur neck Trochanteric region Lumbar spine

Fig. 27.3 Bone mineral density (BMD) of the proximal femur in national and international standard middle- and long-distance runners, with an average age of 26.5 years. The average training distance per week was 78 km. BMD was compared with the age-matched European reference range (expressed as the Z-score, i.e. number of standard deviations above or below the age-matched mean). In all regions measured, the BMD was lower in the groups with menstrual irregularity: amenorrhoeic vs. eumenorrhoeic, P < 0.001; oligomenorrhoeic vs. eumenorrhoeic, P < 0.01. , amenorrhoeic (n = 24); , oligomenorrhoeic (n = 9); , eumenorrhoeic (n = 17). Asterisks show comparison of mean Z-score with the European reference range: *, P < 0.05; **, P < 0.005; †, P < 0.001. (Based on data from Wilson et al., 1994a.)

future risks of osteoporosis is unknown, Effect of body weight on bone density in although it seems unlikely given that BMD per se amenorrhoeic athletes is the best predictor of future fracture. Controversy has arisen about whether bone density should be expressed according to body Consequences of low bone density weight. Most population studies have shown in athletes that body mass is a significant independent pre- dictor of bone density: those who are lightest A number of studies have examined the conse- have the lowest bone density. This is of particular quences of low bone density in athletes (Table relevance in athletes, who in general are lighter 27.1). than their sedentary peers. Amenorrhoeic ath- letes tend to be even lighter. Some authors have Stress fractures therefore analysed their data after adjustment for body mass. Myerson et al. (1992), Young et al. Lloyd et al. (1986) reviewed the medical records (1994) and Robinson et al. (1995) all found that of 207 collegiate athletes and found fractures previously noted differences between amenor- confirmed by X-ray (type of fracture not defined) rhoeic and eumenorrhoeic athletes were elimi- in 9% of regularly menstruating women and 24% nated when this method was used. Only of women with irregular or absent menses. In Drinkwater et al. (1990) found a continuing trend dancers, two studies reported a relationship towards reduced lumbar spine BMD even when between bone injuries or stress fractures and adjusted for weight. Whether this is relevant to amenorrhoea (Warren et al., 1986; Benson et al., 396 the female athlete triad

Table 27.1 Musculoskeletal consequences of athletic amenorrhoea

Increased frequency and duration of musculoskeletal injury Increased risk of stress fractures Low bone mineral density Increased risk of fractures, particularly osteoporotic fractures Risk of early osteoporosis after the menopause

1990) and a survey of 240 female athletes showed a higher incidence of stress fractures in those with fewer than five menses per year (49%) com- pared with those having 10 or more menses per year (29%) (Barrow & Saha, 1988). Lindberg et al. (1984) found that 49% of the amenorrhoeic runners in their study had experienced stress fractures in the previous year, whereas none of the eumenorrhoeic runners had suffered such injuries. However, two reports found no signifi- cant relationship between menstrual history and stress fractures, although both contained small numbers of subjects and so lacked statistical Fig. 27.4 99mTc-methylene diphosphonate bone scan of power (Frusztajer et al., 1990; Grimston et al., the femurs in a female 10 000 m runner. This athlete had 1990). been amenorrhoeic for more than 10 years and had a Stress fractures of the femur seem to be par- bone mineral density of the hip and spine more than ticularly common in amenorrhoeic runners and two standard deviations below that expected for her age. She complained of ‘pulled hamstrings’ unrespon- are sometimes bilateral (Fig. 27.4). They present sive to physiotherapy. The bone scan reveals bilateral as a muscular type of pain that is poorly localized areas of increased uptake reflecting stress fractures. and, because of the inaccessibility of the femur to direct palpation, the diagnosis can be missed. These fractures may be treated for many weeks as a soft tissue injury before being referred for irregularity and lower oral contraceptive use. further investigation. A high index of suspicion However, Carbon et al. (1990) assessed élite of stress fractures in amenorrhoeic women female runners with and without stress fractures is important because delay in diagnosis can and found no difference in the femoral BMD result in full-thickness fracture (Leinberry et al., between the two groups. Others have also 1992). described a lack of association between tibial It remains unclear whether the increased rate BMD and stress fractures in military recruits of stress fractures in amenorrhoeic athletes is (Milgrom et al., 1989). It is likely that the associa- related to low BMD. Myburgh et al. (1990) found tion between amenorrhoea and stress fractures is that in athletes with similar training habits those due to impaired microfracture healing in the with stress fractures were more likely to have absence of adequate levels of oestrogen rather lower femoral neck and spinal bone density, than decreased mechanical integrity. In hypo- lower dietary calcium intake, current menstrual oestrogenic states, such as after the menopause osteoporosis 397

or during amenorrhoea, the increase in pro- most notably in anorexia nervosa (Rigotti et al., grammed cell death (apoptosis) of osteocytes 1991; Laban et al., 1995; Maugars et al., 1996), and (Tomkinson et al., 1997) may affect the ability of it is likely that the incidence of fracture in athletes bone to transduce mechanical forces and to initi- is much higher than appears from the published ate the repair of microscopic cracks, which occur literature. even under normal circumstances in spinal tra- beculae and the femoral head and neck from at case history least middle age onwards. If oestrogen suppres- sion during athletic amenorrhoea leads to osteo- A 30-year-old marathon runner (with a personal cyte apoptosis, there may be a consequent best time of 2 hours 53 min) had been training disruption of the signalling pathways responsi- seriously for 8 years (up to 96 km·week–1) and ble for microfracture repair, leading to crack developed amenorrhoea within 6 months of enlargement and the development of a clinical starting this schedule. Prior to this time she had stress fracture. been eumenorrhoeic since her menarche at age 13. After 6 years of amenorrhoea, she was 164cm tall, weighed 47kg and had a body mass index of Musculoskeletal injuries 17.47kg·m–2 (expected for age, 22.9kg·m–2). Per- Stress fractures may not be the only injury more centage body fat was 15.2%. Eating habits were prevalent in amenorrhoeic athletes. Participants assessed by questionnaires, which revealed sub- in a 10-km race who responded to a question- clinical anorexia nervosa and the presence of naire were more likely to have taken time off mildly disordered compulsive eating, binge- training due to any form of musculoskeletal eating and a preoccupation with being thinner. injury if they had irregular menses (Lloyd et al., Calcium intake, derived from a dietary calcium 1986). Benson et al. (1990) studied 49 female questionnaire, was 587mg daily. dancers and found that those with abnormal She developed a stress fracture of the left pubic menses had more ‘bone injuries’ (mean 15.0) than ramus and was unable to train for 8 months. normally menstruating dancers (mean 5.0) (P< During this time there was a significant weight 0.05). Additionally, dancers with a low body gain of 11kg, an increase in body fat (15.9% to mass index (<19.0kg·m–2) had a greater duration 23%) and menstruation returned. She then of low-grade musculoskeletal injury (mean 24.1 restarted training at a lower level (40km·week–1) days) than those with a higher body mass index but within 2months developed right thigh pain (mean 11.6 days) (P<0.05). that isotope bone scanning confirmed to be a More severe bone injuries also occur in amen- stress fracture of the shaft of the right femur. A orrhoeic athletes. In dancers, scoliosis was found month later she slipped at the side of a swim- to be more common in those with delayed ming pool, fell on to her left side and sustained a menarche and in whom anorectic behaviour was fracture of the neck of the left humerus. Bone more prevalent (Warren et al., 1986). Warren et al. densities at this time (measured by DXA) of (1990) later described a 20-year-old ballet dancer lumbar spine and femoral neck were 2.0 and 1.8 with longstanding anorexia nervosa, primary standard deviations below the age-matched amenorrhoea and low BMD who suffered mean respectively. femoral head collapse. In 1994, Wilson and She was treated with rest in a sling and made Wolman reported an osteoporotic fracture in the an uncomplicated recovery. Since then she has neck of the humerus of a 30-year-old marathon returned to marathon training, is running up to runner with a history of anorexia and low bone 80 km·week–1 and has once more ceased to men- density (see Case history below). Stress fractures struate. Her bone mineral density has continued and osteoporotic fractures are reported in other to decline by 1% to 7% per year since menstrua- young women with long-term amenorrhoea, tion stopped again. 398 the female athlete triad

those who had always been regular menstruators Long-term consequences (R/R), those who had regular cycles interspersed Amenorrhoeic athletes may be at risk of prema- with oligomenorrhoea (R/O/A) and those who ture osteoporosis and fractures but as yet there were oligomenorrhoeic and who had never had are few long-term data on these women. As bone regular cycles (O/A). Of the 11 women in the mass peaks at 20–30 years of age, athletes should O/A group, eight regained regular menstruation have attained their peak BMD during their most within 1year of the previous study, one regained athletic years. Eumenorrhoeic athletes have menstruation a year later and one took the oral higher peak BMD than the mean for the popula- contraceptive pill after a further 7 years of amen- tion. However, if amenorrhoeic athletes fail to orrhoea. Despite the return of menstruation, attain their maximum potential peak BMD at this bone density of the lumbar spine remained age, it is unknown whether they are able to ‘catch at 84.4% of the R/R value compared with up’ later in life. If the lifetime risk of hip fracture 84.8% at the time of the first study. Those with is related to peak bone mass, eumenorrhoeic ath- intermittent oligomenorrhoea remained at an letes are likely to be at reduced risk of osteo- intermediate position of 94.7% of the R/R mean. porotic fracture whereas amenorrhoeic athletes These results strongly suggest that early inter- may always be at a relative disadvantage. vention is necessary to prevent irreversible bone Whether BMD recovers when menstruation loss at this age, although more studies with returns in these athletes remains unclear. greater numbers of subjects are needed to Drinkwater et al. (1986) followed nine amenor- confirm these findings. rhoeic athletes over a 15.5-month period; seven Some data are also available from women with of the women had regained menses and two had anorexia and amenorrhoea. Rigotti et al. (1991) remained amenorrhoeic. Lumbar BMD increased followed cortical bone density of the radius in by 6.3% in the previously amenorrhoeic women non-athletic patients with anorexia nervosa over whilst decreasing a further 0.3% in those who a median of 25 months. Of the 27 women only six had remained amenorrhoeic. Small increases in regained menses, although most gained some BMD were also seen in the radius. These results weight, took calcium supplements and exercised are very similar to those of Lindberg et al. (1987) regularly. There were no significant changes in who retested seven amenorrhoeic runners at 15 BMD in women who regained menses, received months. Four had recovered menses and showed oestrogen therapy or who gained weight to more an improvement of 6.5% in lumbar BMD, while than 80% of their ideal weight. In addition there the other three remained amenorrhoeic and was a high incidence of vertebral compression showed no improvement in BMD. J.H. Wilson fractures and non-spinal fractures. However, et al. (unpublished observations) followed 13 Bachrach et al. (1991) have shown that weight amenorrhoeic runners (mean age 26 years) gain and either oestrogen therapy or return of receiving no treatment. Over the first year of menses are associated with improvements in follow-up, five became eumenorrhoeic and BMD spinal BMD in women with anorexia. Studies on increased by 2.4% in the neck of femur and 1.7% women recovered from anorexia also suggest in the lumbar spine. The remaining eight athletes that total body BMD may return towards normal had no menstrual cycles at all during the first for the age (Treasure et al., 1987; Bachrach et al., year and BMD fell by 5.1% and 3.7%, respec- 1991). tively, in neck of femur and lumbar spine. Thus, although all the short-term studies More recently, Keen and Drinkwater (1997) suggest that small improvements in BMD may returned to 29 of their original cohort of female occur in some regions of the skeleton, particu- athletes after an interval of 8.1 years and com- larly those high in trabecular bone such as the pared bone densities in three subgroups accord- spine, when menstruation returns these gains ing to their menstrual status at the first study: may be short-lived. If sufficient trabeculae are osteoporosis 399

lost, it may be impossible fully to recalcify these return of menstruation. In a study of slightly areas of bone. older premenopausal veteran runners (aged 40 The studies discussed above have of course years and over), BMD of lumbar spine and proxi- focused on young premenopausal athletic mal femur were measured in a group of 13 women. However, cross-sectional studies of runners with a history of menstrual dysfunction populations of older premenopausal and post- and compared with peers who had always had menopausal women have also highlighted the regular menstruation (Wilson et al., 1994b). Bone importance of gynaecological and obstetric para- density was similar in all femoral regions mea- meters in the determination of bone density. A sured but was lower in the lumbar spine in those greater number of pregnancies, early menarche with previous menstrual irregularity (Fig. 27.5). and greater number of days bleeding have all These results suggest that for the femur, if men- been correlated with higher radial BMD (Fox et struation returns, continued weight-bearing al., 1993). In this study, for each decade of men- exercise may be sufficient to offset any bone struation, radial BMD was 2% higher but there mineral loss incurred at a younger age through was no association with length of the menstrual amenorrhoea but that there may be long-lasting cycle or previous history of irregularity. This con- effects on other parts of the skeleton. These find- trasts with findings by Georgiou et al. (1989) who ings are consistent with the long-term prospec- found that bone mineral content of the forearm in tive study by Keen and Drinkwater (1997). postmenopausal women had a better linear cor- relation with the total number of menstrual Treatment of reduced bone density cycles than with age or years since the in athletes menopause. In a study of mature premenopausal athletes The studies and observations described above aged 29–39 years of age, Micklesfield et al. (1995) suggest that bone density at a variety of sites may found that bone density of lumbar spine but not increase in the short term provided menstruation proximal femur was correlated with menstrual returns, although it appears to be unlikely that history index. Low BMD was noted in those ath- there is a total return to expected values. Preven- letes with a history of oligomenorrhoea despite tion of substantial loss of bone mineral is there-

0.9 * 0.7

Fig. 27.5 Bone mineral density (BMD) of premenopausal veteran 0.5 athletes aged 40 years and over. , always eumenorrhoeic (n = 37); , at least 2 years of prior 0.3 oligomenorrhoea although currently eumenorrhoeic (n = 13). Z-score (SD) 0.1 BMD is expressed as the Z-score (number of standard deviations above or below the age-matched –0.1 European reference range). The BMD is lower in all areas but only reaches significance in the lumbar –0.3 spine (*, P < 0.05). (Based on data from Wilson et al., 1994b.) Femur neck Trochanteric region Lumbar spine 400 the female athlete triad

fore of paramount importance and the most published evidence for the efficacy of such treat- natural way of acheiving this goal is the resump- ments, many physicians faced with an amenor- tion of normal menstruation. However, in the rhoeic athlete would elect for some form of studies by Drinkwater et al. (1986) and Lindberg oestrogen/progestin replacement. et al. (1987) return of menses required a reduction in training volume or intensity and a concomi- Combined oral contraceptive pill tant increase in weight. Not all athletes are willing to alter training habits in order to resume Cross-sectional population studies have sug- menstruation. For many, menstruation would be gested that the oral contraceptive pill (OCP) may a nuisance and for some it might interfere with protect against low bone density. In a popula- performance. In such athletes treatment to tion-based study of young women Lindsay et al. prevent further bone mineral loss or to improve (1986) determined that vertebral bone density low bone density despite amenorrhoea would be was increased by approximately 1% per year of of interest. It is thought that demineralization of exposure to the OCP. Further studies have con- the skeleton occurs early in amenorrhoea, as it firmed the dose-related protective effect of does after the menopause, and intervention is oestrogens on bone density and suggest that the advised if menstrual disturbance lasts longer optimal dosage appears to be 25–35µg of ethiny- than 6 months. loestradiol. Formulations such as the ‘mini-pill’, Treatment regimens used in women with sec- which contain lower doses of oestradiol, may ondary amenorrhoea have included calcium therefore not be as effective. supplementation, various forms of hormone In a 2-year non-randomized study of 85 pre- treatment and intranasal calcitonin (Table 27.2). menopausal women with amenorrhoea due to a In a survey of physician members of the Ameri- variety of causes, BMD of the lumbar spine was can Society for Sports Medicine, 92% of respon- seen to increase in all patients treated with either dents supported the use of sex steroid synthetic or natural oestrogens in various forms. supplementation, 87% would prescribe addi- After an interval of 19.6 months of treatment, tional oral calcium, 64% advised increased BMD increased from 0.85 to 0.89g·cm–2, equiva- caloric intake, 57% would reduce exercise inten- lent to a gain of 2.1% per year (Gulekli et al., sity, 43% would aim for weight gain and 26% 1994). The impact of this study is reduced by its advised vitamin supplementation (Haberland et non-randomization and the diversity of diag- al., 1995). Thus despite very little in the way of noses treated, but does suggest that the OCP or standard-formulation hormone replacement therapy would be suitable treatments for Table 27.2 Treatment options for athletic amenorrhoea athletes. It would be expected that OCP use would be Oral contraceptive pill protective against bone mineral loss in athletes Hormone replacement therapy (combined oestrogen and progestogen) by maintaining oestrogen levels even in those Calcium supplementation who, without treatment, would have become ? Cyclic medroxyprogesterone amenorrhoeic. Lindholm et al. (1995) compared ? Intranasal calcitonin 19 former élite gymnasts with 21 women of com- parable age who had not trained vigorously. Of The most appropriate management strategy is to encourage resumption of the normal menstrual the gymnasts 14 had been or were currently cycle by reduction of precipitating risk factors. using the OCP; the remainder were currently Should normal menstruation not resume with eumenorrhoeic. Despite a mean delay in menar- adoption of this strategy, treatment should che of 2.7 years, the former gymnasts had similar commence within 6 months of onset of amenorrhoea total body and spinal bone density compared to avoid rapid loss of bone mineral with the controls. The authors suggest that this osteoporosis 401

shows either ‘catch-up’ on return of menstrua- progesterone in physically active women with tion or a protective effect of the OCP. menstrual cycle disturbance results in significant De Cree et al. (1988) used 2mg cyproterone improvements in spinal BMD. They used cyclic acetate and 50µg ethinyloestradiol as a com- medroxyprogesterone 10mg daily for 10 days bined OCP in seven amenorrhoeic athletes. each cycle, either with or without calcium car- During 8 months of treatment, BMD in the bonate 1000mg daily, in a 1-year, randomized, lumbar spine increased by 9.5% compared with a double-blind, placebo-controlled trial in 61 control group of four athletes in whom BMD active women aged 21–45years. In those receiv- increased by only 1.6%. Very little change ing the active progestin, bone density of the occurred in the radius in either group. It is diffi- lumbar spine increased by 1.7% (SE=±0.5%, P= cult to assess the effect of cyproterone acetate on 0.004) during the year, did not change signifi- bone density; indeed the increase may have been cantly in those receiving calcium and declined in solely due to the relatively high dose of oestro- those receiving both placebos (–2.0±0.6%, P= gen used. In a study of 15 non-athletic women 0.005). Oestrogen levels increased in all groups with primary and secondary amenorrhoea, and were not related to changes in BMD. This Haenggi et al. (1994) showed increases of 2.5% study, although not replicated, suggests that and 2.9% per year in lumbar spine and Ward’s cyclic treatment with medroxyprogesterone may triangle, respectively, when treated with an OCP protect the amenorrhoeic athlete against bone containing 30µg ethinyloestradiol and 150µg mineral loss. desogestrel. Non-significant increases in BMD were observed in the femoral neck and tibia, sug- Calcium gesting that the greatest effects occur at sites high in trabecular bone. Bone mass is higher in children and adolescents However, treatment with oestrogen and pro- with a high calcium intake (Chan, 1991; Sentipal gestins in patients with anorexia nervosa with et al., 1991) and this may result in an increased proven low spinal trabecular BMD has given bone mass in later life (Matkovic et al., 1979). conflicting results. Only those with body weight Work on healthy premenopausal women sup- less than 70% of ideal appeared to derive benefit ports a role for dietary calcium in the develop- from treatment, in that further bone loss was pre- ment of bone, particularly when associated with vented compared with controls. The greatest exercise (Kanders et al., 1988; Halioua & Ander- changes were seen in those controls who son, 1989). The synergistic effect of calcium and regained menses, in whom there was a 19.4% exercise on bone has also been demonstrated in increase in BMD (Klibanski et al., 1995). animal models (Lanyon, 1986). Apositive linear relationship between trabecu- lar BMD in the lumbar spine and calcium intake Progesterone-only treatment in athletes has been demonstrated by Wolman et Studies on non-athletic premenopausal and post- al. (1992), a finding that was independent of men- menopausal women suggest that treatment with strual status and which has not been shown in medroxyprogesterone only, either as a depot oral other studies (Nelson et al., 1986; Grimston et al., contraceptive or to protect against bone loss in 1990; Heinrich et al., 1990). These differences may the postmenopausal period, is associated with be due to methodology, particularly in assess- lower than expected bone mineral in pre- ment of calcium intake, or statistical confound- menopausal users (Cundy et al., 1991) and fails to ing by another risk factor. Alternatively, the protect against bone mineral loss in post- relationship between calcium intake and bone menopausal users (Gallagher et al., 1991). mineral content may not be linear. Kanders et al. However, Prior et al. (1994) report that cyclic (1988) showed a positive relationship between rather than continuous treatment with medroxy- calcium intake and vertebral BMD in normal 402 the female athlete triad

healthy eumenorrhoeic women but not above a progesterone therapy, BMD of the lumbar spine daily intake of 800–1000mg. Additionally, the increased by 4.1% in the former group and by ability of an individual to adapt to a low calcium 9.2% in the latter group (Biberoglu et al., 1990). intake may be genetically determined (Krall et Unlike oestrogen replacement or bisphospho- al., 1993; Ferrari et al., 1995). nate therapy, there is much less population- Low calcium intakes have been reported in based data on the use of intranasal calcitonin in many athletes (Rucinski, 1989; Benson et al., 1990; low oestrogen states. A recent consensus state- Pate et al., 1990; Bergen-Cico & Short, 1992; Delis- ment from Canada on the use of calcitonin in traty et al., 1992; Frederick & Hawkins, 1992; osteoporosis advised that current evidence for Stensland & Sobal, 1992), particularly in amenor- the long-term use of calcitonin in the prevention rhoeic women. Low oestrogen levels are associ- of osteoporosis is limited and that it should not ated with decreased intestinal absorption of be used as a first-line treatment (Siminoski & calcium and increased urinary loss (Nordin & Josse, 1996). Heaney, 1990) so dietary calcium requirements may be even higher in amenorrhoeic athletes. On Bisphosphonates theoretical grounds, therefore, calcium supple- mentation would be reasonable in such athletes. As yet there are no studies on the effect of Treatment with calcium has been suggested to bisphosphonates on low bone density in amenor- be weakly effective by Prior et al. (1994) in their rhoeic athletes. Animal studies suggest that bis- study of 61 active women, although no effect has phosphonates may adversely affect the outcome been shown by others. Baer et al. (1992) treated of pregnancy and therefore are not recom- seven adolescent amenorrhoeic runners with mended for women of child-bearing age. 1200mg calcium carbonate and 400IU vitamin D daily. During a 12-month period the subjects con- Effect on performance sumed an average of 2400mg calcium daily but BMD of the lumbar spine did not increase and in Although these studies mentioned the incidence two subjects it declined further. In larger popula- of side-effects with treatment, no reference was tion-based studies, calcium supplementation made to effects of treatment on sports perfor- does appear to have a small but significant effect mance. The side-effects associated with hormone on BMD, particularly before or at the menopause therapy, such as breast tenderness, weight gain and even in those with established osteoporosis and emotional lability, are unlikely to be toler- (Elders et al., 1994). Supplementation with ated by runners and are particularly common in calcium and vitamin D3 can also reduce fracture women who have not been exposed to oestrogen rates in high-risk elderly women (Chapuy et al., for a long time. Commencing treatment at half 1992). Larger studies on amenorrhoeic athletes doses and building up slowly may reduce the may show more evidence of benefit than has incidence of these side-effects. Calcium in high been demonstrated hitherto, although it is doses may also cause troublesome gastrointesti- unlikely that the effect will be as great as can be nal upsets in a minority of women. gained with oestrogen supplementation. Conclusion Intranasal calcitonin Menstrual irregularity in athletes is common and In non-athletes with menstrual abnormalities, often overlooked. Its profound effects on skeletal intranasal calcitonin has been used. In seven integrity are no longer in doubt and great efforts women with primary amenorrhoea who com- must be made to ensure that all those who care pleted 6 months of treatment with either for young athletes are aware of the problem and intranasal calcitonin or combined oestrogen/ familiar with its management. Athletes too must osteoporosis 403

be educated so that they no longer see loss of density of elite female athletes with stress fractures menstruation as a bonus but appreciate its impli- Medical Journal of Australia 153, 373–376. Chan, G.M. (1991) Dietary calcium and bone mineral cations and know where to seek help. If the status of children and adolescents. American Journal causes and consequences of menstrual irregular- of Diseases of Children 145, 631–634. ity are managed sympathetically with a multidis- Chapuy, M.C., Arlot, M.E., Duboeuf, F. et al. (1992) ciplinary approach, treatment need not interfere Vitamin D3 and calcium to prevent hip fractures in with athletic performance. elderly women. New England Journal of Medicine 327, 1637–1642. However, there is still much that is unknown Cundy, T., Evans, M., Roberts, H., Wattie, D., Ames, R. about this disorder. In particular, the long-term & Reid, I. (1991) Bone density in women receiving effects of prolonged amenorrhoea on bone min- depot medroxyprogesterone acetate for contracep- eralization must be delineated and this requires tion. British Medical Journal 303, 13–16. careful follow-up over decades, an aim that may De Cree, C., Lewin, R. & Ostyn, M. (1988) Suitability of cyproterone actetate in the treatment of osteoporosis not be achievable. Also, therapeutic strategies associated with athletic amenorrhoea. International must be investigated in prospective randomized Journal of Sports Medicine 9, 187–192. trials, a project likely to require multicentre col- Delistraty, D.A., Reisman, E.J. & Snipes, M. (1992) A laboration in order to achieve a substantial physiological and nutritional profile of young female cohort. figure skaters. Journal of Sports Medicine and Physical Fitness 32, 149–155. De Souza, M.J., Miller, B.E., Sequenzia, L.C. et al. (1997) References Bone health is not affected by luteal phase abnormal- ities and decreased ovarian progesterone production Bachrach, L.K., Katzman, D.K., Litt, I.F., Guido, D. & in female runners. Journal of Clinical Endocrinology Marcus, R. (1991) Recovery from osteopenia in ado- and Metabolism 82, 2867–2876. lescent girls with anorexia nervosa. Journal of Clinical Drinkwater, B.L., Nilson, K., Chesnut, C.H., Bremner, Endocrinology and Metabolism 72, 602–606. W.J., Shainholtz, S. & Southworth, M.B. (1984) Bone Baer, J.T., Taper, L.J., Gwazdauskas, F.G. et al. (1992) mineral content of amenorrheic and eumenorrheic Diet, hormonal and metabolic factors affecting bone athletes. New England Journal of Medicine 311, mineral density in adolescent amenorrheic and 277–281. eumenorrheic female runners. Journal of Sports Medi- Drinkwater, B.L., Nilson, K., Ott, S. & Chesnut, C.H. cine and Physical Fitness 32, 51–58. (1986) Bone mineral density after resumption of Barrow, G.W. & Saha, S. (1988) Menstrual irregularity menses in amenorrheic athletes. Journal of the Ameri- and stress fractures in collegiate female distance can Medical Association 256, 380–382. runners. American Journal of Sports Medicine 16, Drinkwater, B.L., Bruemner, B. & Chesnut, C.H. (1990) 209–214. Menstrual history as a determinant of current bone Benson, J.E., Allemann, Y., Theintz, G.E. & Howald, H. density in young athletes. Journal of the American (1990) Eating problems and calorie intake levels in Medical Association 263, 545–548. Swiss adolescent athletes. International Journal of Elders, P.J., Lips, P., Netelenbos, J.C. et al. (1994) Long- Sports Medicine 11, 249–252. term effect of calcium supplementation on bone loss Bergen-Cico, D.K. & Short, S.H. (1992) Dietary intakes, in perimenopausal women. Journal of Bone and energy expenditures, and anthropometric character- Mineral Research 9, 963–970. istics of adolescent female cross-country runners. Ferrari, S., Rizzoli, R., Chevalley, T., Slosman, D., Journal of the American Dietetic Association 92, 611– Eisman, J.A. & Bonjour, J.-P. (1995) Vitamin D recep- 612. tor gene polymorphisms and change in lumbar spine Biberoglu, K., Yildiz, A., Gursoy, R., Kandemir, O. & bone mineral density. Lancet 345, 423–424. Bayhan, H. (1990) Bone mineral content in young Fox, K.M., Magaziner, J., Sherwin, R. et al. (1993) Repro- women with primary amenorrhoea. In C. Chris- ductive correlates of bone mass in elderly women. tiansen & K. Overgaard (eds) Osteoporosis 1990, pp. Journal of Bone and Mineral Research 8, 901–908. 712–714. Osteopress, Copenhagen, Denmark. Frederick, L. & Hawkins, S.T. (1992) A comparison of Cann, C.E., Martin, M.C., Genant, H.K. & Jaffe, R.B. nutrition knowledge and attitudes, dietary practices, (1984) Decreased spinal mineral content in amenor- and bone densities of postmenopausal women, rheic women. Journal of the American Medical Associa- female college athletes, and non-athletic women. tion 251, 626–629. Journal of the American Dietetic Association 92, 299– Carbon, R., Sambrook, P.N., Deakin, V. et al. (1990) Bone 305. 404 the female athlete triad

Frusztajer, N.T., Dhuper, S., Warren, M.P., Brooks- Krall, E.A. & Dawson-Hughes, B. (1993) Heritable and Gunn, J. & Fox, R.P. (1990) Nutrition and the inci- lifestyle determinants of bone mineral density. dence of stress fractures in ballet dancers. American Journal of Bone and Mineral Research 8, 1–9. Journal of Clinical Nutrition 51, 779–883. Laban, M.M., Wilkinns, J.C., Sackeyfio, A.H. & Taylor, Gallagher, J.C., Kable, W.T. & Goldgar, D. (1991) Effect R.S. (1995) Osteoporotic stress fractures in anorexia of progestin therapy on cortical and trabecular bone: nervosa: etiology, diagnosis and review of four cases. comparison with oestrogen. American Journal of Medi- Archives of Physical Medicine and Rehabilitation 76, cine 90, 171–178. 884–887. Georgiou, E., Ntalles, K., Papageorgiou, A., Korkot- Lanyon, L.E. (1986) Modulation of bone loss during sidis, A. & Proukakis, C. (1989) Bone mineral loss calcium insufficiency by controlled dynamic related to menstrual history. Acta Orthopaedica Scan- loading. Calcified Tissue International 38, 209–216. dinavica 60, 192–194. Leinberry, C.F., McShane, R.B., Stewart, W.G. & Hume, Grimston, S.K., Engsberg, J.R., Kloiber, R.M. & Hanley, E.L. (1992) A displaced subtrochanteric stress frac- D.A. (1990) Menstrual, calcium, and training history: ture in a young amenorrheic athlete. American Journal relationship to bone health in female runners. Clinics of Sports Medicine 20, 485–487. in Sports Medicine 2, 119–128. Lindberg, J.S., Fears, W.B., Hunt, M., Powell, M.R., Boll, Gulekli, B., Davies, M.C. & Jacobs, H.S. (1994) Effect of D. & Wade, C.E. (1984) Exercise-induced amenorrhea treatment on established osteoporosis in young and bone density. Annals of Internal Medicine 101, women with amenorrhoea. Clinical Endocrinology 41, 647–648. 275–281. Lindberg, J.S., Powell, M.R., Hunt, M.M., Ducey, D.E. & Haberland, C.A., Seddick, D., Marcus, R. & Bachrach, Wade, C.E. (1987) Increased vertebral bone mineral L.K. (1995) A physician survey for exercise-associ- in response to reduced exercise in amenorrheic ated amenorrhoea: a brief report. Clinical Journal of runners. Western Journal of Medicine 146, 39–42. Sports Medicine 5, 246–250. Lindholm, C., Hagenfeldt, K. & Ringertz, H. (1995) Haenggi, W., Casez, J.-P., Birkhaeuser, M.H., Lippuner, Bone mineral content of young former gymnasts. K. & Jaeger, P. (1994) Bone mineral density in young Acta Paediatrica Scandinavica 84, 1109–1112. women with long-standing amenorrhoea: limited Lindsay, R., Tohme, J. & Kanders, B. (1986) The effect of effect of hormone replacement therapy with ethinyl- oral contraceptive use on vertebral bone mass in pre- oestradiol and desorgestrel. Osteoporosis International and post-menopausal women. Contraception 34, 4, 99–103. 333–340. Halioua, L. & Anderson, J.J.B. (1989) Lifetime calcium Lloyd, T., Triantafyllou, S.J., Baker, E.R. et al. (1986) intake and physical activity habits: independent and Women athletes with menstrual irregularity have combined effects on the radial bone of healthy pre- increased musculoskeletal injuries. Medicine and menopausal Caucasian women. American Journal of Science in Sports and Exercise 18, 374–379. Clinical Nutrition 49, 534–541. Marcus, R., Cann, C., Madvig, P. et al. (1985) Menstrual Harber, V.J., Webber, C.E., Sutton, J.R. & MacDougall, function and bone mass in elite women distance J.D. (1991) The effect of amenorrhoea on calcaneal runners. Annals of Internal Medicine 102, 158–163. bone density and total bone turnover in runners. Matkovic, V., Kostial, K., Simonovic, I., Buzina, R., Bro- International Journal of Sports Medicine 12, 505–508. darec, A. & Nordin, B.E.C. (1979) Bone status and Heinrich, C.H., Going, S.B., Pamenter, R.W., Perry, fracture rates in two regions of Yugoslavia. American C.D., Boyden, T.W. & Lohman, T.G. (1990) Bone Journal of Clinical Nutrition 32, 540–549. mineral content of cyclically menstruating female Maugars, Y., Bertholet, J.M., Lalande, S., Charlier, C. & resistance and endurance-trained athletes. Medicine Prost, A. (1996) Osteoporotic fractures revealing and Science in Sports and Exercise 22, 558–563. anorexia nervosa in five females. Revue du Rhuma- Kanders, B., Dempster, D.W. & Lindsay, R. (1988) Inter- tisme (English edn) 63, 201–206. action of calcium, nutrition and physical activity on Micklesfield, L.K., Lambert, E.V., Fataar, A.B., Noakes, bone mass in young women. Journal of Bone and T.D. & Myburgh, K.H. (1995) Bone mineral density in Mineral Research 3, 145–149. mature premenopausal ultramarathon runners. Keen, A.D. & Drinkwater, B.L. (1997) Irreversible bone Medicine and Science in Sports and Exercise 27, 688–696. loss in amenorrheic athletes. Osteoporosis Interna- Milgrom, C., Giladi, M., Simkin, A. et al. (1989) The area tional 7, 311–315. moment inertia of the tibia: a risk factor for stress Klibanski, A., Biller, B.M.K., Schoenfield, D.A., Herzog, fractures. Journal of Biomechanics 22, 1243–1248. D.B. & Saxe, V.C. (1995) The effects of estrogen Myburgh, K.H., Hutchins, J., Fataar, A.B., Hough, S.F. & administration on trabecular bone loss in young Noakes, T.D. (1990) Low bone density is an etiologi- women with anorexia nervosa. Journal of Clinical cal factor for stress fractures in athletes. Annals of Endocrinology and Metabolism 80, 898–904. Internal Medicine 113, 754–759. osteoporosis 405

Myburgh, K.H., Bachrach, L.K., Lewis, B., Kent, K. & agement of osteoporosis: consensus statements from Marcus, R. (1993) Low bone density at axial and the Scientific Advisory Board of the Osteoporosis appendicular sites in amenorrheic athletes. Medicine Society of Canada. 9. Calcitonin in the treament of and Science in Sports and Exercise 25, 1197–1202. osteoporosis. Canadian Medical Association Journal Myerson, M., Gutin, B., Warren, M.P., Wang, J., Licht- 155, 962–965. man, S. & Pierson, R.N. (1992) Total body bone Slemenda, C.W. & Johnston, C.C. (1993) High intensity density in amenorrheic runners. Obstetrics and Gyne- activities in young women: site specific bone mass cology 79, 973–978. effects among female figure skaters. Bone and Mineral Nelson, M.E., Fisher, E.C., Catsos, P.D., Meredith, C.N., 20, 125–132. Turksoy, R.N. & Evans, J.E. (1986) Diet and bone Snead, D.B., Weltman, A., Weltman, J.Y. et al. (1992) status in amenorrheic runners. American Journal of Reproductive hormones and bone mineral density in Clinical Nutrition 43, 910–916. women runners. Journal of Applied Physiology 72, Noble, B.S., Stevens, H., Loveridge, N. & Reeve, 2149–2156. J. (1997) Identification of apoptotic changes in Stensland, S.H. & Sobal, J. (1992) Dietary practices of normal and pathological human bone. Bone 20, ballet, jazz, and modern dancers. Journal of the Ameri- 273–282. can Dietetic Association 92, 319–324. Nordin, B.E.C. & Heaney, R.P. (1990) Calcium supple- Tomkinson, A., Reeve, J., Shaw, R. & Noble, B. (1997) mentation of the diet: justified by present evidence. The death of osteocytes via apoptosis accom- British Medical Journal 300, 1056–1060. panies oestrogen withdrawal in human bone. Journal Pate, R.R., Sargent, R.G., Baldwin, C. & Burgess, M.L. of Clinical Endocrinology and Metabolism 82, 3128– (1990) Dietary intake of women runners. Interna- 3135. tional Journal of Sports Medicine 11, 461–466. Treasure, J.L., Russell, J.F.M., Fogelman, I. & Murby, B. Prior, J.C., Vigna, Y.M., Schechter, M.T. & Burgess, A.E. (1987) Reversible bone loss in anorexia nervosa. (1990) Spinal bone loss and ovulatory disturbance. British Medical Journal 295, 474–475. New England Journal of Medicine 323, 1221–1227. Tremollieres, F.A., Strong, D.D., Baylink, D.T. & Mohan, Prior, J.C., Vigna, Y.M., Barr, S.I., Rexworthy, C. & S. (1992) Progesterone and promegestone stimulate Lentle, B.C. (1994) Cyclic medroxyprogesterone human bone cell proliferation and insulin-like treatment increases bone density: a controlled trial in human growth factor 2 production. Acta Endocrino- active women with menstrual cycle disturbances. logica 126, 329–337. American Journal of Medicine 96, 521–530. Warren, M.P., Brooks-Gunn, J., Hamilton, L.H., Warren, Rencken, M.L., Chesnut, C.H. & Drinkwater, B.L. L.F. & Hamilton, W.G. (1986) Scoliosis and fractures (1996) Bone density at multiple skeletal sites in in young ballet dancers. New England Journal of Medi- amenorrheic athletes. Journal of the American Medical cine 314, 1348–1353. Association 276, 238–240. Warren, M.P., Shane, E., Lee, M.J. et al. (1990) Femoral Rigotti, N.A., Neer, R.M., Skates, S.J., Herzog, D.B. & head collapse associated with anorexia nervosa in a Nussbaum, S.R. (1991) The clinical course of osteo- 20-year-old ballet dancer. Clinical Orthopaedics and porosis in anorexia nervosa. Journal of the American Related Research 251, 171–176. Medical Association 265, 1133–1138. Wilson, J.H. & Wolman, R.L. (1994) Osteoporosis and Risser, W.L., Lee, E.J., Leblanc, A., Poindexter, J.M.H. & fracture complications in an amenorrheic athlete. Schneider, V. (1990) Bone density in eumenorrhoeic British Journal of Rheumatology 33, 480–481. female college athletes. Medicine and Science in Sports Wilson, J.H., Reeve, J. & Harries, M.G. (1994a) Determi- and Exercise 22, 570–574. nants of bone mineral density in female athletes. Robinson, T.L., Snow-Harter, C., Taaffe, D.R., Gillis, D., Bone 15, 450. Shaw, J. & Marcus, R. (1995) Gymnasts exhibit higher Wilson, J.H., Harries, M.G. & Reeve, J. (1994b) Bone bone mass than runners despite similar prevalence mineral density in premenopausal veteran female of amenorrhoea and oligomenorrhoea. Journal of athletes and the influence of menstrual irregularity. Bone and Mineral Research 10, 26–34. Clinical Science 86, 2p. Rucinski, A. (1989) Relationship of body image and Wolman, R.L., Clark, P., McNally, E., Harries, M. & dietary intake of competitive ice-skaters. Journal of Reeve, J. (1990) Menstrual state and exercise as deter- the American Dietetic Association 89, 98–100. minants of spinal trabecular bone density in female Sentipal, J.M., Wardlaw, M., Mahan, J. & Matkovic, V. athletes. British Medical Journal 301, 516–518. (1991) Influence of calcium intake and growth Wolman, R.L., Faulmann, L., Clark, P., Hesp, R. & indexes on vertebral bone mineral density in young Harries, M.G. (1991) Different training patterns and females. American Journal of Clinical Nutrition 54, bone mineral density of the femoral shaft in elite, 425–428. female athletes. Annals of the Rheumatic Diseases 50, Siminoski, K. & Josse, R.G. (1996) Prevention and man- 487–489. 406 the female athlete triad

Wolman, R.L., Clark, P., McNally, E., Harries, M. & Young, N., Formica, C., Szmukler, G. & Seeman, E. Reeve, J. (1992) Dietary calcium as a statistical deter- (1994) Bone density at weight-bearing and non- minant of spinal trabecular bone density in amenor- weight-bearing sites in ballet dancers: the effects of rheic and oestrogen-replete athletes. Bone and exercise, hypogonadism, and body weight. Journal of Mineral 17, 415–423. Clinical Endocrinology and Metabolism 78, 449–454. PART 7

PSYCHOSOCIAL ISSUES

Chapter 28

The Young Élite Athlete: the Good, the Bad and the Ugly

MAUREEN R. WEISS, ANTHONY J. AMOROSE AND JUSTINE B. ALLEN

Introduction Along with this astronomical increase in the numbers of young people participating in com- I am not suggesting that gymnastics and petitive sport is the equity afforded young girls figure skating in and of themselves are and women. Since the passage of Title IX of the destructive . . . both sports are potentially Educational Equity Act in 1972, the latent wonderful and enriching . . . the average child benefits of this legal action are only now being can develop a sense of mastery, self-esteem, realized in the opportunities available for partici- and healthy athleticism...it’s about the elite pation; the quality of training, equipment and child athlete and the American obsession with coaching; and the potential for college scholar- winning that has produced a training environ- ships and sport-related careers. For example, half ment wherein results are bought at any cost, no of non-school sport participants are female and matter how devastating. It’s about how our in 1995 2.1 of the 5.6 million interscholastic ath- cultural fixation on beauty and weight and letes were female. By the end of 1997 there were youth has shaped both sports and driven the two women’s professional basketball leagues athletes into a sphere beyond the quest for and a women’s professional softball league, physical performance (Ryan, 1995, p. 5). women’s ice hockey was made a new Olympic event for the 1998 Winter Games in Nagano and, Ever since the 1930s, when public elementary inevitably, there was enhanced attention in the schools relinquished their hold over children’s media; just some of the many ‘firsts’ formerly competitive sport in the USA (Wiggins, 1996), reserved for male athletes. With these changes independent sports organizations such as for female youth emerged both advocates and national youth agencies (e.g. YMCA), national critics. youth sport organizations (e.g. Little League On the positive side, advocates argue that girls baseball) and national governing bodies (e.g. and young women now have the same opportu- USA Gymnastics, USA Swimming) have con- nities to develop lifelong skills and attributes as tributed to the dramatic onslaught of millions of their brothers have always had. These include children and teenagers involved in competitive, the development of a variety of motor and physi- and often very intense, participation. The cal skills, leadership and follower qualities, numbers of children and teenagers involved in physical fitness and social relationships with competitive sport today are staggering: an esti- adults and peers, the benefits alluded to in the mated 20–35 million in non-school agency-spon- first part of Joan Ryan’s quote at the beginning sored sports and another 10 million in of this chapter. In contrast, critics question the high-school sports (Ewing & Seefeldt, 1996; costs of the sudden and steep incline in competi- Weiss & Hayashi, 1996). tive and material opportunities, disadvantages 409 410 psychosocial issues

implied by the second half of Joan Ryan’s quote. petitive sport, evaluate and recommend the best Poor self-esteem and high levels of competitive coaching styles, and encourage parenting roles anxiety and stress may result from the increased and responsibilities so that young female athletes pressure to win. In turn, these changes in atti- can maximize the good, minimize the bad and tudes may manifest themselves in such behav- sidestep the ugly. iours as injuries, burnout, eating disorders and The purpose of this chapter is to address substance abuse. several issues concerning the social and psycho- Whether the advocates or critics are right is a logical ramifications of the participation of moot point. Children’s competitive sport, and at young females in high-level competitive sport. highly intense levels, is here to stay, as are the First, we highlight the key psychosocial out- increased opportunities and rewards available comes of competitive youth sport, including the for female athletes. These are good things. good, bad and ugly. Next, we synthesize what However, the world of sport does not occur in the scientific research says about psychosocial isolation but within a social context, one gov- issues across a number of specific sports. Third, erned and controlled by significant adults such we present what the anecdotal literature says, as parents, coaches and administrators, as well as sampling the perspectives of journalists who by the participants themselves. Together they have been granted greater access to child sport determine the attitudes and behaviours con- stars. Fourth, we summarize common themes doned by the subculture of that specific sport from the scientific and anecdotal literatures. (Iversen, 1990; Coakley, 1992; Brustad & Ritter- Finally, we offer recommendations to national Taylor, 1996). Thus ‘good’, ‘bad’ and ‘ugly’ are all governing bodies, coaches and parents for maxi- possible outcomes of sport involvement. Bonnie mizing the good, minimizing the bad and avoid- Blair is a prime example of the good. Starting in ing the ugly in competitive sport for girls and competitive speed skating at an early age, Blair’s young women. perspective on sport participation and winning was shaped by a strong social support network, Psychosocial outcomes of including her parents, siblings, friends and competitive youth sport coach. Mary Pierce, professional tennis player, might be an example of the bad. Although a Positive and negative outcomes of sporting highly successful player on the tour, her father competition are equally possible (Table 28.1). has been banned from tournaments for his Educators and researchers often refer to this as verbally abusive behaviour. Finally, an easy the ‘double-edged sword’ of sport participation example of the ugly is Tonya Harding’s role in (Martens, 1978). On the one hand, competitive the physical assault on Nancy Kerrigan, who participation affords opportunities for develop- stood in her way of making the Olympic figure- ing positive self-perceptions (e.g. self-esteem, skating team. self-confidence), emotions/affect (e.g. pride, As we ponder the role of high-level competi- enjoyment, excitement) and motivation (i.e. the tive sport in the development of young females, intrinsic desire to continue participating). Posi- there are no black and white answers to many tive outcomes can also include achievement questions. At what age should girls start special- behaviours (e.g. effort and persistence in the face izing? Should certain sports (e.g. gymnastics, of challenges, attaining personal performance boxing) be discouraged for girls? How much is goals), moral and social development (e.g. too much—number of sports, time commitment, sportspersonship, interpersonal skills with financial investment? These are difficult to adults and peers), a positive attitude towards the answer at a superficial level. However, research value of physical activity for health-related and experiential evidence can help us make behaviours and the ability to cope with competi- informed decisions about how to structure com- tive stress (Weiss & Glenn, 1992; Weiss, 1993). the young élite athlete 411

Table 28.1 Positive and negative psychosocial outcomes of high-level sport. (Data from Gould, 1993; Weiss, 1993)

Positive Negative Ugly

Self-perceptions Self-perceptions Injuries Self-esteem Self-esteem Burnout Self-confidence Self-confidence Eating disorders Affect Affect Substance abuse Enjoyment Anxiety Parental control Motivation Motivation Coach abuse Intrinsic Extrinsic Unidimensional High achievement Low achievement self-identity Character ‘Characters’ Loss of enjoyment Interpersonal skills Maladaptive social Poor self-image Positive attitude skills Lost childhood Cope with stress Negative attitude Politics of the sport Experience stress

However, when the sword is wielded reck- level sport emphasizes performance enhance- lessly, competitive participation can contribute ment rather than the overall social and psycho- to: low self-esteem and low levels of self- logical development of the young athlete, it may confidence; negative emotions, such as anxiety, be easy for these undesirable behaviours to disappointment and shame; and a dependence emerge: injuries which, if ignored, may result in on extrinsic forms of motivation, such as feeling disabilities (e.g. bone loss, arthritis) that carry that participation is compulsory rather than lifelong health implications; burnout, which is voluntary, which may eventually lead to burnout most often defined as the physical, psychological (Gould, 1993). This undesirable type of motiva- and emotional withdrawal of a once enjoyable tion may be driven by coercion from parents or activity due to excessive stress; and eating disor- coaches, by internal guilt about the money ders (bulimia and anorexia), which young invested by parents or by an emphasis on females adopt in order to conform to the aes- winning fame, status and fortune through thetic image expected, albeit unrealistically, of élite-level participation. This ‘win at all costs’ athletes in their sport or as a means of controlling mentality unfortunately takes its toll in a most something in their life because adults control unbecoming way on a young athlete’s psycho- everything else about their competitive sport logical core, her self-esteem. Other negative world (Nash, 1987). outcomes that mirror the positive ones are There are other potentially ugly consequences achievement behaviour (e.g. low performance for females participating at élite levels of compet- accomplishment), low levels of moral develop- itive sport. Substance abuse may be adopted as a ment (e.g. cheating to gain an advantage), poor means of coping with the undue levels of stress interpersonal skills (e.g. poor anger management and anxiety of competition, to gain a competitive skills, disrespect for coaches and team-mates), a edge over similarly talented opponents or to dull negative attitude towards sport and physical the feelings of low self-image or helplessness activity, and high levels of competitive stress prevalent during training regimens designed to that, if not corralled early, may escalate to over- pursue high status and financial pay-offs. training, staleness or psychological burnout. Another hazard of high-level competition is When an overemphasis on winning gets out the abusive coach or parent, who may see the of hand, high-level competitors start to exhibit potential for fame, glory and monetary gain as some rather ugly consequences. Because élite- vicarious reward for their prodigy/daughter’s 412 psychosocial issues

performances. This abuse is most commonly number of studies have been conducted over the psychological abuse, such as name-calling, with- last 20 years to understand more fully the condi- drawal of love and affection, and intangible pres- tions under which this can occur. Many studies sure placed on the young athlete as a result of the have examined children’s participation from a expectations placed on their performance (Don- psychosocial perspective, the large majority of nelly, 1993; Ryan, 1995). which have been on children and teenagers in In addition to these ugly consequences, organized agency-sponsored competitive sport, Coakley (1992) warns that young athletes may be such as ‘select’ soccer, age-group swimming, prone to a unidimensional self-identity. This self- club gymnastics and Little League baseball. identity is one in which the young athlete’s view Although these levels are not considered élite per of herself is totally as an athlete (e.g. gymnast or se, they can be quite competitive in their own tennis player or swimmer) and not as a normal right. Only a handful of studies have been con- multidimensional being who holds academic, ducted on élite, high-level young athletes. A social and artistic goals as well as athletic good reason for this is access; researchers are dreams. This proneness towards a unidimen- often unable to gain permission from parents and sional athletic identity, Coakley laments, may coaches to survey or interview young athletes leave young female athletes with nothing to fall about their experiences. If scientific research on back on when their sport is no longer there, for élite young athletes is to advance, it is necessary example when they decide to retire or if they are for national governing bodies to be willing to forced out. This may lead to a ‘crash and burn’ look inwards at their own sport and grant access period that may prove devastating to normal to researchers. After all, both researchers and growth and development as a child and teenager practitioners are involved in this field for the if not handled immediately and professionally. same reason: the positive development of the This overview of the good, the bad and the young female through sport participation and ugly is meant to communicate the potential for competition. the sword to swing in either positive or negative We focus our discussion on those studies that directions. The traditional role of sport has been have investigated élite young female athletes, believed to lie in the development of virtues such although we also include results from studies of as honesty and fair play, as well as being an arena highly competitive but not élite athletes where in which to learn life skills such as coping with appropriate. They can provide a window stress and developing self-confidence. In order through which to understand the potential of for these virtues and skills to outplay their sport to contribute positively or negatively to negative alter ego (i.e. unethical behaviour, low youth psychosocial development. There are a self-esteem, excessive stress), it is crucial to number of characteristics about the literature understand how the positives and negatives may that should be kept in mind. First, most of the be nurtured in the same environment and what studies have been conducted on both female and we can do to ensure that the benefits outweigh male athletes. In the mixed samples, in many the costs of participation. Thus, we start with an cases, the differential responses of females and in-depth look at the scientific literature in order males have not been teased out. Thus it is pos- to determine the effects of frequency and inten- sible that the combined results may be skewed in sity of sport participation on these psychosocial a more positive or negative direction than if sepa- outcomes. rate analyses had been conducted. Second, most of these studies have investigated children in high-level individual sports, such as gymnastics, Scientific research skating, swimming, wrestling and running. Given the potential for intense competitive sport Although generalization to team sports is to produce positive or negative outcomes, a inappropriate, individual sports are more likely the young élite athlete 413

to place athletes in the limelight who are most susceptible to negative stressors. Finally, several studies have used retrospective, rather than prospective, research designs. This means that adults who were once élite youth competitors were asked to reflect upon their childhood experiences. Although some believe that this approach contains problems, such as memory inaccuracy, we believe that there are strong and compelling reasons why this type of design offers unique opportunities for understanding youth sport experiences. Among these reasons are language articulation skills (children do not usually have the vocabulary to express experi- ences as vividly as adults), motivation (adults enjoy being asked about their experiences and see the value of giving back to their sport) and emotional maturity, which is essential given the sensitive topics that are likely to be discussed (e.g. disordered eating, coach and parent styles, playing with pain).

Gymnastics

There is no doubt that Olga Korbut in 1972 and Nadia Comaneci in 1976 changed the face of Fig. 28.1 Young gymnast performing a floor routine at women’s gymnastics forever. Following their the 1996 Olympics. (© Allsport / Doug Pensinger.) dramatic Olympic performances, droves of young girls in the USA were enrolled in gymnas- tics by their parents, many of whom were eager ducted on young élite gymnasts who occupied to shape or drive their daughters to become two Olympic-development academies (Klint, champions. Ryan (1995) reports that the 1976 US 1985; Klint & Weiss, 1986, 1987; Weiss et al., 1989; Olympic gymnasts were, on average, 17.5 years Weiss & Hayashi, 1995). These investigators old, 161.3cm tall and weighed 48kg; in 1992, questioned young athletes about their reasons these averages were 16 years old, 144.8cm and for participating in, and discontinuing, gym- 37.6kg—a year and a half younger, 16.5cm nastics, the sources of stress in competitive shorter and 10.4kg lighter. A subculture was gymnastics and the perceptions of athletes and born, one in which long hours of training, lithe parents of the parent–child relationship through bodies fortified by shallow calories and compet- gymnastics. ing in pain are accepted as ‘normal’ practices This series of studies uncovered several posi- in this sport (Ryan, 1995; Brustad & Ritter-Taylor, tive as well as negative issues. Klint and Weiss 1996; Krane et al., 1997). It is no surprise, then, (1986) sought to understand the reasons for con- that interest in the perceptions of these tinued participation as well as reasons for attri- young athletes was sought by educators and tion in current (n=21 females, 22 males) and researchers. former (n=27 females, 10 males) highly competi- When one of the authors (M.R.W.) was at the tive gymnasts. Current gymnasts ranged in age University of Oregon, a series of studies was con- from 7 to 18 (mean 12.4) years and practised for 414 psychosocial issues

an average of 23.9 (SD 8.9) h·week–1. Former viewed as quitters, they have not given up sport gymnasts ranged in age from 10 to 25 (mean 16.7) participation completely. Rather a dropout is years and reported an average of 31.4 (SD 11.9) most likely to be a ‘sport transfer’, who shifts to h·week–1 of practice/competition when they other activities that demand less time commit- were still involved. Reasons for participation ment, more opportunities for playing time and were quite similar for both groups of competi- more exposure to social relationships in different tors: action (e.g. excitement), team atmosphere contexts. Thus, once a young athlete leaves a par- (e.g. being on the team), social recognition (e.g. ticular sport it appears likely that she will seek popular with others), challenge (e.g. learning out another sport that aligns with her interests new skills) and friends (e.g. being with or and motives rather than dropping out of sports meeting new friends). When queried about why completely (Weiss & Petlichkoff, 1989). they had left gymnastics after investing an The interviews also helped glean information average of 4 (SD 1.8) years of competition, former about different categories of athletes leaving participants cited being injured as the most gymnastics. Three categories of leaver were iden- important (18.9%), followed by not having tified in this study: reluctant, voluntary and enough fun (13.5%), not liking the pressure resistant. Reluctant leavers were characterized (10.8%) and taking up too much time (10.8%). by gymnasts who had incurred bona fide injuries At first glance, ‘being injured’ may appear to that prevented them from continuing, by those be a neutral reason for discontinuing involve- for whom the cost of gymnastic continuation was ment. However, subsequent interviews with prohibitive for their parents or by those who had these former competitors indicated that they rec- moved away from the area and thus no longer ognized when they were no longer happy with had the opportunity to practise at the gymnastic their involvement but found making the decision club. Voluntary leavers were those who insisted to leave very difficult, often taking 2 months and that they wanted to try other things, including sometimes a year before finally departing. Many sports, academic clubs or other activities such as reported that they were afraid to leave because music or theatre; these youngsters felt that the of the stigma of being labelled a ‘quitter’, not time and energy commitment required of them knowing what to do with their extra time or in gymnastics forced them to miss other types of losing contact with their friends in gymnastics. social opportunities. All the interviewees indicated that they were In contrast to these neutral or acceptable waiting for a ‘good enough’ reason to leave; two reasons for gymnastics attrition, which suggest a confided that they ‘caused’ the injury, allowing continued valuing of their gymnastic experience, them a socially acceptable reason to leave the the third classification of leaver was not as posi- sport gracefully. The notion that being injured is tive. Resistant leavers were individuals who perceived as a legitimate reason for leaving or as were unhappy with their gymnastics experience a viable alternative to high-pressure competition but felt that personal unhappiness was not a has been echoed by Nash (1987), who goes on to good enough reason to leave. They had the most say that young gymnasts often linger over their difficulty making the decision to leave the sport injuries well beyond normal healing time as a because of outside pressures from parents and way of avoiding competitive pressure. coaches to stay and because of the fear of losing In contrast to some of these negatives, the gym friendships. Unfortunately, gymnastics had study also showed that 35 of the 37 former élite ceased to be a fun endeavour or one in which gymnasts had continued their athletic involve- they felt they were developing or demonstrating ment in other organized sports or gymnastics at a their skills. Some of these gymnasts disclosed lower level of intensity (i.e. high-school team). that they caused their own injury as a legitimate Thus, although they have dropped out of élite- means of escaping their dilemma. level gymnastics and could be potentially As part of the interview, the gymnastic leavers the young élite athlete 415

Table 28.2 Athlete-recommended changes to her peers of the same age at school. Menarche, a Olympic-development gymnastic programmes. (Data normal developmental marker for girls, is looked from Klint & Weiss, 1986) upon as an abnormal or deviant occurrence in the Decrease the number of practice hours/make practice social context of gymnastics. This normal matu- more efficient ration can lead to potentially traumatic conse- Have more organized social time together quences and experiences for the young gymnast, Less segregation according to ability who may now be cast as an outsider from a once Less pressure from the coaches stable social support network (parents, coaches, More shared decision-making between athlete and coach team-mates). Iversen emphasizes the crucial role More understanding and empathy from coaches of the gymnast’s support network in promoting More encouragement from coaches healthy physical and psychological development Less emphasis on weight control during the critical period of puberty.

Figure skating were also asked what they felt they had gained Dubbed the ‘ice princesses of the winter games’ from gymnastics, as well as what advice they (Ryan, 1995), the awe of skaters in the USA that would give to gymnastics organizers for making started with such stars as Peggy Fleming and positive changes to the programme (Table 28.2). Dorothy Hamill continues to grow. However, The former gymnasts felt that their training gave recent attention has turned from the glory and them confidence, discipline and independence, glamour to the politics and pressure of the sport. taught them how to set realistic challenging This may be attributable in part to events such as goals and helped them achieve in their other the insurmountable pressure placed on Debi sport activities. Thus, their participation in gym- Thomas in the 1988 Calgary Olympics as the first nastics was not necessarily viewed as a negative African-American skater in line to win a gold phenomenon. Rather the stigma attached to medal and of course the outrageous tactics of leaving by coaches was internalized by the ath- Tonya Harding in her pursuit of an Olympic letes themselves and most likely led to the diffi- berth. Studies of young élite figure skaters have cult process of deciding to leave and the used a retrospective approach, in which current associated behaviours (i.e. causing an injury). In athletes and coaches reflected upon their sources summary, this study allowed researchers access of enjoyment and positive experiences in skating to a group of high-level young gymnasts, and (Scanlan et al., 1989a,b; Gould et al., 1993a), nega- their responses offered a rich and insightful look tive experiences and sources of stress (Scanlan et at both the positives and negatives of the sport. al., 1991; Gould et al., 1993b) and coping strate- In a thoughtful reflection of her own experi- gies they used to deal with the excessive ence as an élite gymnast, Iversen (1990) offers a demands of the sport (Gould et al., 1993c). These compelling look at the psychosocial correlates of studies have shed insight on what skaters find delayed puberty in young élite female gymnasts. enjoyable about their sport and why they endure Because the female adolescent athlete faces two the pressure in pursuit of winning performances. completely different social contexts, that of Scanlan et al. (1989a,b, 1991) interviewed 26 her school environment and the one in the former élite figure skaters who had competed at gym, different sets of rules or norms dictate national championships and who at the time what attitudes and behaviours are acceptable were coaching the sport in southern California. and condoned by significant adults (parents, This sample had averaged four visits to nation- coaches) and peers in each environment. The als. In addition eight went on to compete at the competitive gymnast’s body is in synchrony world championships and five of these eight with her cohorts in the gym but out of step with were former Olympians. At the time of the inter- 416 psychosocial issues

view, skaters ranged in age from 22 to 49 (mean ties afforded by touring). Perceived competence 35.1) years and included 15 male and 11 female was another source of enjoyment and was participants. The female skaters began skating defined as personal perceptions of competence on average at 6.1 years of age compared with 10.6 derived from one’s autonomous and/or social years for the male skaters. Former skaters were achievement in sport (e.g. mastery, competitive interviewed concerning the most competitive achievement). A third contributor to skaters’ phase of their skating career (about ages 13–19 enjoyment was social recognition of competence, for the females), one in which they devoted their defined as receiving recognition for having greatest commitment to the sport, skating 5.5 skating ability through acknowledgement of hours a day, 6 days a week and 50 weeks a year. one’s performances and achievement by others. Table 28.3 reveals the sources of enjoyment of The act of skating itself provided such qualities these skaters during the most competitive, and as the movement sensations of skating and self- thus potentially most stressful, time of their expression/creativity. Two final sources of enjoy- career. The most frequently cited source of enjoy- ment included a sense of specialness due to ment was social and life opportunities, defined personal perceptions of being highly talented, as forming meaningful relationships with signifi- and coping through skating such as using cant adults and peers (e.g. friendship opportuni- skating to escape from non-skating-related prob- ties), as well as having broader experiences lems or to gain a sense of personal competence or outside the boundaries of sport (e.g. opportuni- control. These results illuminate the multifaceted

Table 28.3 Sources of enjoyment and stress in élite figure skaters. (Data from Scanlan, 1989b, 1991)

Sources of enjoyment Sources of stress

Social and life opportunities (92%) Negative aspects of competition Friendship opportunities (81%) Going to competitions and touring Worries about competition Family/coach relationships Competitive failure Perceived competence (88%) Preparation for competition Mastery Competitive hurdles Competitive achievement Negative significant-other Performance achievement relationships (77%) Demonstration of athletic ability Interpersonal conflict Social recognition of competence (81%) Performance expectations Achievement recognition Skating politics Performance recognition Psychological warfare Act of skating (65%) Demands or costs of skating Movement and sensations (69%) Self-expression/creativity Financial demands or costs Athleticism of skating Time demands or costs Flow/peak experiences Personal costs Special cases (50%) Personal struggles (65%) Sense of specialness Physical or mental difficulties Coping through skating Self-doubts about talent Perfectionism Dealing with homosexuality Traumatic experiences (19%) Family disturbances

Numbers in parentheses denote percentage of sample that cited this source of enjoyment or stress. the young élite athlete 417

nature of sources of enjoyment in élite skating ment. Thus a comparison of sources of stress at and illustrate the potential benefits of competi- two different points in their skating career could tion at this level. be made. These same former élite skaters were also Several common sources of stress occurred at interviewed about the sources of stress experi- phase 1 and 2 according to the skaters. These enced during their most intense period of com- included the physical demands of skating (e.g. mitment to the sport (Scanlan et al., 1991). Five maintaining weight, injury), environmental major sources of stress were cited (see Table 28.3): demands (e.g. media exposure, skating politics) (i) negative aspects of competition (e.g. worries and psychological demands (e.g. competitive about failure); (ii) negative relationships with anxiety, self-doubts). High performance expecta- significant others (e.g. performance expectations tions were also common, although in phase 1 this of others); (iii) demands or costs of skating (e.g. had more to do with expected potential while financial and time demands); (iv) personal strug- in phase 2 concerns revolved around living up gles (e.g. weight problems, perfectionism); and to previous performance standards. Concerns (v) traumatic experiences such as death of a about relationships or stressors related to signifi- loved one or family problems. Some of these cant other were common to both phases, includ- sources of stress, most notably negative aspects ing conflicts with coach and skating partner and of competition, personal struggles and negative stress on the family. Concern about life direction interactions with significant others, had been was a stressor in phase 2 but not phase 1; this seen previously from a different perspective as involved thinking about the end of their careers positive sources of participation (i.e. as sources of (i.e. ‘What next?’). Finally, the majority of athletes enjoyment in the form of social opportunities, (71%) indicated that they felt more stress after, social recognition of competence and perceived rather than before, winning their national title. competence). Thus, the notion that competitive The increased stress resulted from increased sport can be a double-edged sword emerges once media attention, more criticism, pressure to again: some of the same sources that were impli- please judges, increased expectations and being cated as enjoyable also emerged as stressors when in the ‘big time.’ In summary, physical, psycho- observed from a different perspective. The logical and relationship sources of stress domi- problem is how to maximize the positive or nated the life of the élite young skater. enjoyable aspects of skating and minimize the negative or stressful aspects. Tennis Gould et al. (1993b) extended Scanlan et al.’s research on sources of stress for figure skaters in Andrea Jaeger, Tracy Austin, Mary Pierce, Jen- several ways. First, all 17 (10 female, 7 male) of nifer Capriati: the one thing these women have in their participants were former national cham- common is that they entered professional tennis pions. In addition, the sample included three at the ripe old age of 14 or 15 years; and shortly world champions and seven medallists at world after attaining success and even high status at championships or Olympics. The interviewees one or more of the grand slam events of their were about 25 years of age (range 18–33 years) era, these ‘women’ disappeared from the sport. with 13 years of skating experience at the time of Whether these disappearances were attributable interview. They were asked to reflect upon two to injury, burnout or social distractions, the phases of their skating career: phase 1 covered rather consistent entry of young female players the time from when they first began skating at a into the professional tennis world at the age of 14 senior level until they won a national champi- has raised some eyebrows and calls for docu- onship; and phase 2 covered the time between mented data to substantiate recommendations winning a national championship and the for change. present interview or at the time of their retire- To assess the extent to which burnout is a 418 psychosocial issues

problem in junior elite tennis, Gould et al. coach interactions) and psychological concerns (1996a,b, 1997) investigated factors related to (e.g. unfulfilled expectations, lack of enjoyment, burnout in élite young players (mean 16.4 years, pressure from self, coach and parents). This type SD 2.4). The study participants were ranked in of in-depth reporting made it possible to ‘walk a the top five in their state, the top six in their mile in the heads’ (Scanlan et al., 1989a) of these region and the top 55 in the nation for their age young athletes in order to understand why they group. In this study, burnout was defined as the left the sport they once loved. One of the more psychological, emotional and physical with- encouraging findings from Gould et al.’s assess- drawal from a formerly pursued and enjoyable ments (1996a,b, 1997) was that of the 30 burned- activity because of chronic stress. In a quantita- out athletes who participated in the study, 17 tive assessment of burnout vs. control subjects (55%) later returned to tennis, usually at a lower (24 females, 36 males), a number of demo- intensity of competition (e.g. high-school team). graphic, personality, psychological and coping Finally, a section of the interview allowed the variables differentiated the two groups. The athlete to offer advice to other players, parents strongest differences between the two groups, as and coaches in dealing with the stresses of com- assessed by size of effect, were that players with petitive tennis. These recommendations are sum- burnout reported less input into their training marized in Table 28.4. and tournament schedules, a greater number of To acknowledge the unique attributes of each years ‘playing up’ in age category, more parental individual’s experiences, Gould et al. (1997) pre- criticism, more concern over mistakes and less sented case studies of three burned-out young constructive coping skills. athletes (a 13-year-old female who burned out at In a qualitative follow-up assessment of 10 12, an 18-year-old male who burned out at 17 and players (6 females, 4 males) who scored highest a 21-year-old female who burned out at 17). on the burnout and perfectionism scales, several Although each identified a number of physical, interesting findings were uncovered. Factors logistical, social interpersonal and psychological leading to burnout included physical concerns concerns reflective of the earlier content analysis, (e.g. injured, overtraining, poor play), logistical each case was unique in the most salient motives concerns (e.g. time demands, travel, adjusting to that impelled their withdrawal from the sport of school), social interpersonal concerns (e.g. dis- tennis. The younger female cited pressure from satisfaction with social life, negative parent or her mother, who continually compared her with

Table 28.4 Advice by junior élite tennis players to other players, parents and coaches. (Data from Gould et al., 1996b)

Other players Parents Coaches

Play for your own reasons Recognize optimal amount of Cultivate personal involvement Balance tennis with other things ‘pushing’ needed with player No fun — do not play Lessen involvement Have two-way communication Try to make it fun Reduce importance of Use player input Relax outcome Understand player feelings Take time off Show support/empathy Other Other Parent–coach role separation Coach at your right level Have goal structure Solicit player input Foster right atmosphere Leave things on court Other Talk to pressuring parents Let people know how you feel Do non-tennis activities Make lots of friends with children Allow children to be children the young élite athlete 419

her older sister and with other better players, as were that she succeeded despite the insensitive well as her desire to be more social and spend coaching she received as a youngster, a style that time with her friends, none of whom were tennis drove all her friends from the sport. The study players. The older female, in contrast, indicated investigated 312 swimmers (168 females, 144 that the most important factor for her was males) who ranged in age from 10 to 18 years and placing too much pressure on herself to attain represented 11 USA Swimming registered teams. high but unrealistic expectations, which in turn The sample represented levels from novice to led her to overtrain (average 5 hours daily for 7 junior national status. Swimmers rated their days a week), resulting in a back injury that made coaches with regard to frequency of giving it harder to play and thus less fun. praise, encouragement, instruction and criticism, In summary, while Gould and colleagues and these ratings were correlated with the swim- noted a number of individual factors related to mers’ perceptions of competence, enjoyment and burnout (physical, logistical concerns), this phe- motivation for trying challenging skills. nomenon occurred within a social context in The results were analysed separately by which the structure of tennis, with its emphasis gender. Coaches who were perceived as giving on performance outcome, combined with more frequent praise combined with instruction parental expectations and demands, the need for following good performances and encourage- and importance of having friends to maintain ment plus instruction following unsuccessful motivation, and coaching communication styles performances were associated with young and behaviours played a big role in these female swimmers who rated themselves higher athletes’ perceptions of their tennis experiences. in swim success, swim ability, enjoyment of their The results of this series of studies substantiated swimming experience, perceived effort and chal- the age eligibility rule for women’s tennis (see lenge motivation. In contrast, those swimmers Chapter 37). who reported that their coaches engaged less fre- quently in these behaviours reported lower per- ception of ability, enjoyment and motivation. Swimming Interestingly for males, results were quite similar Like gymnastics, figure skating and tennis, in perceived coaching behaviours and psychoso- highly competitive swimmers start their sport at cial outcomes. These results suggest that a posi- an early age and thus overtraining, staleness or tive coaching style predominated by praise, burnout is imminent if not carefully monitored. instruction and encouragement is related to posi- In addition the intense pressure to win is height- tive self-perceptions and motivation among ened by the fact that thousandths of seconds can highly competitive young female swimmers. separate winners from losers, thus leading in Raedeke (1997) conducted a rather extensive recent years to substance abuse in young élite examination of the determinants of burnout swimmers. However, until recently very little levels in senior swimmers, the highest level for information has been gleaned from young com- age-group swimmers, who participated on club petitive swimmers to understand what factors teams under the auspices of USASwimming. The contribute to their enjoyment, as well as the per- sample consisted of 145 female and 84 male ceived pressures, of the sport. swimmers who ranged in age from 13 to 18 years Two studies of age-group swimmers have (mean 15.5, SD 1.5). These swimmers reported been reported that focus upon a number of working out 10.6 months a year, 14 hours a week, salient factors present in swimming (Black & 7.2 sessions a week and 36500m per week; Weiss, 1992; Raedeke, 1997). The study by Black indeed a high level of investment in their sport. and Weiss (1992) was inspired by Black’s own Raedeke adopted a commitment perspective in climb through the age-group system to qualify order to understand the phenomenon of burn- for the fateful Olympics of 1980. Her memories out; this perspective contends that individuals 420 psychosocial issues

may be committed to continuing an activity to, others to remain involved in swimming and either because they ‘want to’ stay involved (i.e. perceived little choice about their participation in attraction to the sport) or because they feel they swimming or about decisions regarding their ‘have to’ stay involved (i.e. feel entrapped or swim workouts. obligated to stay based on pressure by others). In contrast to the malcontents, ‘enthusiastic’ Raedeke hypothesized that swimmers who are swimmers (n=104) reported favourable impres- committed because of attraction to swimming sions of their swim involvement. This was indi- should show low levels of burnout, while swim- cated by their comparatively high scores on mers who feel entrapped in swimming should enjoyment and benefits; low costs, low social show high levels of burnout. constraints and attractive alternatives; and high To test his predictions, Raedeke assessed the investments, perceived choice and swim identity. swimmers on a number of psychological con- The third profile, dubbed the ‘obligated’ swim- structs that help determine commitment types: mers (n=40), were distinguished by their high perceptions of enjoyment, benefits and costs of social constraints, low perceived choice and high swimming, attractiveness of alternative activi- investments. Moreover, they reported moder- ties, personal investments (i.e. time, energy), ately low enjoyment and benefits and moder- social constraints (i.e. pressure from parents, ately high costs and attractive alternatives. team-mates, coaches), swim identity, and control Finally, the ‘indifferent’ swimmers (n=66) scored or choice over swim-related activities. A cluster comparatively low on swim investments and analysis identified four distinct profiles of swim- swim identity. Moreover, scores for enjoyment, mers who varied in their pattern of scores on benefits and social constraints were moderately measured constructs (Table 28.5). ‘Malcontent’ low. swimmers (n=26) perceived their swim involve- In summary, enthusiastic swimmers character- ment comparatively negatively in relation to ized the ‘want to’ or attraction-based commit- other profiles. They were characterized by low ment profile, while malcontent and obligated enjoyment, low benefits and high costs, low swimmers were notable for a more ‘have to’ or investments in swimming and felt that other entrapment form of commitment to swimming. activities were more attractive than swimming. Finally indifferent swimmers appeared to be In addition, they felt pressured by, or obligated neither attracted nor entrapped by their swim

Table 28.5 Commitment profiles of swimmers and scores on burnout dimensions. (Data from Raedeke, 1997)

Variable Malcontent Enthusiastic Obligated Indifferent

Enjoyment Lower Higher Average Average Benefits Lower Higher Average Moderately lower Costs Higher Lower Moderately higher Average Attractive alternatives Higher Lower Average Average Investments Lower Higher Moderately higher Lower Social constraints Higher Moderately lower Higher Moderately lower Swim identity Lower Higher Moderately higher Lower Perceived control Lower Higher Lower Average

Emotional/physical Higher Lower Higher Average exhaustion Reduced swim Higher Lower Moderately higher Average accomplishment Swim devaluation Higher Lower Moderately higher Average the young élite athlete 421

involvement; these swimmers may be candi- and 16 males who ranged in age from 19 to 35 dates for giving up the sport because of their years of age at the time of interview and who rep- unremarkable scores on any of the positive (e.g. resented a variety of sports: artistic and rhythmic enjoyment) or negative (e.g. social constraints) gymnastics, figure skating, swimming (includ- variables. ing synchronized), skiing, ice hockey, tennis, These four rather distinct swimmer profiles track and field, football, martial arts, rowing and were then compared on levels of burnout. In this wrestling. Female athletes were represented in study burnout was defined as a psychological all but skiing, field events, football, martial arts syndrome of physical and emotional exhaustion, and wrestling. The purpose of the study was to devaluation of swimming and perceptions of determine if common problems were associated reduced swim accomplishments. As Raedeke across a variety of sports and for both female and predicted, enthusiastic swimmers, who dis- male athletes. played attraction-based commitment, recorded Athletes were asked to recall the positive and the lowest scores on all three burnout dimen- negative aspects of their childhood athletic sions (see Table 28.5). In contrast, malcontent careers. A number of positive experiences were swimmers, who characterized entrapment- noted, such as opportunities to travel, gain pres- based commitment, scored highest on all tige, make lifelong friendships and the sheer burnout dimensions. Obligated swimmers, who enjoyment of the sport. However, respondents also resembled entrapment-based commitment, spent much more time expounding their nega- scored high on exhaustion and moderately high tive experiences. Among the problems reported on swim devaluation and reduced swim accom- were troubled family relationships (e.g. parental plishment dimensions. The indifferent swim- pressure, missing a part of family life, sibling mers registered average scores on all three jealousy), problems in social relationships (e.g. burnout dimensions. no time for friends, missing out on activities like Based on the results of this study, the swimmer ‘hanging out’, peer pressure), athlete–coach rela- profiles were distinguished from one another by tionships (e.g. physical and mental abuse, depen- a set of consistent variables, including enjoy- dence, domination), educational problems (e.g. ment, benefits and costs, social constraints and balancing school and sport), and physical and perceived choice. Although Raedeke adopted a psychological problems (e.g. overtraining, different framework to examine burnout to that illness, lack of sleep, burnout). used by Gould et al. (1996a,b, 1997), in both sets Female athletes predominated in problems of studies there are common findings regarding regarding the athlete–coach relationship. The élite young tennis players and swimmers: (i) majority of female athletes had male coaches and social psychological factors, in the form of per- several incidents of sexual encounters and abuse ceived support or pressure from significant were cited. Problems regarding the relationship adults and peers; and (ii) psychological charac- with coaches were rarely raised by the male ath- teristics, such as enjoyment or lack of enjoyment, letes. Sexual abuse and sexual harassment of input or lack of input into training schedules, young female athletes have been much publi- and high or low motivation. cized recently with a shocking article about Rick Butler, a USA volleyball coach of a top-level youth team, who has been indicted for sexual Across-sport findings misconduct with several of his former players Peter Donnelly (1993) conducted in-depth inter- when they were under the age of 18 years views with 45 retired Canadian élite athletes who (Howard & Munson, 1997). The greater fre- were asked to reflect upon their childhood high- quency of abusive coach–athlete relationships level sport participation (i.e. national team, has resulted in a call for national governing nationally ranked). Athletes included 29 females bodies to develop, endorse and implement a 422 psychosocial issues

code of conduct for coaches that would spell out hockey players (Ewing et al., 1988) and speed the rights of athletes and the responsibilities of skaters (Gutmann et al., 1984, 1986). These coaches, and the consequences for coaches who studies are not reviewed here because they violate the code (Donnelly, 1993). primarily described personality characteristics Several other negative experiences were noted or included only young male athletes. However, by these athletes. Excessive behaviours (e.g. it is clear that considerably more research is binge-eating and drinking, vandalism), use of needed on young, élite female athletes across a performance-enhancing drugs, dietary problems number of diverse sports so that we can better (e.g. eating disorders), politics of the sport (e.g. understand, explain and predict behaviours that team selection, judging, poorly trained coaches) occur within the sport context or because of their and retirement from competition (e.g. adjust- sport experiences. ment difficulties) were other issues the athletes cited as difficult to cope with during childhood. Anecdotal literature Of these problems, the majority of females cited problems with diet and body image that led in Over the last 15 years a number of books have many cases to excessive dieting or eating disor- been written by journalists and athletes about ders. These problems were not reported by the the child susperstar athlete (Greenspan, 1983; male athletes. Stabiner, 1986; Joravsky, 1995; Louganis, 1995; Donnelly implicated three major factors that Ryan, 1995). These works are notable because contributed to the negative experiences reported they include exclusive interviews with, and by these athletes: the organizational structure of observations of, élite young athletes, their the sport; large time commitments at such an parents and coaches in sports such as gymnas- early age; and gender. Donnelly’s analysis of the tics, tennis, figure skating, swimming, diving, data suggests that the negative experiences were basketball and distance running. The ability to far more serious and far-reaching for the female get ‘up close and personal’ with the major compared with the male athletes. In citing spe- ‘players’ of the élite child’s world provides a cific examples, he indicated that dietary prob- unique perspective on her perceptions, social lems seem to be brought on by the pursuit of environment and the pressures and demands of beauty, image and delayed puberty, which were the sport. perceived as requirements for success in certain Each of these books adopts a slightly different sports like gymnastics and figure skating. More- slant on the topic. For example, Little Winners over, the girls’ struggle to fight off natural (Greenspan, 1983) includes many different types growth contrasted starkly with the boys’ of individual sports and examines well-known embrace of natural growth that allows them to as well as little-known names (i.e. those who did become bigger and stronger and to extend their not ‘cut it’) in sports. Courting Fame (Stabiner, careers as professional athletes. 1986) looks exclusively at the world of the women’s professional tennis tour and the chal- lenges and barriers involved in attempting to rise Other sports up the ranks. Hoop Dreams (Joravsky, 1995), made Studies of psychosocial factors related to élite or into an award-winning documentary, magnifies highly competitive young athletes in sports other the lives of two young superstar boy basketball than gymnastics, figure skating, tennis and players in the city of Chicago and the widely dif- swimming have also been conducted. These ferent roads they travelled based on their growth include studies of young distance runners and development patterns and their coach’s (Rowland & Walsh, 1985; Feltz & Albrecht, 1986; expectations. In Breaking the Surface (Louganis, Seefeldt & Steig, 1986; Vogel, 1986; Feltz et al., 1995), eight-time gold medal winner in Olympic 1992), wrestlers (Gould et al., 1983a,b, 1991), ice diving Greg Louganis provides a birds-eye view the young élite athlete 423

of his formative years, focusing on several of the usually depends on ‘image’ (i.e. femininity), barriers to success in his early and later life such costume (i.e. ‘attractive’ or gaudy), weight (‘be as a learning disability, conflicts with his father, thin and win’), development (‘boobs and hips’), ethnic discrimination and attitudes toward his ability to charm the judges or simply predeter- homosexuality. Finally, Little Girls in Pretty Boxes mined expectations of performance. Two other (Ryan, 1995), perhaps the book to make the themes run through all these journalists’ biggest impact on public opinion, challenges the accounts: the development of one-dimensional subculture in élite women’s gymnastics and athletic identities and the notion of lost child- figure skating by calling it ‘celebrated child hoods. Time and again the athletes interviewed abuse’. Through numerous interviews with identified themselves exclusively as ‘gymnasts’, former and current athletes, coaches, parents and ‘tennis players’ or ‘figure skaters’ without other team-mates, Ryan documents mostly the horrors avenues of achievement to balance their days, of what the élite-level young athlete faces day in weeks and years consumed with training and and day out in a social context that condones competing in their sport. When their careers working out in pain, unhealthy weight- ended, often prematurely from developing management techniques and coaches who simu- bodies betraying them, these young, talented late dictators in their control over their athletes’ athletes often had a difficult time adjusting or lives. adapting to the ‘normal’ life of a child or Despite the unique contribution each book teenager. In a similar vein, young athletes makes to our understanding of élite young ath- lamented ‘lost childhoods’ because of the letes, these books also communicate strikingly demanding schedules and pressures of their similar messages. One consistent theme is the sport. They expressed a longing for hanging out adoption and internalization of behaviours that with friends, participating in normal school are accepted in the subculture of many individ- activities and living the unhurried, relatively ual sports, such as disordered eating, substance hassle-free life of a child or teenager. abuse (e.g. laxatives) and competing with serious Counteracting these negative experiences are injuries. Another theme is the controlling and the almost unanimous comments by athletes of often abusive behaviours adopted by coaches the positive learning experiences and psycholog- and parents in their vicarious pursuit of fame ical attributes they gained from élite sport par- and glory, pressuring young athletes to attempt ticipation and the special status they held among developmentally difficult skills and to train for sporting and non-sporting peers. The majority of an exorbitant number of hours. Some of the athletes in Donnelly’s (1993) study indicated that chapter titles of Ryan’s (1995) book encompass they would repeat their careers and would these issues: ‘Whatever it takes: coaches’ and ‘We involve their children in the sport if they could. all became junkies: parents’. Joan Ryan recounts These affirmative responses were dependent, at the comments of Elaine Zayak, national figure- least in part, upon resolution of some of the skating champion at age 15, when she decided current problems in the sport. However, these she wanted to quit the sport. Her parents told her responses and those of athletes in other studies that she had no say in the decision and that they (Klint & Weiss, 1986; Scanlan et al., 1989a,b, 1991; had scrimped to pay the prohibitive skating fees Coakley, 1992) highlight that the time, energy each year; finally, they exerted their control by and financial costs of competing at the élite level taking away her new car, which her father drove also come with unique benefits or opportunities himself. that may be difficult to attain in other domains. A third theme that emerged was the politics Thus, with some convergence between scientific inherent in the sport, especially in gymnastics and journalistic research we now turn to the and figure skating, where the difference in order question of what these findings mean and what of placing and thus amount of prize money national governing bodies, coaches and parents 424 psychosocial issues

can do to maximize positive experiences in high- was related to higher levels of burnout; and in level competitive young female athletes. the research by Gould et al. (1996a), the tennis players advised other athletes to play for their own reasons and urged parents and coaches to What do these findings mean? solicit player input. The anecdotal literature is One theme that has emerged consistently from replete with examples of controlling or coercive the research-based and anecdotal findings is the behaviours on the part of coaches and parents to importance of sport as a source of enjoyment for exhort young athletes to higher levels of perfor- high-level athletes. Recall that the results of mance. It is clear that high-level competitive Scanlan et al. (1989b) showed that social and life young athletes want control over their actions opportunities, perceived competence, social and choice in their training schedules and rou- recognition and the act of skating were most fre- tines. It would appear, then, that a balance in quently cited as sources of enjoyment in figure coaching and parenting styles that allows young skating. Similarly, it was shown that a lack of athletes to have an input in decision-making and enjoyment may lead to withdrawal or burnout. choice of activities would be of paramount Many of the gymnastic leavers in the study by importance for positive consequences. Klint and Weiss (1986) indicated ‘not having A third implication of the findings is the enough fun’ as a major reason, and their advice importance of emphasizing social support over to organizers included providing opportunities social constraints. Social support refers to the for more organized social time. In the studies by encouragement, personal concern for the athlete Gould et al. (1996a,b) lack of enjoyment was cited as a human being, empathy and unconditional as a psychological concern leading to burnout, affection that coaches and parents can provide and in the study by Raedeke (1997) malcontent for élite young females who are faced with tough swimmers scored low in enjoyment and high in demands and expectations. A young athlete’s burnout. Clearly, the enjoyment, pleasure and sense of worth or value as a person should not be fun experienced by élite young athletes are contingent on good performances or winning crucial factors for their involvement in the sport. medals. Social constraints, in contrast, refer to the However, it should be emphasized that ‘enjoy- emphasis on pressure, guilt trips, unrealistically ment’ does not mean frivolous play and lack of high expectations and the sense of obligation that focus. Rather, as indicated by Klint and Weiss coaches and parents place on young athletes to (1986), Scanlan et al. (1989) and Raedeke (1997), force them to stick to their training. Although this mastering difficult skills and strategies, working latter set of methods certainly succeeds in most hard to attain realistic but challenging goals, cases, the child and teenager comes to resent feeling a sense of competence and accomplish- these tactics and strives to detach herself at the ment, and expressing oneself and being creative first possible opportunity. This not only makes through the movements of the sport all constitute common sense but is also sound from a develop- sources of enjoyment for young, top-level mental perspective, as early adolescence marks a athletes. period where youngsters are motivated to estab- A second common theme that emerges from lish a sense of independence from adults. the data is the young athlete’s need and desire for The data support the necessity of maximizing control and autonomy over her involvement in social support and minimizing social constraints: sport. This view is bolstered by the research data: the gymnasts in the study by Klint and Weiss in the investigation by Klint and Weiss (1986), (1986), who suggested less pressure, more sym- gymnasts advised organizers to urge athletes pathy and more understanding from coaches; the to become involved in decision-making; in tennis players in the studies by Gould et al. Raedeke’s (1997) report, the perceptions of (1996a,b, 1997), who requested that parents and swimmers that they had little choice or control coaches engage in an optimal amount of the young élite athlete 425

‘pushing’, ‘mellowing out’, more support and empathy and ‘being there’ in tennis and outside What can national governing bodies, the sport; the swimmers in the study by Raedeke coaches and parents do? (1997), who reported that high social constraints The behaviours and norms adopted within élite were a risk for higher levels of burnout; and the child sports can be easily subjected to a number skaters in the study by Scanlan et al. (1991), who of psychologically based remedies, such as stress reported negative relationships with significant management skills for athletes, educating others as a major source of stress. coaches on child development, and shared goal- Finally, a multidimensional self-identity is a setting sessions for coach and athlete. However, characteristic that is essential for a balanced the structure or organization of sport is a larger lifestyle inside and outside of one’s sporting exis- entity that condones the types of activities that tence. This topic raises the issue of how young or may lead to heightened stress, overtraining, at what age youngsters should specialize in their burnout and excessive behaviours. Therefore, sport and the risks of doing so. On the one hand, it is important to consider both sociologically focused training from a young age is likely to or structure-based and psychologically or give a young female the competitive edge over individual-based strategies for change (Coakley, others who started later. On the other hand, the 1992; Donnelly, 1993; Gould, 1993; Gould et al., potential for injury, staleness and lack of a 1996a). normal childhood may contribute to ‘burn out’ the light in a young athlete’s passion for the Structural changes sport. The tennis players in the studies by Gould et al. (1996a,b, 1997) were most likely referring to Coakley (1992) suggests that changes to the this attribute when they acknowledged social structure and organization of sport programmes interpersonal concerns (e.g. dissatisfaction with can ‘empower’ young athletes so that they have social life) and logistical concerns (e.g. ‘gave up control over their lives inside and outside of all my time for tennis’, ‘tennis overwhelmed life’, sport. This, he believes, offers the child athlete ‘sole tennis focus’, ‘conflicting interests’). Also, the best chance of healthy social and psychologi- Donnelly’s (1993) élite sample commented on cal development. One way in which the structure problems in social relationships (e.g. no time for of sport can be changed is through laws govern- friends, missing out on activities) and on balanc- ing adult control of young athletes. Coakley ing school and sport. (cited in Nielsen, 1994) and Donnelly (1993) Coakley (1992) cautions that the structure of contend that child labour laws and laws regulat- sport for high-level adolescent athletes demands ing children in entertainment emerged to protect a sole or unidimensional focus on athletic children from the control of employers, agents achievements. Also, this structure exerts a great and parents. They raise the analogy: Should deal of control over the athlete’s life in and out of there be child athlete labour laws? In today’s sport. These structural qualities of élite sport, world of child athletic superstars, some families Coakley contends, contribute strongly to an depend upon their child’s earnings from athlete’s stress reactions, maladaptive behav- endorsements and winnings to sustain their iours and burnout. Thus in light of the scientific family income and a comfortable lifestyle. Thus data and the anecdotal findings, and the conver- the potential for control and conflict may occur gence of these sources, it is clear that structural because parents, coaches and agents stand to changes to the sport (e.g. code of conduct for gain from the talents of young athletes. coaches) as well as individual interventions (e.g. Coakley (1992) and Donnelly (1993) argue that support systems for athletes) are necessary to it is time to establish laws for élite child athletes. avoid the negative outcomes that can emerge These would include the maximum number of (Coakley, 1992; Donnelly, 1993; Nielsen, 1994). hours of training per day, number of days per 426 psychosocial issues

week children can practise and compete, amount • Confidence: to use a clear set of principles to of time elapsed between performances, amount guide themselves and their athletes. of time devoted to compulsory education, pro- • Motivation: to be excited about their sport, tection of income in trust funds, and health and their athletes and their team. safety regulations guaranteed in the gym (pool, • Personal concern: to be concerned about them field). To date, only the trust fund for young as children first and as athletes second. athletes is in effect. Because of the increased • Support: to recognize and praise their good business and corporate nature of amateur and performances and constructively instruct them professional sports, Coakley’s and Donnelly’s on skill errors. advice is not as sensational as one might at first In addition to providing caring and competent think. Perhaps a code of conduct for coaches in coaches, other crucial qualities of a code of specific sports is an idea that would be more conduct entail several issues previously dis- immediately embraced. Coakley (cited in cussed in this chapter. Most notable are the issues Nielsen, 1994) outlines the crucial qualities that related to healthy and constructive coach–athlete should characterize such codes, which should relationships and the importance of develop- include a number of goals and guidelines (Table mental goals for young athletes, including physi- 28.6). In addition, athletes in Donnelly’s (1993) cal (skill development, injury free), social study echoed many of the same goals when (friendships, moral development) and asked to make recommendations for improving psychological (self-confidence, coping with their sport. Foremost among these goals is priori- stress) goals. Recently the International Olympic tizing what children and adolescents want from Committee and the US Olympic Committee have their coaches, including the following (Nielsen, developed codes of conduct for coaches. Now 1994). the challenge is to launch the codes of conduct • Competence: to know the sport and be able to into action and hold governing bodies, adminis- communicate this knowledge to children. trators and coaches accountable for adhering to • Approachability: to be open to what young the code. athletes have to say and be willing to take criti- cism and admit to errors. Individual change strategies • Fairness and consistency: to recognize and treat young athletes according to their unique Both ego-involved (i.e. social comparison, needs. winning) and task-involved (i.e. learning, improving, fun) goals coexist in the highly com- petitive world of youth sport. The key is how to Table 28.6 Goals and guidelines for a coach’s code of keep a perspective on winning so that it does not conduct. (Data from Coakley cited in Nielsen, 1994) dominate all other goals. Therefore, a number of individual-centred or psychological-change Prioritize what athletes want from their coaches Identify realistic developmental goals strategies can be offered based on the literature Create support systems for athletes reviewed in this chapter. Provide a sound education for young athletes A consistent finding is that the potential for Code should be part of coaching qualifications undue levels of stress exists in the competitive Reorganize and regulate high-level sport to promote context. Thus, young athletes should be edu- overall athlete development Facilitate athlete informed choices about participation cated about what causes stress and how they can Ensure that children do not lose their childhood in cope with it in practice and competition. Both high-level sport Orlick and McCaffrey (1991) and Weiss (1991) Prevent sexual abuse and sexual harassment suggest a number of self-regulated learning Outline models of constructive coach–athlete strategies, such as relaxation, imagery, self-talk relationships and goal-setting, that young athletes can learn the young élite athlete 427

and improve with practice. These skills can also reserved for first-rate skilled individuals. On the be transferred to other social situations, such as other hand, they also recognize that they missed academic tests, public speaking and music or out on many normal activities that colour most dance performance. children’s lives: hanging out with friends, eating Other individual-orientated strategies derive and sleeping at normal hours, joining school from advice by élite young athletes (Klint & clubs and achieving in other domains, and just Weiss, 1986; Gould et al., 1996a) or from factors being a kid. The cost–benefit trade-off is one that that they believed contribute to continued moti- still needs to be examined and resolved if young, vation in their sport (Raedeke, 1997). The advice highly competitive, female athletes are to mature and reasons for motivation revolve around the physically, psychologically and socially. consistent themes outlined in this chapter: the need for a multidimensional identity (i.e. balanc- ing sport with other activities), having choice References and control over sport involvement (e.g. input Black, S.J. & Weiss, M.R. (1992) The relationship among on decision-making), experiencing fun and perceived coaching behaviors, perceptions of ability, enjoyment (e.g. achievement-related and non- and motivation in competitive age-group swimmers. achievement-related areas) and the need for Journal of Sport and Exercise Psychology 14, 309–325. social support not social constraints (e.g. seeking Brustad, R.J. & Ritter-Taylor, M. (1996) Applying social and requesting positive coach–athlete and psychological perspectives to the sport psychology consulting process. Sport Psychologist 11, 107–119. parent–athlete relationships). Coakley, J. (1992) Burnout among adolescent athletes: a personal failure or social problem? Sociology of Sport Journal 9, 271–285. Conclusion Donnelly, P. (1993) Problems associated with youth It is clear that considerably more research is involvement in high-performance sport. In B.R. Cahill & A.J. Pearl (eds) Intensive Participation in Chil- needed on the élite young female athlete from dren’s Sports, pp. 95–126. Human Kinetics Publishers, a psychosocial perspective in order to make Champaign, Illinois. informed conclusions about sport participa- Ewing, M.E. & Seefeldt, V. (1996) Patterns of participa- tion and recommendations for change. For tion and attrition in American agency-sponsored researchers, this means being granted more youth sports. In F.L. Smoll & R.E. Smith (eds) Chil- dren in Sport: A Biopsychosocial Perspective, pp. 31–45. opportunities for access to young athletes so that Brown & Benchmark, Indianapolis. they can be interviewed about their experiences Ewing, M.E., Feltz, D.L., Schultz, T.D. & Albrecht, R.R. in a setting that is non-threatening and protected (1988) Psychological characteristics of competitive from negative adult consequences (i.e. anony- young hockey players. In E.W. Brown & C.F. Branta mous, group data reported). To empower ath- (eds) Competitive Sports for Children and Youths, pp. 49–61. Human Kinetics Publishers, Champaign, Illi- letes it is important to give them a voice so that nois. they can provide input about what they want Feltz, D.L. & Albrecht, R.R. (1986) Psychological impli- from their experiences, their coaches and the cations of competitive running. In M.R. Weiss & D. governing body that oversees their particular Gould (eds) Competitive Sport for Children and sport. Youths, pp. 225–230. Human Kinetics Publishers, Champaign, Illinois. It is important to note that both positive and Feltz, D.L., Lirgg, C.D. & Albrecht, R.R. (1992) Psycho- negative aspects were recognized and acknowl- logical implications of competitive running in elite edged by the élite young athletes in the studies young distance runners: a longitudinal analysis. reviewed. Athletes understand and appreciate Sport Psychologist 6, 128–138. the unique benefits of being a talented young Gould, D. (1993) Intensive sport participation and the prepubescent athlete: competitive stress and performer and realize that their experiences burnout. In B.R. Cahill & A.J. Pearl (eds) Intensive travelling, competing, being recognized by audi- Participation in Children’s Sport, pp. 19–38. Human ences and occupying centre stage are events Kinetics Publishers, Champaign, Illinois. 428 psychosocial issues

Gould, D., Horn, T. & Spreeman, J. (1983a) Competitive Klint, K.A. & Weiss, M.R. (1986) Dropping in and drop- anxiety in junior elite wrestlers. Journal of Sport Psy- ping out: participation motives of current and former chology 5, 58–71. youth gymnasts. Canadian Journal of Applied Sport Sci- Gould, D., Horn, T. & Spreeman, J. (1983b) Sources of ences 11, 106–114. stress in junior elite wrestlers. Journal of Sport Psychol- Klint, K.A. & Weiss, M.R. (1987) Perceived competence ogy 5, 159–171. and motives for participating in youth sports: a test Gould, D., Eklund, R., Petlichkoff, L., Peterson, K. & of Harter’s competence motivation theory. Journal of Bump, L. (1991) Psychological predictors of state Sport Psychology 9, 55–65. anxiety and performance in age-group wrestlers. Krane, V., Greenleaf, C.A. & Snow, J. (1997) Reaching Pediatric Exercise Science 3, 198–208. for gold and the price of glory: a motivational case Gould, D., Jackson, S.A. & Finch, L.M. (1993a) Life at study of an elite gymnast. Sport Psychologist 11, the top: the experience of U.S. national champion 53–71. figure skaters. Sport Psychologist 7, 354–374. Louganis, G. (1995) Breaking the Surface. Random Gould, D., Jackson, S.A. & Finch, L.M. (1993b) Sources House, New York. of stress in national champion figure skaters. Journal Martens, R. (1978) Joy and Sadness in Children’s Sports. of Sport and Exercise Psychology 15, 134–159. Human Kinetics Publishers, Champaign, Illinois. Gould, D., Finch, L.M. & Jackson, S.A. (1993c) Coping Nash, H.L. (1987) Elite child-athletes: how much does strategies used by national champion figure skaters. victory cost? Physician and Sportsmedicine 15, Research Quarterly for Exercise and Sport 64, 453–468. 129–133. Gould, D., Tuffey, S., Udry, E. & Loehr, J. (1996a) Nielsen, W.V. (1994) Ethics in coaching: it’s time to do Burnout in competitive junior tennis players: II. A the right thing. Olympic Coach 4, 2–5. qualitative analysis. Sport Psychologist 10, 341–366. Orlick, T. & McCaffrey, N. (1991) Mental training with Gould, D., Udry, E., Tuffey, S. & Loehr, J. (1996b) children for sport and life. Sport Psychologist 5, Burnout in competitive junior tennis players: 322–334. I. A quantitative analysis. Sport Psychologist 10, 322– Raedeke, T.D. (1997) Is athlete burnout more than just 340. stress? A sport commitment perspective. Journal of Gould, D., Tuffey, S., Udry, E. & Loehr, J. (1997) Burnout Sport and Exercise Psychology 19, 396–417. in competitive junior tennis players: III. Individual Rowland, T.W. & Walsh, C.A. (1985) Characteristics of differences in the burnout experience. Sport Psycholo- child distance runners. Physician and Sportsmedicine gist 11, 257–276. 13, 45–53. Greenspan, E. (1983) Little Winners: Inside the World of Ryan, J. (1995) Little Girls in Pretty Boxes: The Making and the Child Sports Star. Little, Brown and Company, Breaking of Elite Gymnasts and Figure Skaters. Double- Boston. day, New York. Gutmann, M.C., Pollock, M.L., Foster, C. & Schmidt, D. Scanlan, T.K., Ravizza, K. & Stein, G.L. (1989a) An in- (1984) Training stress in Olympic speed skaters: a depth study of former figure skaters: I. Introduction psychological perspective. Physician and Sportsmedi- to the project. Journal of Sport and Exercise Psychology cine 12, 45–57. 11, 54–64. Gutmann, M.C., Knapp, D.N., Foster, C., Pollock, M.L. Scanlan, T.K., Stein, G.L. & Ravizza, K. (1989b) An in- & Rogowski, B.L. (1986) Age, experience, and gender depth study of former elite figure skaters: II. Sources as predictors of psychological response to training in of enjoyment. Journal of Sport and Exercise Psychology Olympic speedskaters. In D.M. Landers (ed.) Sport 11, 65–83. and Elite Performers, pp. 97–102. Human Kinetics Scanlan, T.K., Stein, G.L. & Ravizza, K. (1991) An in- Publishers, Champaign, Illinois. depth study of former elite figure skaters: III. Sources Howard, J. & Munson, L. (1997) Betrayal of trust: the of stress. Journal of Sport and Exercise Psychology 13, case against a top volleyball coach focuses attention 103–120. on the sexual abuse of young athletes. Women/Sport Seefeldt, V. & Steig, P. (1986) Introduction to an inter- 1, 66–77. disciplinary assessment of competition on elite Iversen, G. (1990) Behind schedule: psychosocial young distance runners. In M.R. Weiss & D. Gould aspects of delayed puberty in the competitive female (eds) Competitive Sport for Children and Youths, pp. gymnast. Sport Psychologist 4, 155–167. 213–218. Human Kinetics Publishers, Champaign, Joravsky, B. (1995) Hoop Dreams. Turner Publishing, Illinois. Atlanta. Stabiner, K. (1986) Courting Fame: The Perilous Road Klint, K.A. (1985) Participation motives and self- to Women’s Tennis Stardom. Harper & Row, San perceptions of current and former athletes in youth gym- Francisco. nastics. Master’s thesis, University of Oregon, Vogel, P. (1986) Training and racing involvement of Eugene. elite young runners. In M.R. Weiss & D. Gould (eds) the young élite athlete 429

Competitive Sport for Children and Youths, pp. 219–224. Weiss, M.R. & Hayashi, C.T. (1996) The United States. Human Kinetics Publishers, Champaign, Illinois. In P. De Knop, L.M. Engstrom, B. Skirstad & M.R. Weiss, M.R. (1991) Psychological skill development in Weiss (eds) Worldwide Trends in Child and Youth Sport, children and adolescents. Sport Psychologist 5, pp. 43–57. Human Kinetics Publishers, Champaign, 335–354. Illinois. Weiss, M.R. (1993) Psychological effects of intensive Weiss, M.R. & Petlichkoff, L.M. (1989) Children’s moti- sport participation on children and youth: self- vation for participation in and withdrawal from esteem and motivation. In B.R. Cahill & A.J. Pearl sport: identifying the missing links. Pediatric Exercise (eds) Intensive Participation in Children’s Sports, pp. Science 1, 195–211. 39–69. Human Kinetics Publishers, Champaign, Illi- Weiss, M.R., Wiese, D.M. & Klint, K.A. (1989) Head nois. over heels with success: the relationship between Weiss, M.R. & Glenn, S.D. (1992) Psychological devel- self-efficacy and performance in youth gymnastics. opment and females’ sport participation: an interac- Journal of Sport and Exercise Psychology 11, 444–451. tional perspective. Quest 44, 138–157. Wiggins, D.K. (1996) A history of highly competitive Weiss, M.R. & Hayashi, C.T. (1995) All in the family: sport for American children. In F.L. Smoll & R.E. parent–child socialization influences in competitive Smith (eds) Children in Sport: A Biopsychosocial youth gymnastics. Pediatric Exercise Science 7, 36– Perspective, pp. 15–30. Brown & Benchmark, 48. Indianapolis. Chapter 29

Ethical Issues

ANGELA SCHNEIDER

Introduction decisions about rules prohibiting drug use or equipment limitations designed to improve par- The ethical story of women’s participation in ticipant safety should apply equally to women sport in general, and Olympic sport in particular, and men. Thus, those moral problems com- is the story of two ideals in apparent conflict. mon to the realm of sport, important as they are, From inception, the ideal of the Olympic Games are more appropriately discussed elsewhere and the ideal Olympic athlete applied specifi- (Schneider, 1992, 1993; Butcher & Schneider, cally and exclusively to men. In de Coubertin’s 1993; Schneider & Butcher, 1993, 1994, 1998). ideal the goals to be achieved by the athletes However, this chapter is devoted to the moral through participation in the Olympic Games issues that arise because it is women who are the were not appropriate for women (de Coubertin, athletes. Thus the discussion that follows focuses 1986). It is this basic idea, that sport (or some- on gender, ethics and sport, and the interrelation- times even physical activity) and particularly ships amongst them. high-level competitive sport is somehow in- compatible with what women are or what they How to approach ethical issues for should be, that dominates any discussion of women in sport and sport medicine ethical issues for women in sport. The notions of ideal Olympic sport and ideal women lie behind There are three standard elements of a methodol- many of the discussions in modern sport: ogy that attempts to deal with ethics and women whether to permit women to compete, the types in sport and sport medicine (this methodology of sport in which women can compete, the devel- was first identified by Tong (1995) in the field of opment of judging standards for adjudicated as bioethics). The first involves asking what was opposed to refereed sports (contrast gymnastics originally referred to as ‘the woman question’ and basketball), attitudes to aggression and com- and is now called by some researchers ‘the petition, and indeed the very existence of gender biased question’ (Tuttle, 1986). This ques- women’s sport as a separate entity at all. tion challenges the supposed objectivity of scien- Before examining some of these issues in tific research findings regarding the nature of detail, it is worth making a distinction at the woman and the objectivity of the profession of outset. Many of the moral issues that arise in medicine based on that research (Dreifus, 1977; sport arise equally for men and women. At the Corea, 1985; Schiebinger, 1989, 1993; Okruhlik, personal level, the decision whether or not to 1995). Underpinning this question is the claim cheat, what attitude you will take to your oppo- that many of the ‘facts’ about female ‘nature’ nents or the unearned win are moral problems actually result from values founded on biased any athlete must face. At the institutional level, social constructions (Ehrenreich & English, 1979; 430 ethical issues 431

Fausto-Sterling, 1992). The precepts and prac- empowered and able to take on some of the tices of medicine can be and are misshaped by responsibility for changing the sport world. gender bias (Sherwin, 1992; Tong, 1995). This The last part of this methodology is based on gender bias works almost unconsciously and three philosophical moral theorists: Aristotle, occurs when decision-makers in sport and physi- Rawls and Mill. It is an attempt to gain a Rawl- cians in sport medicine treat all athletes, all sian reflective equilibrium between principles, human bodies, as if they were all male athletes rules, ideals, values and virtues on the one hand, and male bodies. They then view athletes or their and actual cases in which moral decisions must bodies as dysfunctional if they fail to function be made on the other. Aristotelian practical rea- like male bodies or express little or no curiosity soning assumes that moral choices are made, for or interest in the problems unique to women. the most part, between several moral agents There are issues in sport medicine that are, for the rather than isolated within one individual. Mill’s most part, unique to women, e.g. the female views on the importance of listening, as well as athlete triad (eating disorders, amenorrhoea and speaking, in the course of a moral dialogue is osteoporosis), gender verification, reproductive stressed. Since the practice of ethics requires control and pregnancy, sexual harassment, etc. communication, corroboration and collabora- There are issues unique to men. There are issues tion, we are not alone when we grapple with unique to certain sports. There are common applying ethics to sport and sport medicine. issues for participants across regions, sports and Accepting our limited ability to explain and particular quadrennial cycles. Sport medicine, as justify our decisions and actions to each other, a profession, and sport organizers need to be while simultaneously insisting that we try aware of sex/gender similarities and differences harder to find the appropriate words, is a neces- in order to deal adequately with ethical issues. sary part of this practical reasoning. The second part of this methodology is that of Using this three-part methodology we can dis- consciousness-raising. This requires that women cover mutually agreeable ways to weaken pat- be invited to contribute their personal experi- terns of human domination and subordination ences to sport and sport medicine so that it has in the realm of sport and sport medicine and, wider meaning for all women. To a certain ex- in particular, patterns of male domination and tent this kind of invitation was issued by the female subordination. This type of discussion International Olympic Committee when it held requires the adoption of a particular stance and the First World Conference on Women and Sport the development of a particular set of questions. in October 1996. For example, women who share The answers to these questions must be dealt experiences of sexual stereotyping or sexual with and understood within the context of harassment in sport often come to realize that women’s experiences in sport. If we truly seek their feeling of having been treated as a girl understanding of these issues, we must under- rather than as a woman is not unique to them but stand the perspective and thus the social, common to most women. Such women, if given psychological and political predispositions that the opportunity, routinely gain the courage and we ourselves bring to the discussion. For confidence to challenge those who presume to example, I am a white, female, well-educated, know what is best for them as they become socially/politically advantaged, Canadian, agn- increasingly convinced that it is not they but the ostic, heterosexual, mother, former Olympic sport ‘system’ that is crazy. The purpose of this silver medallist, etc., and I am going to bring a consciousness-raising is to achieve fundamental different perspective and context to the questions changes by connecting the personal experiences of gender, ethics and sport than someone who of women to developments in sport and sport has a different race, gender, education, social/ medicine. Consciousness-raising suggests that political position, nationality, religion, sexuality, women, sharing among themselves, will become etc. This does not mean that we cannot reach 432 psychosocial issues

some agreement on important issues, but it does horses, skiing or playing soccer’ (Spears, 1988). mean that we must be willing to listen and give Several discussions of de Coubertin’s position on due respect to differing perspectives in our women and sport include the following quota- search for justice. This search for justice also tion from the Olympic Review of 1912 as evidence requires an understanding of where the power to of his gender-biased view of the Olympic Games: make changes lies and the willingness of those ‘[as] the solemn and periodic exaltation of male who hold it to share that power. athleticism, with internationalism as a base, loyalty as a means, art for its setting, and female applause as reward’ (Leigh, 1974; Spears, 1988; The Olympic ideal and De Frantz, 1993). De Coubertin, and many others women athletes in the Olympic Movement, believed that sport Although there are competing interpretations of was the proper preserve of men. Women were de Coubertin’s conception of Olympism (Lowe, somehow unsuited to sport and should, for their 1977; Rioux, 1986; Segrave, 1988; Loland, 1994), own good, be excluded (Veblen, 1953). This is one there is general agreement on some of the domi- area where the attitudes and values of Olympism nant themes. The values that seem to have the have shown steady (albeit slow) development. greatest support are those deemed to have defined Olympism for most of this century: Ideal woman (i) education; (ii) international understanding (peace); (iii) equal opportunity; (iv) fair and It should be clear that the battles which represent equal competition; (v) cultural expression; (vi) the ethical issues for women in Olympic sport independence of sport; (vii) excellence; and (viii) will be fought over conceptions of women: their amateurism until fairly recently. On the face of it, bodies and their minds. The traditional ideals there seems to be no reason whatsoever that any of woman upheld during the ancient Olympic of these values be exclusive to male athletes or Games and during the revival of the modern males in general. However, it is equally clear that Olympic Games (up to and including some women athletes have not been given the same current ideals) are intimately tied to a particular opportunities as male athletes, from the ancient view of woman’s body. Some of these character- Greek Olympics through the 19th century until istics are soft, graceful, weak and beautiful. The current times. It would now seem rather obvious desirable qualities for a woman in the time of the that the value of equal opportunity would logi- ancient Olympics can generally be summarized cally entail women athletes. as beauty, chastity, modesty, obedience, incon- spicuous behaviour, a good wife and a good mother (Lefkowitz & Fant, 1982) (Fig. 29.1). Of Equal opportunity course, these characteristics are tied to the roles Baron de Coubertin intended his vision of sport of wife, mother and daughter. These characteris- to be universal and available to all classes tics are not similar to those of the traditional ideal (Segrave & Chu, 1988; Loland, 1994) but there are of man as hard, powerful, strong and rational, interesting gaps in the scope of his late-19th which are tied to the roles of leader, warrior and century vision in that he does not include just father. More importantly, if we examine the over half the population—women. However, de underlying characteristics of the traditional ideal Coubertin’s views on women in sport were not athlete, in particular the Olympian hero, we can atypical for the late 19th century: ‘Throughout plainly see that the ideal man and the ideal his writings, he expressed his views against Olympian are very similar, particularly in the women in sport. He did not think well of women role of warrior (for a current personal account of perspiring in public, assuming positions he the relationship between masculinity and sport deemed ungainly, and appearing in public riding in North America see Messner & Sabo, 1994). ethical issues 433

Fig. 29.2 Amazon. (Adapted from Mercatante, 1988.)

Fig. 29.1 Venus (Aphrodite). (Adapted from Mer- catante, 1988.) wanted from the ancient games and rejected aspects that did not fit his ideal (Spears, 1988). He Conversely, we can plainly see that during the also had some exceptional counter-examples times of the ancient Olympic Games and during from ancient Greece in the writings of Plato, even the rebirth of the modern Olympic Games the though it is unlikely that de Coubertin knew that ideal woman and the traditional ideal Olympian girls did compete in athletic festivals in ancient athlete are almost opposites, so much so that Greece. Plato argued that women should be women were hardly ever mentioned in conjunc- accorded the right to attain the highest rank he tion with sport. could conceive of in human excellence—the ‘In contrast to these infrequent and casual philosopher ruler—and to be equally educated references to women’s sport, accounts of men’s in the gymnasium by exercising naked with sport and athletics abound in ancient Greek lit- the men (Bluestone, 1987). Other exceptional erature. Homer vividly describes events from counter-examples from ancient Greece that stress chariot racing to boxing. Pausanias furnishes physicality and a warrior nature for woman are a detailed account of the Olympic Games, the archetypes of Artemis, Atalanta and the and Herodotus, Thucydides, and other Greek Amazons, who all rejected the traditional role for authors refer to the Olympic Games and athletic women (Creedon, 1994) (Fig. 29.2). However, festivals such as the Pythian, Isthmian, and de Coubertin apparently never saw women as Nemean Games’ (Spears, 1988). having central roles in Olympism; he preferred One might argue that since the ancient athletic them as spectators and medal bearers for the pre- festivals did not embrace women, why should de sentation to the victors. Coubertin, in his attempt to successfully revive The fundamental ethical issue in this entire them, do so? One response is that de Coubertin discussion is who decides which images of had an ideal in mind and he selected what he woman are permitted, desired or pursued in 434 psychosocial issues

Olympic sport. The primary ethical question for takes for granted is that no one is entitled to women in sport is inextricably linked to the ques- speak on another’s behalf without that person’s tion of power and autonomy. At the institutional permission. level, if men decide what sports women are per- mitted to attempt, the standards of physical per- Sport paternalism and women’s participation fection that are to be met in adjudicated sports or the levels of funding accorded women’s as Is there any reason why women should not opposed to men’s sport, then women have a participate in sports that men have traditio- legitimate grievance of not being treated with nally played? It is instructive to look at what due respect. Just as it is the responsibility of each could possibly count as a morally acceptable male to decide for himself the type of body and answer. If there was a sport practised by men the type of life he wishes to pursue, moral or that was physiologically impossible for women, otherwise, it is the responsibility and right of this would count as a reason for the non- each woman to deal with the challenges with participation of women. However, there is no which the female athlete must contend. such sport. To qualify, the sport would probably have to primarily involve male genitalia and there is no institutionally sanctioned sport of this Paternalism and autonomy type. A second possibility would be if there was a The Oxford Dictionary of Philosophy defines ‘pater- sport played by men that no women in the world nalism’ as ‘government as by a benign parent’. actually wanted to play. It is possible that a sport Paternalism is not necessarily sexist, although it might be invented that not one woman would often has been in sport and sport medicine, and is want to play, but then the reason the women often well-meaning. It occurs when one person would not be playing would be that they had makes a decision on behalf of, or speaks for, chosen not to play, not that someone else had another that he or she takes to be in the latter decided that they should not. Morally unac- person’s best interest. In the case of children, this ceptable answers for prohibiting women from is a necessary part of the parenting process until playing sport include ‘it would be bad for the child becomes an adult. Paternalism is also women to participate’ or ‘there is not enough morally acceptable in cases where the person money to allow women to participate’. Let us concerned is unable, for good reason, to speak or look at each of these answers in turn. make decisions for himself or herself. It is ‘It would be bad for women to participate’ is morally troubling when it occurs on behalf of the standard line that has been used throughout competent adults. the history of sport. The exact nature of the harm The concept of autonomy in ethical decision- that would befall women changes: it could be making is very important. In the Oxford Dictio- that participation ‘defeminizes’, which might nary of Philiosophy autonomy is defined as the mean that it would make some women less ‘capacity for self-government’; furthermore, attractive in the eyes of some men, either physi- ‘agents are autonomous if their actions are truly cally or mentally, or that it would be harmful for their own’. The crucial point here is that an essen- women such that they or their yet unborn chil- tial part of being human is having the right and dren would suffer some physiological damage the capacity to make the choices and decisions (for a good discussion of these points see Schnei- that most affect oneself. Each competent human der, 1993; Cahn, 1994). There are two points to be adult has the right to choose to pursue the pro- made here. The first is practical: the assertions jects and endeavours that he or she most cares that women are harmed and men are not harmed about. That right is naturally limited by the by strenuous physical exertion are simply not rights of others to pursue their own desires and true. However, it is the second point that is more interests, but what the concept of autonomy important: women have the right, just as men do, ethical issues 435

to decide what risks of harm they will run. minimize the health risks they impose on the Subject to the normal limitations on every athlete. person’s freedom, it is immorally paternalistic to Amenorrhoea and pregnancy are unique to decide on behalf of another competent adult women athletes and raise issues concerned with: what personal risks he or she can choose to (i) the implications all women face when repro- accept. ductive aspects of their lives are designated as The argument that ‘there is not enough money’ illness; and (ii) the tension between the two con- can be a more difficult case to answer. It can- flicting traditional ideals of woman and athlete. not be morally required to do the impossible. An essential part of the traditional ideal woman However, ‘there is not enough money’ often is fertility because it is necessary for child- masks an inequitable distribution of the bearing. Fertility and child-bearing are not only resources that are available. If there is money superfluous for the ideal athlete, they are anti- available for anyone to participate in sport, then thetical to the role of athlete as warrior (e.g. that money must be available on an equitable Amazons). In many ways the Amazons were basis for both women and men. Men’s sport is viewed as monstrosities because they rejected not intrinsically more important or more worth the primary biological role of woman. while than women’s sport and therefore has no Historically, some medical authorities have automatic right to majority funding. created a series of double binds (i.e. situations in which options for an oppressed group are reduced to a very few and all of them expose the Challenges to women athletes group to penalty, censure or deprivation; Frye, In this section, some of the challenges that 1983; Sherwin, 1992) for women because of the women athletes face are examined from a moral decision to view menstruation, pregnancy, point of view. Some of these challenges are a menopause, body size and some feminine behav- result of the institutional climate for women in iours as diseases (Broverman et al., 1981; Martin, sport (e.g. biased, resistant and ‘chilly’), which 1987; Lander, 1988). For the female athlete the will require policy and practice changes. Other situation is more complicated because she can challenges, physical, mental and indeed spiri- be classified as even more abnormal when re- tual, occur at a personal level. From a physical productive changes are evaluated in the context perspective these challenges may include, but of the traditional male sports arena. For example, are not limited to, body composition and devel- if the normal healthy woman is considered an opment issues related to the health and well- unhealthy adult from a medical perspective, being of the athlete. Some of these problems are a because the ideal healthy adult is based on being direct result of the demands of participation in male (Broverman et al., 1981), the female athlete sport. For example, many élite-level sports have starts out as an unhealthy adult because she is a a high risk of injuries and, generally speaking, woman. Further, if the female athlete shows élite-level training produces fit but not necessar- signs of masculinization, this is thought of as a ily healthy athletes. The results of those pres- further abnormality because it is not normal for a sures can be, and in many cases are, different for woman to have masculine characteristics. Fol- men and women but the choice of whether or not lowing this kind of medical classification, when a to train and compete is the same. However, in woman bleeds she is ill (‘Woman . . . is generally those sports where performance is judged (e.g. ailing at least one week out of four . . . woman is gymnastics, diving, ice skating), the physical not only an invalid, but a wounded one’; Lander, requirements and resulting risks are directly 1988) and if she does not bleed (e.g. amenor- caused by decisions about what counts as an rhoea, menopause and pregnancy) she is ill, excellent performance (Suits, 1988). The judging because it is not normal for her to be unable to criteria for these sports should be tailored so as to conceive and thus make successful use of her 436 psychosocial issues

reproductive organs (Martin, 1987; Lander, 1988; sport. Some researchers suggest that this pre- Zita, 1988; Sherwin, 1992). Pregnancy constitutes dominance may be linked to the socially and a state of health for the traditional ideal woman legally acceptable extreme levels of violence in and should not be treated as a disease requiring some sports (S. Kirby & C. Brackenridge, unpub- a significant amount of specialized treatment. lished observations). The control over, and moral However, throughout pregnancy women, and responsibility for, violence, abuse, harassment women athletes in particular, are not encouraged and discrimination in and surrounding sport lies to think of themselves or their lifestyles as mainly in the hands of those in the sport commu- healthy. Serious charges of irresponsibility can be nity and is a concern for both men and women. levelled when the relationship between a woman Some women, weary of being ignored on these athlete and her fetus is characterized as adversar- issues and for a host of other reasons, advocate ial. Most pregnant women athletes, who are completely separate sport for women as opposed falsely charged with harming their fetuses, face to any integration at all. at least moral pressure based on the view that One argument against integration is that being pregnant and participating in sport is a women have to accept the current selection of socially unacceptable behaviour. However, sports that were primarily designed for and prac- genuine harm to the fetus may occur with partic- tised by men, with an established culture that ipation in some sports, such as scuba diving. rewards and recognizes values that most women Rather than sanctioning interference with a do not hold (e.g. viewing sport as a battleground female athlete’s reproductive freedom that on which one conquers one’s foes). Separation denies her interest in the health of her fetus and might allow women the freedom to create sport her role as an active independent moral agent, based on the values they choose (Lenskyj, 1984). the focus should be on education. In this argument, capacities viewed as unique to The classification of these reproductive aspects women are stressed: sharing, giving, nurturing, as illnesses has led to wide-scale paternalistic sympathizing, empathizing and, above all, con- medical management of women under the necting as opposed to dividing. Nevertheless, façade of beneficence (Sherwin, 1992). In sport, some would urge women to pay the high price these so-called illnesses have been part of the of integration so that they can have the same basis for excluding women. This does not mean opportunities, occupations, rights and privileges that serious complications requiring medical that men have. This drive for the uniformity interventions cannot occur during a female of women with men has sometimes denied athlete’s reproductive life or life-cycle changes women’s unique qualities and that these quali- and ageing. There will be particular cases where ties might contribute very positively to sport and the label of illness or disease is appropriate, pro- the study of sport medicine. The argument is that vided that it does not lead to discrimination if women emphasize their differences from men, against women athletes from a sport policy per- viewing these as biologically produced and/or spective (e.g. banning them from participation culturally shaped, they will trap themselves in rather than educating them about coping with ghettos while men will continue as they have their illness and participating in sport). been. The female athlete must also face challenges If we think that women athletes must either act regarding the mental requirements of sporting as men if they accept the male ideal or be sepa- competition, i.e. aggression and violence. Male rate and generate their own ideal, then the sport athletes also face these challenges, but it is experience is highly gender specific. However, considered ‘normal’ for men and ‘abnormal’ for the two views of sport, i.e. sport as competition women to engage in violence. Traditionally it has (‘agonistic’) or sport as connected co-questers also been predominantly men who have commit- searching and striving for excellence, may be ted sexual abuse against women and minors in logically independent of the gender of the ethical issues 437

athlete. The greatest tension arises for women if women’s event. A male may even, with good we have an agonistic view of sport and women intentions, choose to enter a women’s event such are found to be inherently or ‘essentially’ caring as synchronized swimming as a form of protest and connected to others (Gilligan, 1982; Nod- against gender discrimination. Without a test to dings, 1984). In such a model of sport, women decide who is eligible, we could be forced to may be required to disconnect from their embod- accept participants in women’s events who were ied experience. This could be the basis for some quite obviously and unashamedly male but who form of alienation. It is probably the case that merely professed to be female. most athletes (male and female) find themselves One case which illustrates the conceptual and torn between conflicting views of sport because moral issues that litter the issue of gender verifi- pushing oneself to one’s limits challenges even cation is that of Renée Richards. In 1976 a new the strongest sense of self; because in their player, Renée Clarke, appeared on the US moments of agony and joy they tend to experi- women’s tennis circuit and ‘soundly thrashed’ ence themselves as both radically alone, since no the defending champion in the women’s divi- one else can really understand what they feel, sion. She was subsequently shown to be Renée and fundamentally united to their team-mates, Richards, who had recently undergone a sex- their competitors and with all of humanity, par- change operation and was previously an élite- ticularly when this experience happens during level male tennis player (Birrell & Cole, 1994). competition in the Olympic Games. The US Women’s Tennis Federation wanted to exclude the player, who was genetically male but reconstructed physiologically and presumably The logic of gender verification psychologically as a female, as unfair competi- Entirely separate sport, even just separate tion. The United States Tennis Association, the women’s events, inevitably leads to the question Women’s Tennis Association and the United of the logic of gender verification. If there are to States Open Committee therefore introduced be separate sports or sporting events for women the requirement that players take the Barr test only, it must be possible to exclude any men that (Birrell & Cole, 1994), a chromosomal test. may wish, for whatever reason, to compete. This Richards refused and went to court to demand means that there must be a rule of eligibility that the right to participate in women’s events. In excludes men. Conversely, if we have such a rule court she was deemed to be female on the basis of for excluding men, should we, for consistency, the medical evidence produced by the surgeons have such a rule excluding women from men’s and medical professionals who had overseen her events even if the women believed they would transformation from male to female. In the media inevitably lose but wanted to take part anyway? this story played as an example of a courageous This in turn requires that we have a test of gender individual fighting for personal rights against an and/or sex that can be applied fairly to any intransigent and uncaring ‘system’ (Birrell & potential participant. There are at least three Cole, 1994). There are other ways of viewing the methods of applying such a test: (i) test all con- story. testants; (ii) test random contestants; and (iii) test What makes a woman a woman? Is it chromo- targeted individuals. somes, genitalia, a way of life or set of roles, or a Before examining testing further, we must first medical record? It is not clear why medical evi- deal with the response that we do not need to test dence of surgery and psychology should out- because a man would never wish to compete in a weigh chromosomal evidence; in fact it is not women’s event. ‘Never’ is a very strong word. It clear why any one answer should be taken as cat- is not beyond the realm of imagination that a egorically overriding any other. However, if the money-hungry promoter might decide that it methodology outlined in the second section was a great publicity stunt to enter a man in a of this chapter is used, the process of arriving 438 psychosocial issues

at a conclusion becomes clearer: (i) asking ‘the tribution of power in each case can identify a par- woman or gender biased question’; (ii) raising ticular factor as the primary cause of women’s consciousness by connecting the personal experi- subordinate status in sport, which for the most ences of women to developments in gender part has traditionally been based on biology. verification in sport and sport medicine; and However, to adequately deal with these prob- (iii) using practical reasoning that attempts to lems, researchers must also look at economics, gain a reflective equilibrium and accepts our law, education, national boundaries, language limited ability to explain and justify our deci- and so on, because all of these factors have con- sions, while simultaneously insisting that we tributed, more or less strongly, to the current try harder to find the appropriate ways. Thus status of women’s sport and sport medicine per- women themselves can, and need to, be the taining to women athletes. Researchers can, and guardians and decision-makers concerning should, attempt to ascertain the actual status women’s sport. of both sexes in sport and the actual health of Some women argue that any gender or sex test both sexes in sport medicine and determine how is demeaning (especially visual confirmation of far that condition deviates from what justice the ‘correct’ genitalia) and discriminates against prescribes. women athletes if it is not also applied to men. The current conditions in sport and sport med- Clearly the use of any test, given the complexity icine may be made more objective by providing of human sex and gender, may lead to anomalies more facts, as opposed to myths or stereotypes, and surprises. Yet many women wish to have about women athletes, thus alleviating or even sporting competition that excludes men. The best eliminating the past and ongoing injustices. result we can achieve will be one that arises The knowledge required to create good, just through discussion, debate and consensus and and rational sport practice and sport medicine thus will be the fairest we can arrive at. practice can be acquired. It is a matter of discov- ering and acknowledging all the true facts. Unfortunately for women athletes, it may still be Recommendations for future research some time before all rational agents see the same Dealing with instances of gender oppression or thing when the facts stare them in the face. neglect in sport and sport medicine requires mul- Women are now beginning to be credited with tiple combinations of social, biological, political, being able to recognize the realities of sport that ontological and epistemological methods. This men do not typically see (Messner & Sabo, 1990). complex approach enables the development of The ‘master’s position’ in any set of dominating an ethical framework that can provide the means social relations—the general position of men for discerning and solving the problems regard- vis-à-vis women in sport—tends to produce ing women and sport and requires the acknowl- distorted visions of the real regularities and edgement that there is no clear line between underlying causal tendencies in social relations. ethics and social/political concerns. Some of the Men experience their power over women as most important moral questions to be asked in normal, even beneficial, but this is not women’s cases of gender oppression and neglect in sport experience. Women see systems of male domina- and sport medicine are specifically about male tion and female subordination in sport and sport domination and female subordination. A coher- medicine as abnormal and harmful ways for men ent understanding of the causes of women’s and women to relate to one another. Rather than subordination to men in sport, coupled with a being irrelevant, political and social position refined programme of action designed to elimi- determines the way in which we see the facts, nate the systems and attitudes that oppress or including fundamental facts, about the human cause neglect of women in sport, must guide this body and mind. It is possible to find truth and complex approach. A detailed analysis of the dis- justice for women in sport, but presently they are ethical issues 439

partial, provisional and changing in nature Issues and Controversies, pp. 185–193. Sage Publica- (as Tong (1995) has concluded in the area of tions, California. Dreifus, C. (ed.) (1977) Seizing Our Bodies: The Politics of bioethics). Everyone’s knowledge about sport, Women’s Health. Vintage Books, Random House, sport science and the health and well-being of all New York. athletes, including women athletes, is limited. If Ehrenreich, B. & English, D. (1979) For Her Own Good: we wish to understand a broader experience 150 years of the Experts’Advice to Women. Anchor than just the dominant one, we must talk to and Books, Garden City, New York. Fausto-Sterling, A. (1992) Myths of Gender: Biological take seriously as many athletes as possible. Truth Theories About Women and Men, 2nd edn. Basic Books, and justice will emerge through these shared New York. conversations. Frye, M. (1983) The Politics of Reality: Essays in Feminist Theory. Crossing Press, Freedom, California. Gilligan, C. (1982) In a Different Voice: Psychological Acknowledgements Theory and Women’s Moral Development. Harvard Uni- versity Press, Cambridge, Massachusetts. I would like to thank Drs S. Kirby, K. Okruhlik, Lander, L. (1988) Images of Bleeding: Menstruation as and S. Brennan for their informative input to Ideology. Orlando Press, New York. this chapter. I would especially like to thank Lefkowitz, M. & Fant, M. (1982) Women’s Life in Greece my partner Dr R.B. Butcher for the critical and Rome: A Source Book in Translation. Johns Hopkins University Press, Baltimore. analysis and insights he contributed throughout Leigh, M. (1974) The evolution of women’s participation in this chapter and his patience, support and the Summer Olympic Games, 1900–1948. Doctoral dis- encouragement. sertation, Ohio State University, Columbus. Lenskyj, H. (1984) Sport Integration or Separation. Fitness and Amateur Sport, Ottawa. References Loland, S. (1994) Pierre de Coubertin’s ideology of Olympism from the perspective of the history of Aristotle (1941) Ethica Nicomachea (Nicomachean ideas. In R.K. Barney & K.V. Meier (eds) Critical ethics). In R. McKeon (ed.) The Basic Works of Reflections on Olympic Ideology: Second International Aristotle, pp. 935–1127. Random House, New York. Symposium for Olympic Research, pp. 26–45. Centre for Birrell, S. & Cole, C.L. (1994) Women, Sport, and Culture. Olympic Studies, University of Western Ontario, Human Kinetics Publishers, Champaign, Illinois. London, Ontario. Bluestone, N. (1987) Women and the Ideal Society: Plato’s Lowe, B. (1977) The Beauty of Sport: A Cross-disciplinary Republic and Modern Myths of Gender. University of Inquiry. Prentice-Hall, Englewood Cliffs, New Jersey. Massachusetts Press, Amherst. Martin, E. (1987) The Woman in the Body: A Cultural Broverman, I., Broverman, D., Clarkson, F., Analysis of Reproduction. Beacon Press, Boston. Rosenkrantz, P. & Vogel, S. (1981) Sex role stereo- Mercatante, A.S. (1988) The Facts on File: Encyclopedia of types and clinical judgments of mental health. In E. World Mythology and Legend. Oxford University Howell & M. Bayes (eds) Women and Mental Health, Press, New York. pp. 112–121. Basic Books, New York. Messner, M. & Sabo, D. (eds) (1990) Sport, Men and the Butcher, R.B. & Schneider, A.J. (1993) The Ethical Ratio- Gender Order: Critical Feminist Perspectives. Human nale for Drug-Free Sport. Canadian Centre for Drug- Kinetics Publishers, Champaign, Illinois. free Sport, Ottawa, Ontario. Messner, M. & Sabo, D. (1994) Sex, Violence and Power Cahn, S. (1994) Coming on Strong: Gender and Sexuality in in Sports: Rethinking Masculinity. Crossing Press, Twentieth-Century Women’s Sport. The Free Press, Freedom, California. New York. Mill, J. (1972) Utilitarianism, On Liberty, and Considera- Corea, G. (1985) The Hidden Malpractice: How American tions on Representative Government. H. Acton (ed.). Medicine Mistreats Women, revised edn. Harper E.P. Dutton & Co., New York. Colophon Books, New York. Noddings, N. (1984) Caring: A Feminine Approach to Creedon, P. (ed.) (1994) Women, Media and Sport. Sage Ethics and Moral Education. University of California Publications, California. Press, Berkeley. De Coubertin, P. (1986) Revue Olympique. In N. Muller Okruhlik, K. (1995) Gender and the biological sciences. (ed.) Textes Choisis, Vol. II, Olympisme, pp. 707–708. Canadian Journal of Philosophy 20, 21–42. Weidmann, Zurich. Plato (1961) Republic. In E. Hamilton & H. Cairns (eds) De Frantz, A. (1993) The Olympic Games: our Plato: The Collected Dialogues, pp. 575–844. Princeton birthright to sports. In G. Cohen (ed.) Women in Sport: University Press, Princeton. 440 psychosocial issues

Rawls, J. (1971) A Theory of Justice. Harvard University Schneider, A.J. & Butcher, R.B. Fair play as respect for Press, Cambridge, Massachusetts. the game. Journal of the Philosophy of Sport 25, 1–22. Rioux, G. (1986) Propos liminaires: Pierre de Coubertin Segrave, J. (1988) Toward a definition of Olympism. In educateur (1863–1937). In G. Rioux (ed.) Pierre de J. Segrave & D. Chu (eds) The Olympic Games in Tran- Coubertin, Textes Choisis, Tome I, Revelations, pp. sition, pp. 149–162. Human Kinetics Publishers, 19–21. Weidmann, Zurich. Champaign, Illinois. Schiebinger, L. (1989) The Mind Has No Sex? Women in Segrave, J. & Chu, D. (eds) (1988) The Olympic Games in the Origins of Modern Science. Harvard University Transition. Human Kinetics Publishers, Champaign, Press, Cambridge, Massachusetts. Illinois. Schiebinger, L. (1993) Nature’s Body: Gender in the Sherwin, S. (1992) No Longer Patient: Feminist Ethics and Making of Modern Science. Beacon Press, Boston. Health Care. Temple University Press, Philadelphia. Schneider, A.J. (1992) Harm, athletes’ rights and Spears, B. (1988) Tryphosa, Melpomene, Nadia, and doping control. In R.K. Barney & K.V. Meier (eds) Joan: the IOC and women’s sport. In J. Segrave & D. First International Symposium for Olympic Research, pp. Chu (eds) The Olympic Games in Transition, pp. 164–172. Centre for Olympic Studies, University of 365–374. Human Kinetics Publishers, Champaign, Western Ontario, London, Ontario. Illinois. Schneider, A.J. (1993) Doping in sport and the perver- Suits, B. (1988) Tricky triad: games, play and sport. sion argument. In G. Gaebauer (ed.) The Relevance of Journal of the Philosophy of Sport 13, 1–9. the Philosophy of Sport, pp. 117–128. Academia Verlag, Tong, R. (1995) What’s distinctive about feminist Berlin. bioethics? In F. Baylis, J. Downie, B. Freedman, B. Schneider, A.J. (1995) Gender, sexuality and sport in Hoffmaster & S. Sherwin (eds) Health Care Ethics in America. Journal of the Philosophy of Sport 22, 136–143. Canada, pp. 22–30. Harcourt Brace Canada, Toronto. Schneider, A.J. & Butcher, R.B. (1993) For the love of the Tuttle, L. (1986) Encyclopaedia of Feminism. Longman, game: a philosophical defense of amateurism. Quest Harlow, Essex. 45, 460–469. Veblen, T. (1953) Theory of Leisure Class: An Economic Schneider, A.J. & Butcher, R.B. (1994) Why Olympic Study of Institutions. New American Library, New athletes should avoid the use and seek the elimina- York. tion of performance-enhancing substances and prac- Zita, J. (1988) The premenstrual syndrome: dis-easing tices in the Olympic Games. Journal of the Philosophy the female cycle. Hypatia 3, 77–99. of Sport 20/21, 64–81. Chapter 30

Women’s Role in National and International Sports Governing Bodies

KARI FASTING

Introduction authority, coaching systems and role models for girls in all athletic situations. National and international sports governing One other characteristic of sports governing bodies have one common characteristic: they are bodies is that fewer women are found in the chaired primarily by men. This lack of women in higher echelons of a hierarchical sports organiza- the decision-making bodies of sport applies even tion. Based on Canadian studies, Beamish (1985) to sports where the members are predominantly writes that ‘as sports executives become more women. Whereas formerly there were separate encompassing and have more powerful man- sports organizations for women and men and dates, women tend to be excluded’. On the posi- women had a leadership role, today these tive side, however, during the last few years organizations have merged. According to Dyer more and more national and international sports (1982), when sex-separated organizations governing bodies have discussed the lack of have merged, men have taken over the leader- women in decision-making positions and have ship positions. The situation in the USA illus- decided on different approaches to increase the trates this point very clearly. As an effect of number of female sports leaders. In some coun- Title IX (a law requiring equal rights in school tries, for example Sweden and Canada, this work and college sport), many women’s and men’s has continued for about 20 years. Experience athletic departments were merged. At about from these countries indicates that it is very diffi- the same time the National Collegiate Athletic cult to reach a democratic representation based Association (NCAA) opened up for women; on the percentage of the female membership. in practice the Association for Intercollegiate Some of the reasons for this are outlined later in Athletics for Women (AIAW) was absorbed this chapter. by the NCAA. Title IX produced an enor- Research in the area of women in sports gov- mous increase in the number of female ath- erning bodies is scarce. A search on the SPORT letes in the USA, although there seems also Discs SIRC database, combining women and to have been an ‘unexpected’ effect. American sport with sports governing bodies, produced 98 professor Joan H. Hult (1989) expressed it this references. Much of what has been written pre- way: sents distributive statistics and/or the popular The success of Title IX has led to male gover- media presentation of women in sports organiza- nance power in all amateur sports from high tions, with little empirical data or theoretical school competition through college, nonschool foundation. Other research presents the life agencies, and the Olympic movement. Title IX stories of famous women, such as the female has left untouched pervasive fundamental members of the Olympic Movement. The re- inequities in leadership, decision-making search and literature drawn on in this chapter are 441 442 psychosocial issues

mostly from Europe or North America, which tice, run as ‘all-male’ clubs, in which women means that one must be very careful about gener- are tolerated only in small doses as guests. alizing to other parts of the world, such as Asia or For 87 years the IOC had only male members. Africa. It is relevant to mention here that Canada In 1981 the first ‘guests’ were permitted, when seems to be the country with the most research in Flor Isara Fonesca from Venezuela and Pirjo this area, such as the work of Theberge (1984), Häggman from Finland became the first female Beamish (1985), Hall et al. (1989) and Whitson members. Since then nine more women have and MacIntosh (1989). An important source of been appointed and one has retired. Today the information has also been a state of the art report number of women on the IOC is 10, which on women in leadership positions published by accounts for about 10% of the membership. the Swedish Sports Federation (Cederberg & The IOC supports 22 commissions of which Olofsson, 1996). only one is chaired by a woman. Many commis- In the first part of this chapter some statis- sions have no female members. One example tics on women in sports governing bodies are is the Sport for All Commission which has no presented. Since the International Olympic Com- female members, in spite of the fact that large mittee (IOC) is the most powerful sports organi- numbers of females around the world partici- zation in the world, special attention is focused pate in recreational sports. Of the 34 interna- on its engagement in this area. Based on an tional federations represented in the Olympic overview of the most important studies, the main programme, only two are headed by a woman part of the chapter attempts to answer the and two have female secretary generals (L. Darli- question: Why are there so few women in son, unpublished observations). Of the 200 sports governing bodies? The answers to this national Olympic committees, three have a question should also provide the direction for the female president and nine have female secretary most effective strategies needed to correct the generals (Women and Sport Bulletin, 1999). current imbalance and also to determine what Based on the different initiatives that the IOC kind of future research needs to be done in this has recently enacted it is hoped that this low area. female representation will change. At their Cen- tennial Congress in Paris in 1994 the following recommendations (International Olympic Com- Number of women in sports mittee, 1994) were among those agreed. governing bodies • Increase the numbers of IOC members who Until recently the Olympic Movement has been are women, doubling the number by the year heavily dominated by men. However, the IOC is 2000. different from other sports organizations and • Increase the number of women who serve on therefore is not comparable with other sports IOC commissions, recommending the appoint- governing bodies. This is due primarily to the ment of women when they are not nominated by fact that the IOC is a self-perpetuating body international federations or national Olympic whose new members are elected by the exist- committees. ing members. According to Davenport (1988), • Create incentives for each international fed- IOC members do not represent their countries, eration, national federation and national they represent the IOC and are ambassadors Olympic committee to develop women as of Olympism to their countries. The former coaches and administrators. Director of the IOC, Mme Berlioux, wrote in 1981 Two years later the IOC appointed a working that: group on women and sport. At its initial meeting National Olympic committees, national or in March 1996 the following decisions were international federations, regional organiza- among those agreed. tions, organizing committees are all, in prac- • Increase the numbers of IOC members who women’s role in sports governing bodies 443

are women, doubling the number by the year implement a plan of action with a view to pro- 2000. moting women in sport. • More women must be appointed to commis- • Commissions dealing specifically with the sions and working groups as well as to the inter- issue of women in sport should be set up at national federations and national Olympic national and international levels. committees, recommending the appointment • Within Olympic solidarity a special fund of women when they are not nominated by should be earmarked for the promotion of international federations or national Olympic women’s sport at all levels, as well as for the committees. training of women administrators, technical of- • Seminars for women in administration and ficials and coaches, particularly in developing leadership, coaching and sports journalism countries. should be organized every year. • The IOC should organize each year, and on the • The Olympic Study Centre is encouraged to five continents, a training course for women in make studies on the role of women and sport. one of the following areas: coaching, technical These recommendations were followed up at activity, administration or media/journalism. the IOC’s session in Atlanta 1996, where it was During the 102 years that the IOC has existed, decided to establish the goal of ensuring that by the last two years may be looked upon as a new the year 2000 at least 10% of all offices in the era for the role of women in sport. The crucial IOC’s decision-making structures should be held point is whether, and in what way, these actions by women; by 2005 it should be 20%. It was and recommendations will be put into practice. further decided that all the sports organizations As discussed later, it may be difficult to gain belonging to the Olympic Movement should equity for women in sports governing bodies establish the goal of ensuring that similar de- without changing some fundamental structures velopments take place (L. Darlison, unpublished of the sports organizations themselves, their observations). values and the way they operate. The IOC has the The IOC also held its first conference on power to do this, but the question is whether women and sport in October 1996. At the end of they want to. the three days of discussion the participants The low number of women in decision-making adopted a list of recommendations, of which the positions in sports governing bodies has also following concern women’s role in sports gov- been discussed in Europe. According to Delforge erning bodies. (1989), the point has been raised on various • Recognition that the Olympic ideal cannot be occasions by the Council of Europe, which has fully realized without, and until there is, equality arranged two conferences on this theme, one in for women within the Olympic Movement. Dublin, Ireland in 1980 and one in Bisham Abbey, • The IOC, international federations and UK in 1989. One finding of the seminar in Dublin national Olympic committees should take into was that due to the low number of female sports consideration the issue of gender equality in all leaders, ‘decisions concerning women are taken their policies, programmes and procedures, and by men without any real knowledge of women’s recognize the special needs of women so that true needs’. The Dublin seminar also decided they may play a full and active part in sport. upon several recommendations, such as ‘that • All women involved in sport should be pro- governments should encourage sports federa- vided with equal opportunities for professional tions to consider new measures that would and personal advancement, whether as athletes, ensure, in line with their own regulations, the coaches or administrators, and that the interna- recruitment of women in leadership positions tional federations and national Olympic commit- at local, national, and international levels’. Euro- tees create special committees or working groups pean surveys were carried out in 1980 and 1989, composed of at least 10% women to design and the last one aimed at assessing the impact of the 444 psychosocial issues

Dublin recommendations. In the report where about the number of female board members the results of this study were presented, Delforge in five significant sports federations (European (1989) stated that: handball, swimming, soccer, gymnastics and most countries have a legal framework that tennis). The proportion of countries that had provides for equal opportunities for men female board members was 28% for gymnastics, and women. Despite the legal framework, 12% for swimming, 9% for European handball, however, discrimination still exists at all levels 8% for tennis and only 3% for soccer. Three coun- and in particular in matters of sport (discrimi- tries, Norway, Romania and Sweden, had female nating regulations applied by sports bodies, members on all the executive boards of these five especially in certain disciplines; access to sports federations (Fasting, 1995). These results sports facilities, awkward opening and closing confirm that even sports like gymnastics, which times, quality of the equipment; influence of is strongly dominated by female members, are certain cultural values, etc.). led or ruled by men. Another conclusion was that the proportion Statistics available from different countries of women in leadership positions seemed to be indicate large variations in the number of women increasing in most countries, although fair repre- in sports governing bodies at both regional and sentation was still a long way off. However, the national levels. In addition there is reason to proportion of women in leadership positions believe that these also vary according to the tended to increase as the focus shifted from the sport. Many of the statistics are a few years old national to the regional and local levels, although and therefore not presented here, because there the highest positions were generally occupied by is reason to believe that they have changed. men whatever the level (Delforge, 1989). Women are underrepresented on sports govern- Some months after the meeting in the UK, ing bodies both internationally and nationally. another European sports body, the European The Scandinavian countries seem to be leading Sports Conference, held its ninth conference in other nations in the inclusion of women, for Bulgaria. Here a working group on the role of example in Norway female representation on the women in sport was set up. The overall aim pro- executive boards of the sport districts (regional posed by the working group 2 years later was ‘to level) is more than 40% (Fasting, 1996). increase the involvement of women in sport at all levels and in all functions and roles’. To fulfil this Why are there so few women in aim, three goals were suggested. One of them sports governing bodies? concerns the theme of this chapter: ‘To increase the number of women coaches and women in According to Kvande (1995), the development of advisory, decision making and administrative gender research is mirrored by research about bodies at all levels’ (Fasting, 1993). Twenty Euro- gender and organization, which started in the pean countries participated in a monitoring mid 1980s and can be divided into three phases, study in 1993 and the gender representation on which she terms women’s voice, women’s expe- the executive boards was surveyed. The results rience and the postfeminist phase. In the first demonstrated great variations inside Europe. phase, which may be characterized as gender Three countries did not have any female neutral, it is taken for granted that women are members in their highest decision-making orga- equal to men or like men. In the second phase, nization; in others, the female representation was the differences between women and men are about 45%. However, the overall picture was that examined in detail. Women are looked upon women seemed to be proportionally underrepre- as a resource. The male norms are criticized. Dis- sented on the executive boards (Fasting, 1993). cussion focuses on female leadership and that Two years later a similar question was posed in females may be better leaders than men due to another European survey. Countries were asked different value orientations. This perspective is women’s role in sports governing bodies 445

criticized in the third phase because it is said tion in an organization can also lead to women’s to lead to essentialism, i.e. gender (sociology) feelings of social isolation, heightened visibility, became as determinant as sex (biology). The mistaken identity and pressures to adopt stereo- focus now is on the meaning of gender in differ- typed roles. This again may lead to confusion ent connections. and depression. We now talk about many different forms of In a study from the UK (White & Brackenridge, masculinity and femininity and about gender as 1985), the low number of females in British sport a perspective, as a fundamental analytical cate- is explained by some of the same factors. These gory. How gender is constructed and recon- authors mentioned particularly: (i) the inap- structed in the relationship between women and propriateness of the male model of sport; (ii) men becomes central. With such a perspective, women’s lack of access to political systems; and how organizations construct gender and how the (iii) recruitment mechanisms that operate in gender relations construct an organization sports organizations. Raivio (1987) interviewed become important. For example, newer research Finnish women in decision-making positions in focuses on how men in an organization are often sport. These women believed that there were preoccupied with constructing and maintaining mainly two reasons for the lack of women in different forms of masculinity. The research on these positions: (i) that men were afraid to place sports organizations, presented in the following an equally, or more, competent woman in a lead- paragraphs, to a certain extent reflects these ership position; and (ii) that women did not give phases, although most of the organizations can support to other women in elections. The respon- be characterized as belonging to the second dents also thought that the sports organizations phase or between the second and third phases. were very bureaucratic, so that they might not Lane (1980) states that job descriptions are see their ideas carried out. Acosta and Carpenter seldom found in sports organizations and that (1985) surveyed both women and men on why most organizations comprise an informal system there were so few women in athletic administra- of relationships that have their origins and tion. The answers reflected the gender differ- present functions in the male culture and the ences presented earlier. The women stressed, in male experience. The males within these in- order of importance: (i) perpetuation of the ‘old- formal systems understand and support one boy’ network; (ii) weakness of the ‘old-girl’ another and the structure: they make up the ‘old- network; (iii) moderate discrimination against boy’ network. The different aspirations and women; and (iv) a lack of qualified women. The experiences that women and men have as a result corresponding answers from the men were: (i) of different socialization may lead to different lack of qualified women; (ii) women’s unwilling- ways of responding to typical sports manage- ness to travel; (iii) women’s failure to apply for ment situations. This may also make it difficult openings; and (iv) family responsibilities. Bohlig for women to accept and influence the informal (1988) discusses the fact that in the USA women ‘male’ system. Lane (1980) also writes that the disappeared from athletic administration. She image of the female future often is sexual and suggests four main reasons: (i) the stereotypes of sexually linked, which again is due to the fact women in leadership roles; (ii) careers and con- that the people in positions of power are males. flicts; (iii) Title IX; and (iv) the merging of the She says that: AIAW and NCAA. contrary to the stereotyped notion, females do In 1985 the Norwegian Confederation of Sport compete, although the conditions of our established a Central Women’s Committee. The culture are such that they compete in different work of this committee is guided by the knowl- ways, for different ends, and with different edge gained from the study of gender, i.e. that standards from the males. women and men are different and that women According to Lane, an uneven gender distribu- have a lot to contribute to sport. Fasting and 446 psychosocial issues

Skou (1994) studied 43 heads of women’s com- stressed that the work itself has to be taken seri- mittees in the Norwegian Confederation of Sport ously and must be given status and power. This and found that the most important predictors for was the reason that the chair of the ‘women’s success were: committee’ also needed to be a member of the • the knowledge and the personal characteris- executive board or another decision-making tics of the chair of the women’s committee; body. This is exactly what the IOC has done; the • how the work was formally based and struc- chair of the Committee for Women and Sport is tured in the sport organization; Anita de Franz, the only woman on the Executive • the level of consciousness and the common Board of the IOC. understanding in the sport organization. In a Canadian study (Whitson & MacIntosh, Each of these factors was also influenced by the 1989) 56 senior officers in six national sports others. The barriers for success were the opposite organizations were interviewed, of whom one- of those listed above: third were women. According to the investiga- • lack of roots in the organization: the board, the tors, most of the officers saw the promotion of administration and the network; women as a low-priority issue, even a non-issue. • lack of common understanding concerning Having few women or no women in decision- the work of women and sport; making sports organizations was not regarded as • low consciousness about the female and male a problem. ‘Family responsibilities’ was men- culture among the female chairs; tioned as the reason for the lack of women. As • female chairs with an unsuitable personality. Whitson and MacIntosh state: Based on this study the following conclusions The problems lay not in the practice or preju- were drawn. It seems to be important that some- dices of the National Sports Organization, but one in the organization, either an individual rather with individual women, and/or with or a committee, has to have the responsibility structural features of Canadian (family) life, for developing women-related work. This could which it was not a sport organization’s task to be a man, but he needs to have knowledge about address. gender issues and about the difference between The authors focused on gender relations and the female and male cultures. For example, he gender power structure in discussing these should know that the increasing degree of pro- results. They refer to Deem (1987) who had fessionalism, specialization and rationalization shown that much of men’s leisure is facilitated by are trends that are antagonistic to traditional women’s services, while men affect women’s women’s values and therefore may discourage leisure opportunities in their roles as policy- women from taking on positions of leadership. makers and executives. He should also take into account that more and Hall et al. (1989) focused on the processes and more women are working full-time. Also it is dynamics that structure gender in organizations. women who still have the main responsibility for Their purpose was ‘to understand and explain housework and the care of children and elderly how organizational elites (males) work to recre- parents, which leaves them with very little time ate themselves in order to retain their power, of their own. Thus the task of encouraging and how women collude in this process’. The women to take on leadership positions has to be methods used in this study were interviews with rooted in the organization, both formally and 70 key persons in five different sports plus an economically. Consciousness-raising for both analysis of documents. As in the study by female and male sports leaders seems to be Whitson and MacIntosh (1989), one of the find- important. The authors also mentioned that one ings was that members did not believe the cannot put into practice a plan of action to try to organization itself was to blame for the low per- increase female leadership in sports without centages of females. The reasons were either resources, both time and money. They also personal deficiencies, such as women’s lack of women’s role in sports governing bodies 447

motivation, or social factors, such as women’s reproduce itself. According to the authors, more family situations. The solution was seen to lie not research is needed. This should focus on the with the organization but with either society intermingling of power, sexuality and structure or the women themselves. This was also the before effective attempts for change can be opinion of many of those female officers who suggested. participated in the study. They had accepted the Being an officer in a sports governing body organizational male culture and did not want to requires a heavy investment of time and energy be identified with women’s issues. plus a flexible home and work life. The structure In trying to understand this gender structure of the sports organizations themselves and the of sports organizations and how it could be way they are organized and operate are often changed in a way that could benefit the women not addressed. However, this was looked at in a in them, Hall et al. (1989) reviewed different Norwegian study among female coaches and organizational theories and feminist perspec- administrators in the Norwegian Volleyball Fed- tives on organizational theory. They state that it eration (Hovden et al., 1993). All female members is not enough to get more women into the organi- of the executive board of the federation from zation if women are merely imitations of men. 1982 to 1990 were surveyed plus female coaches, Such thinking is based on an equity model a total of 54 women; of these 20 were also (Adler, 1986), which implies that women’s and interviewed in depth. The following factors men’s contributions to an organization will be seemed to be important in relation to recruit- identical. This model emphasizes access to ment and dropout among female executives management positions, with women then assi- and coaches in Norwegian volleyball. First, the milating male norms. Progress is measured by respondents felt that they were given little counting the number of women and men at each support and little respect for their own resources. hierarchical level in the organization, just as is In addition they thought that they did not have often done in sport. the chance to define their own frames of action. Women who enter this world must learn to Second, since women often had less free time play the game, which they often do. They must than men, there were also gender differences in learn the language, symbols, myths, beliefs and relation to how women and men wanted to use values of the sporting culture (Fasting, 1994). their free time. The women felt that their life Hall et al. (1989) say that the complementary situation was difficult to discuss within the model, also described by Adler (1986), recog- organization. It was looked upon as something nizes, assesses and values the differing contribu- private. The organization did not take into tions that both sexes bring to the organization. account what is meant by gender or that women Such a model can therefore have an element of and men do not have the same starting point. change in it. In discussing feminist perspectives Many of the participants in this study wanted on organizations, the authors demonstrate how to use their knowledge and resources for the organizations construct sexuality with particular good of volleyball, but not at any cost. In spite of reference to the double standard that exists in the fact that they were highly educated women relation to lesbians. Since this double standard is with good resources, they found that the a mixture of the visible, the unspoken and the demands of the federation and the way the work elusive, it also demonstrates how sexuality con- was structured and organized made it impos- structs organizations. The gender structure of sible for them to work in their beloved sport. organizations is characterized by power rela- Three main reasons for this were mentioned: (i) tions, which subject and control sexuality in most of them wanted to have a family and give different ways. Hall et al. conclude that funda- priority to their families; (ii) they wanted to have mental change would be more likely if structural time for friends and other types of leisure time changes occur so that the powerful élite cannot activities; and (iii) the male-dominated culture 448 psychosocial issues

restricted their frame of action. The respondents an inherent type of discrimination. The studies wished that women could have more opportuni- reviewed in their survey showed that the way ties to influence the direction of the work of the men experience women’s situations is different sports organization. They also believed that to the way women describe their experiences the coaching, as well as the executive roles, had themselves. Men believe that women are under- to be practised in a less authoritarian way. A represented in sports governing bodies because stronger female network and a stronger gender they do not dare, or want, to be involved, i.e. the integrated network were high on the women’s explanation reflects the individual level. The list of priorities. Lastly, they thought it was women’s explanation reflects the organizational important to change both the league system and level: they seem to focus on the structure of the the activity profile of their sport, so that fewer organization and believe that their competence is weekends were occupied and less time was used invisible; they also lack support and encourage- for travelling. They also felt that the social values ment. This is also in accordance with the specific of the sport had to be upgraded (Hovden et al., studies on sports organizations presented earlier 1993). in this chapter. Dorfinger and Moström (1995) surveyed 56 presidents in different sports federations in Conclusion Sweden. The results showed that it was impor- tant to include more women in sports governing It is essential to focus on why more women bodies, partly because more women would be are needed in international and national sports recruited to sports practice but also because governing bodies. First, it can be regarded as of the complementary model just mentioned. a matter of equality. Equality can be defined in Cederberg and Olofsson (1996) comment that, in different ways and I have found the following spite of this, women seem not to be recruited, definition, taken from the Swedish Sports Con- which may be due to the fact that prejudice and federation (1990), useful: discrimination are built into the sports system. Equality means that women and men have the Another study among Swedish female sports same rights, obligations and opportunities in executives showed that 80% thought that all the main fields of life; women and men women’s questions had low status in the share power, influence and responsibility in all organization; 75% had also experienced that sectors of the community. many people seemed to think it was not impor- The data presented in this chapter have shown tant to have equal gender representation, as that unfortunately this is not the case for sport. found in the studies from Canada. The same pro- There are three arguments why it is important to portion of the women thought that equity would change this situation. not develop naturally by itself, but that it was 1 Women account for more than half the popula- necessary to have increased consciousness about tion. They are underrepresented in sports organi- the problems and a more active political zations not only in membership but also in approach. relation to other roles such as leadership, coach- In their summary of why there are so few ing, management and referees. Equality in women at the top of organizations in general, decision-making assemblies is therefore a matter Cederberg and Olofsson (1996) stated that the of democracy. construction of the gender system leads to a 2 Women and men have different knowledge devaluation of women’s work and an increase in and expertise. Therefore it is important that the the value of men’s work. The structure does not views of both groups are considered. often enough take into account the life situation 3 Women and men have different values and dif- of women, which in practice may be viewed as ferent interests. Therefore increased representa- women’s role in sports governing bodies 449

tion of women can lead to new perspectives on butions by Clearing House. Proceedings from Euro- many issues. pean Seminar, Bisham Abbey National Sport Center, 11–14 September. Sports Council, UK. In conclusion, sports organizations need the Dorfinger, K. & Moström, K. (1995) Tiden hjälper til: participation of women more than the women men räcker inte! Om jämställdhet inom idrotten. Jäm- need sports organizations. The solution to ställdhetsutvickling AB, Stockholm. recruiting more women into the leadership of Dyer, K.F. (1982) Catching up the Men. Women in Sport. sports organizations, and keeping them, is diffi- Junction Books, London. Fasting, K. (1993) Women and Sport. Monitoring Progress cult. The results of the studies presented in this Towards Equality. A European Survey. Norwegian Con- chapter indicate that changes in the sports orga- federation of Sports, Oslo. nizations themselves are necessary. Emphasizing Fasting, K. (1994) Sport Bodies in the ‘New’ Europe: women’s lives, experiences and values in the Progress Towards Equality? Norwegian Confedera- further development of sport may be one way. tion of Sports/Norwegian University of Sport and Physical Education, Oslo. This can most easily be done by women them- Fasting, K. (1995) European Women in Sport. Swedish selves just because they are women. To be certain Sports Confederation, Stockholm. that many more women can gain access to lead- Fasting, K. (1996) Hvor går kvinneidretten? Norges ership roles in practice, more knowledge, i.e. Idrettsforbund, Oslo. research, is needed. This should focus on the Fasting, K. & Skou, G. (1994) Developing Equity for Women in the Norwegian Confederation of Sports. interrelationship between power, sexuality and Norwegian Confederation of Sports/Norwegian the structure of sports governing bodies and/ University of Sport and Physical Education, Oslo. or how sports organizations construct gender Hall, M.A., Cullen, D. & Slack, T. (1989) Organizational and how gender relations construct the sports elites recreating themselves: the gender structure of organizations. national sport organizations. Quest 41, 28–45. Hovden, J., Solheim, L.J. & Andreassen, S. (1993) Er det prisen verdt? En studie av kvinnelege trenarar References og tillitsvalde sine erfaringar med arbeid i Norges Volley- ballforbund. Norges Idrettsforbund, Oslo. Acosta, R.V. & Carpenter, L.J. (1985) Status of women in Hult, J.S. (1989) Women’s struggle for governance in athletics: changes and cases. Journal of Physical Educa- U.S. amateur athletics. International Review for the tion, Recreation and Dance 56, 35–37. Sociology of Sport 24, 249–261. Adler, N.J. (1986) Women in management worldwide. International Olympic Committee (1994) International International Studies of Management and Organization Olympic Congress Report, pp. 415–419. International 16, 3–32. Olympic Committee, Lausanne. Beamish, R. (1985) Sport executives and voluntary Kvande, E. (1995) Forståelser av kj¢nn og organisasjon. associations: a review of the literature and introduc- Sosiologisk Tidsskrift 4, 285–300. tion to some theoretical issues. Sociology of Sport Lane, K. (1980) Women as sport administrators. In Journal 2, 218–232. S. Fraser (ed.) The Female Athlete, pp. 133–139. Berlioux, M. (1981) Women in the promotion and Institute for Human Performance, Burnaby, British administration of sport. Federation International Edu- Columbia. cation Physique Bulletin 51, 22–27. Raivio, M. (1987) The life path and career of the women Bohlig, M. (1988) Women coaches and administrators: in leading positions in Finnish sport organizations. an endangered species. Scholastic Coach 57, 89–92. In J.A. Mangan & R.B. Small (eds) Sport, Culture, Cederberg, I. & Olofsson, E. (1996) En katt bland herme- Society: International Historical and Sociological Per- liner: forskningsöversikt om kvinnor och ledarskap. Umeå spectives, pp. 270–276. E. & F.N. Spon, London. Universitetet, Pedagogiska Institutionen, Umeå. Swedish Sports Confederation (1990) A Plan for Equality Davenport, J. (1988) The role of women in the IOC and between Women and Men in Sport in the 1990s. Swedish the IOA. Journal of Physical Education, Recreation and Sports Confederation, Stockholm. Dance 59, 42–45. Theberge, N. (1984) Some evidence on the existence Deem, R. (1987) The politics of women’s leisure. Socio- of a sexual double standard in mobility to leader- logical Review Monograph 33, 210–228. ship positions in sport. International Review for the Delforge, M. (1989) Appendix. In Women and Sport: Sociology of Sport 19, 169–196. Taking the Lead. Synoptic Report of the National Contri- White, A. & Brackenridge, C. (1985) Who rules sport? 450 psychosocial issues

Gender division in the power structure of British national sport organisations. International Review for sports organisations from 1960. International Review the Sociology of Sport 24, 137–150. for the Sociology of Sport 20, 95–107. Women and Sport Bulletin (1999) News about the Whitson, D. & MacIntosh, D. (1989) Gender and power: Olympic Movement. International Olympic Commit- explanations of gender inequalities in Canadian tee, Lausanne. PART 8

SPORT-SPECIFIC INJURIES: PREVENTION AND TREATMENT

Chapter 31

Swimming

NAAMA CONSTANTINI AND MAYA CALE¢-BENZOOR

Introduction to female swimmers, although other medical aspects of swimming are discussed. Swimming, both recreational and competitive, is one of the most popular sports and the number Physiological aspects of females participating is continually increas- ing. In the 1996 Olympics Games in Atlanta, 512 Physical characteristics females competed in the various swimming events. Female swimmers train and compete The typical female swimmer is taller and some- from a very young age until late adulthood as what heavier than the average female. In a master swimmers. They participate in swim- review on the growth and maturation of athletes, ming events that previously were only per- Malina (1994a) concluded that the mean stature formed by males, such as the 4¥200m relay or of female swimmers from various parts of the the Ironman triathlon. It is not uncommon to see world was generally above the 50th percentile. girls and young women training together with Nationally selected swimmers in the USA had their male counterparts and reaching similar statures at or just below the 90th percentile, while exercise volumes and intensities. In the past, the weights of these swimmers were at or above female swimmers were believed to reach their the 50th percentile (Malina, 1994a). In the last peak performance below the age of 20 and used Olympic Games in Atlanta, the average height of to be the youngest contestants in the Olympic the female swimmers was 1.71m and the average Games except for gymnasts (Hirata, 1979). In weight was 59kg. recent years this has changed and one can find In most sports a lean body is considered an many successful female swimmers over 25 years advantage as it is quicker and generally performs of age. In fact, the average age of female swim- better than a body with a higher proportion of mers in Atlanta was 23, almost identical to the fat. This does not hold true for swimming, where men’s average of 23.4 years. fat provides buoyancy, thereby reducing the As a training modality, swimming is beneficial energy cost of staying on the surface of the water. for all the population, including those with On the other hand, excess fat can alter the body various health problems such as asthma, obesity contour and increase drag. The ideal percentage and various physical and mental handicaps. A of body fat for the best performance has not been further advantage of swimming is that injury or established for swimmers. The percentage of illness are relatively uncommon. In this chapter body fat reported for both age-group and mature we discuss special issues concerning the female female swimmers is between 12% and 20% swimmer: physiological, medical and muscu- (Malina et al., 1982a; Hergenroeder & Klish, 1990; loskeletal. Emphasis is placed on aspects unique Sinning, 1996). 453 454 sport-specific injuries: prevention and treatment

Most studies on age-group female swimmers both arms and legs are significantly higher in (10–17 years) suggest that skeletal age is average male compared with female swimmers. or advanced relative to chronological age. At an However, when adjusted for lean body mass, early age, female swimmers with advanced Constantini and Cale-Benzoor (unpublished skeletal age tend to be more successful. Coaches observations) found that leg power was greater should thus be cautious when predicting future among the female masters swimmers compared success, since achievements of early mature with their male counterparts. In the same study, females may be only temporary. female arm–leg anaerobic power ratios were about 55% compared with 80% in the males. Thus, it is not surprising that the difference in Strength swimming time between females and males is Muscular strength appears to be the second most generally greater when using the arms only (i.e. important determinant after skill for success pulling) compared with full stroke and smaller in competitive swimming (Costill et al., 1992). when kicking only. Generally, males are much stronger than females; however, when expressing strength relative to Sexual development lean body mass, it is interesting to note that female swimmers have similar leg strength but Data collected between the 1950s and 1970s on markedly lower arm strength compared with the age of menarche in swimmers suggested a males (Costill et al., 1992; Magnusson et al., 1995). similar (Malina, 1983) or even earlier (Astrand In both genders trunk extension is significantly et al., 1963) mean age of menarche compared stronger than trunk flexion, but women test sig- with that of non-athletes. However, later surveys nificantly weaker than men in both trunk revealed a significantly later age of menarche in extension and flexion (Magnusson et al., 1995). swimmers compared with their sedentary coun- Swimming is a symmetrical sport, and indeed terparts (Stager et al., 1984; Stager & Hatler, 1988; there is no significant side-to-side difference in Constantini & Warren, 1995) (Table 31.1). Malina either shoulder or thigh strength among swim- (1994a) attributed this finding to the shift in mers (Magnusson et al., 1995). the age of female swimmers. In earlier years female swimmers retired by 16–17 years of age, whereas nowadays they continue to train and Anaerobic power compete into their twenties. This provides an There is a very strong correlation between the opportunity for late-maturing swimmers, who results of anaerobic tests (especially arm tests) previously retired at an early age due to rela- and swimming performance (Inbar & Bar-Or, tively low success, to catch up with their early- 1977; Hawley & Williams, 1991; Hawley et al., maturing peers and to persist in the sport at an 1992; Lowensteyn et al., 1992). Peak power and older age. mean power in the Wingate anaerobic test of Whether early intensive training delays men-

Table 31.1 Mean age at menarche in swimmers (mean ± SD)

Reference Swimmers (n) Controls (n)

Constantini & Warren (1995) 13.8 ± 0.2 (SE) (69) 13.0 ± 0.1 (SE) (279) Frisch et al. (1981) 13.9 (21) 12.7 (10) Malina (1991) 14.4 ± 1.6 (43) 13.0 ± 1.4 (123) Stager et al. (1984) 13.4 ± 1.4 (287) 13.0 ± 1.6 (495) Stager & Hatler (1988) 14.3 ± 1.5 (140) 12.9 ± 1.3 (113) swimming 455

arche or whether the later onset of menarche in dieting and eating disorders are less common swimmers is due to genetic factors combined (Rosen et al., 1986; Brooks-Gunn et al., 1988; Barr, with preselection is a matter of controversy 1991; Sundgot-Borgen, 1993). Thus, it is not sur- (Malina, 1994b). Two studies have demonstrated prising that most studies of swimmers with that swimming training prior to menarche corre- either regular or irregular menses have described lates with the age of menarche and that training a different hormonal pattern: normal to high delays menarche (Frisch et al., 1981; Stager & LH levels, elevated LH:FSH (follicle-stimulating Hatler, 1988). However, these observations have hormone) ratio, normal to high oestradiol levels been challenged and may turn out to be an ana- and increased androgen levels compared with lytical artefact (Stager et al., 1990). As in non- controls (Constantini & Warren, 1995; Nichols athletes, a high correlation (r=0.69) exists et al., 1995). It has therefore been suggested that between age at menarche of swimmers and that swimmers exhibit a distinct type of menstrual of their mothers (Constantini, 1985). However, dysfunction (Constantini, 1994) (Fig. 31.1), in genetics is probably not the only explanation. which reproductive dysfunction is associated not Swimmers are older at menarche than their with hypogonadotrophic hypo-oestrogenism sisters, whereas age of menarche is similar but rather with mild hyperandrogenism. between the control non-athletes and their sisters Whether this specific hormonal profile (i.e. (Stager & Hatler, 1988). higher levels of androgens and an elevated LH: FSH ratio) is secondary to activation of the adrenal axis as a result of intensive training in Medical problems the absence of energy deficit or whether it is ‘primary’ (genetic factors, such as polycystic Reproductive system dysfunction ovary syndrome, precocious adrenarche, late The prevalence of short luteal phase and anovu- onset of congenital adrenal hyperplasia) is lation (Bonen et al., 1981), oligomenorrhoea unknown. Further research is needed, including and secondary amenorrhoea (Frisch et al., 1981; follow-up studies on hormonal levels after the Sanborn et al., 1982; Russell et al., 1984; Fauno cessation of competitive swimming. Ultrasonic et al., 1991) in female swimmers is about 12–40%. examination of the ovaries is also indicated to This is lower than the prevalence of menstrual look for signs of polycystic ovary syndrome. abnormalities in ballet dancers and long- High levels of androgens can be advantageous distance runners (Constantini & Warren, 1994) for swimmers as they affect muscle mass posi- but significantly higher than the 5% prevalence tively. Since power is a major determinant in in the non-athletic population. swimming performance, girls with ‘naturally’ In sporting disciplines that require low body elevated levels of androgens may be self-selected weight, negative energy balance is thought to be for this sport (Constantini & Warren, 1995). the major cause of menstrual abnormalities and Indeed, this profile has also been demonstrated the hormonal profile shows a hypothalamic type in female athletes who participate in other sports of amenorrhoea, i.e. impaired gonadotrophin- that require muscle power (Cumming et al., releasing hormone secretion, altered luteiniz- 1987). ing hormone (LH) pulsatility and low levels of gonadotrophins and oestradiol (Keizer & Rogol, Bone mass 1990; Theintz, 1994). However, the case of swim- mers may be different from that of ballet dancers The main factor responsible for osteoporosis or long-distance-runners. Swimmers are typi- is reduced bone mass. The amount of bone mass cally heavier, have a higher percentage of body is determined by the amount of bone acquired fat (Malina et al., 1982b; Brooks-Gunn et al., 1988; during puberty and by the rate of bone loss. Peak Hergenroeder & Klish, 1990; Malina, 1994a) and bone mass is determined by four major factors: 456 sport-specific injuries: prevention and treatment

? ? Exercise Energy Eating Eating Energy Exercise effects drain disorders disorders balance effects

Mental Mental stress stress Hypothalamic dysfunction Anovulatory profile GnRH (pulse) LH Genetic Genetic FSH and LH LH/FSH factors factors Oestradiol Oestradiol normal Progesterone Androgens or normal Reproductive Reproductive immaturity immaturity

Delayed menarche Short luteal phase/ anovulation Oligo/amenorrhoea

Possible lipid changes Reduced bone mass Infertility Normal bone mass (temporary) Stress fractures (temporary)

(a) (b)

Fig. 31.1 Schematic illustration of the authors’ hypothesis for the two different types of athletic menstrual dysfunc- tion. (a) The more frequently seen ‘hypothalamic amenorrhoea’, which occurs in sports demanding very low body weight (e.g. dancing, long-distance running) and may result in skeletal problems secondary to hypo-oestrogenism. (b) An anovulatory hormonal profile with normal oestrogen levels in swimmers and possibly in other sports where thinness is not required. FSH, follicle-stimulating hormone; GnRH, gonadotrophin-releasing hormone; LH, luteinizing hormone; ≠, increased; Ø, decreased.

genetics, nutrition, exercise and hormonal tion by itself affects bone mass positively milieu. (Marcus et al., 1992) and because swimmers often Physical activity increases bone mass through use modalities such as zoomers and hand- strain imposed on the skeleton by gravity, paddles in their water workouts in order to mechanical loading and muscle contraction. It increase workload on the muscles. In addition, has been claimed that since swimming is a non- competitive female swimmers spend many weight-bearing exercise and there is no mechani- hours in the fitness room engaging in weight cal loading on the bones, bone mineral density training. (BMD) in swimmers is lower than that in athletes BMD in female swimmers and non-athletes involved in high-impact, weight-bearing sports. has been measured in several studies that have Indeed, in several cross-sectional studies that yielded contradictory results. Some found compared BMD among different groups of ath- reduced lumbar bone density in swimmers com- letes, female swimmers were found to have pared with controls (Jacobson et al., 1984; Risser lower bone mass compared with other athletes et al., 1990; Nichols et al., 1995), while others (Heinrich et al., 1990; Risser et al., 1990; Lee et al., found either similar (Lee et al., 1995; Cassell 1995; Cassell et al., 1996). On the other hand, et al., 1996) or even higher (Heinrich et al., higher BMD can be expected in swimmers com- 1990) densities in swimmers vs. sedentary pared with non-athletes because muscle contrac- controls. These different results are most proba- swimming 457

bly due to methodological difficulties, such as of discharge and lymphadenopathy. Therapy small samples and different ages, training includes otic solutions and oral antimicrobial history, measurement site and measurement therapy in cases of severe infection. techniques. Prevention of recurrent otitis externa includes: Female swimmers have a later age of menar- (i) use of water repellent prior to swimming che and a higher prevalence of menstrual irregu- practices; (ii) avoidance of cotton swabs for dry- larities compared with non-athletes, but they ing or cleaning since they remove the wax and do not suffer from low levels of oestrogens. can scratch the ear; (iii) drying of the canal after However, high oestradiol levels have been found exposure to water with acidifying ear-drops; and in young swimmers (Constantini & Warren, (iv) use of ear-plugs while swimming if the 1995) and androgens, which affect bone mass above measures are unsuccessful. positively, were consistently higher in several studies. Other risk factors for reduced bone mass otitis media in dancers and long-distance runners are less prevalent among swimmers, such as low body In young swimmers, middle ear infections may weight, low body fat, eating disorders, insuffi- be a problem. Acute otitis media starts suddenly cient caloric intake and inadequate calcium and is associated with severe pain, and often intake. Our hypothesis is that swimmers with fever and hearing loss. The tympanic membrane menstrual dysfunction will not suffer from bulges, obscuring its normal landmarks; perfora- osteopenia compared with their eumenorrhoeic tion and otorrhoea may occur. The common peers (Fig. 31.1), but this issue should be further causes are Streptococcus pneumoniae, Haemophilus investigated. influenzae and Branhamella catarrhalis. Treatment includes analgesics, decongestants and appro- priate antibiotics. Swimming is prohibited until Swimmer’s ear the acute symptoms have subsided. If the tym- otitis externa panic membrane ruptures, water must be kept out of the ear until the drum has healed. If The term ‘swimmer’s ear’ refers to both acute healing does not occur or if tubes are inserted and chronic otitis externa, which is the most in cases of chronic serous otitis media, the common ear problem in swimmers. The cerumen swimmer can continue to train and compete with (wax) that normally lubricates the external ear ear-plugs. and prevents infection is washed away by pool water, leading to drying and cracking of the skin exostosis of the canal. In addition, swimmers often dry and ‘clean’/scratch their ears, causing further local Prolonged exposure to water may cause a bony trauma. This, in conjunction with the high tem- growth in the external ear called exostosis. If this perature and humid environment in the external becomes large it may cause ear infection by trap- ear canal, facilitates the invasion of endogenous ping water or even block the canal. Surgery is or exogenous organisms. required in this case. The most common infecting organisms are Pseudomonas aeruginosa and fungi (Marcy, 1985). Nasal and sinus problems The acute infection is characterized by severe deep pain often accompanied, or preceded, by Swimmers may suffer from vasomotor reaction itching (especially if associated with otomyco- of the nasal mucosa in response to stimuli such sis). There is redness, swelling and tenderness as chlorine in the pool water, bacterial pathogens of the canal and occasionally a variable amount or allergens in the swimming area. Sinusitis is 458 sport-specific injuries: prevention and treatment

another potential problem, especially in swim- ered a suitable sport for patients with asthma. mers with pre-existing abnormalities of nasal A swim-training programme has been shown to and sinus anatomy. Nasal plugs are advised in lessen the clinical severity of asthma (Huang these cases. et al., 1989). It is also one of the sports in which these athletes can excel and even reach the top level. In a survey of 738 competitive swimmers, Eye problems 13.4% reported asthma and of these 21% swam Prolonged exposure to chlorinated water can at international level (Potts, 1996). cause conjunctivitis, keratitis or corneal oedema. Swimmers with clinically significant EIA The eye is red and the swimmer will complain should use aerosol b-adrenergic agents 15min of the sensation of a foreign body in the eye as before exercise. Significant bronchodilatation well as pain. The eye should be irrigated with occurs within 1min of inhalation and continues ophthalmic solution. Use of swim goggles can for up to 5–6 hours. Cromolyn sodium is also efficiently prevent these problems. Due to chlori- effective; although it does not cause bronchodi- nation of pools and use of goggles, infectious con- latation, it blocks both early and late EIA and is junctivitis, either viral or bacterial, is very rare. virtually without side-effects. Another effective agent is theophylline 1–2hours before exercise. Asthma Other respiratory problems Asthma is a disease characterized by an increased responsiveness of the bronchial tree to a variety of Chlorine, which is often used in pool water, can stimuli, such as environmental irritants and aller- cause several respiratory problems, such as gens, resulting in widespread narrowing of the sneezing, difficulty with breathing, coughing, airways and decreased expiratory flow rate. With sore throat, wheezing, chest tightness and chest increased obstruction, there is decreased vital congestion (Potts, 1996). The combination of capacity, increased effort of breathing and mis- chlorine gas with the ammonia and urea that match of ventilation and perfusion leading to comes from the sweat and urine of swimming- hypoxaemia and hypercarbia. In about 90% of pool users creates inorganic compounds, which individuals with asthma and in 35–40% of the further react with amino acids to form organic allergic non-asthmatic population, exercise can molecules. These organic compounds are known induce bronchospasm, a phenomenon called to cause irritation of the respiratory tract, as well exercise-induced asthma (EIA) (Virant, 1992). as of the eyes, skin and mucous membranes. This Symptoms include wheezing, chest tightness, problem becomes worse in the winter when air dizziness or cough during or after exercise. A15% is recirculated, increasing the concentration of decrease in peak expiratory flow rate or forced the aforementioned factors (Bar-Or & Inbar, expiratory volume in 1s during the period after 1992). The problem can be minimized if fresh air exercise is diagnostic of EIA. is continually supplied to the indoor pool envi- Swimming seems to induce less bronchocon- ronment. Use of alternative methods of water striction compared with land activities. The low disinfection can also reduce the concentration of asthmogenicity of swimming is partly explained the chemical irritants. by the high humidity of the inspired air. Other mechanisms for this protective effect have been Dermatological problems thoroughly reviewed by Bar-Or and Inbar (1992). Whether swim training reduces the frequency skin and severity of EIA is not yet clear and should be further investigated. Due to the low asthmo- Cutaneous problems related to swimming are genicity of swimming, it has long been consid- uncommon and when they occur are usually swimming 459

relatively minor. The cause in freshwater lakes or found a strong correlation between flexibility salty sea water is usually one of various organ- and female gender in young swimmers. isms, which are not discussed here. In pools they External and internal rotation strength ratios are caused mainly by chemicals that can irritate in female swimmers were found to be lower than the skin. Prolonged exposure can dry the skin or those in controls, being 0.6 and 0.8 respectively cause contact urticaria. (Reid, 1987; Beach et al., 1992; McMaster & Troup, 1993; Fowler, 1995; Magnusson et al., 1995). hair The adduction–abduction ratio of the female swimmers was significantly higher than that in Prolonged contact with chlorinated water causes normal controls and higher than that reported bleaching of the hair. This occurs especially in for normals by Shklar and Dvir (1993). These the summer months due to increased exposure to torque shifts may represent a sport-specific sunlight. Sometimes the hair of blond swimmers adaptation of swimming. Assessing joint range can become greenish due to the copper-based of motion, Magnusson et al. (1995) reported algicides used in swimming pools (Lampe et al., external rotation values of about 116° in female 1977). swimmers, well above the standard for non-ath- letes. Internal rotation was also high. Fowler teeth (1995) reported a similar incidence of posterior translation of the humerus in swimmers vs. con- Prolonged contact with swimming pool water, as trols and concluded that swimming does not pre- well as the mixture of oral flora with water, may dispose an athlete to increased posterior laxity. cause yellowish-brown or dark stains on swim- On the other hand, posterior and anterior exces- mers’ teeth (Rose & Carey, 1995). Swimmers’ cal- sive tightness should be considered as predis- culus can be removed by routine professional posing factors for shoulder pain. The significance dental prophylaxis (scaling and polishing). and possible applications of these findings are unclear and further research is needed. Musculoskeletal profile characteristics Common orthopaedic problems From a musculoskeletal perspective, swimming presents a number of challenges to the female Shoulder pain swimmer. It is estimated that, on average, the competitive swimmer trains 10–11 months each The greatest orthopaedic problem that afflicts year and practises 5–7 days a week, often twice competitive swimmers is the so-called ‘swim- daily. Swimmers may cover 8–20km daily mer’s shoulder’. Johnson et al. (1987) reviewed depending on their specialty. Richardson et al. the literature and reported shoulder injury rates (1980) estimated that the male swimmer takes an of 40–80%. McMaster and Troup (1993) found average of 15 strokes per 25-m lap and calculated current shoulder complaints among 35% of élite that each shoulder undergoes about 9900 strokes women compared with 17.7% of men and a posi- per week. Since women generally have shorter tive history of shoulder pain at some point in limbs relative to their body length (Arendt, 1994) 73% of élite women swmmers. Female swimmers and are not as strong, the female swimmer might also complained more frequently of shoulder require 25 strokes to cover the same lap, thus looseness as well as shoulder instability. bringing the total number of arm strokes to Common features of the three styles most 16500 per week. In addition, females are more often associated with shoulder pain (freestyle, prone to joint hyperlaxity than males and joint butterfly and backstroke) are repetitive motions laxity is often associated with joint pain (Warner of progressive adduction and internal rotation et al., 1990). For example, Maffuli et al. (1994) of the glenohumeral joint during the power 460 sport-specific injuries: prevention and treatment

Fig. 31.2 Shoulder position during the recovery phase of the butterfly: Susan O’Neill of Australia at the 1996 Olympic Games in Atlanta.(© Allsport / Simon Bruty.)

phase and abduction and external rotation bicipital groove, resisted forward flexion will be during recovery (Allegrucci et al., 1994; Kenal & painful and resisted supination of the forearm Knapp, 1996) (Fig. 31.2). For example, pain in the will occur. A more detailed review of the diag- freestyle stroke was reported at either entry or nostic steps for shoulder impingement can be first half of pull phase by 45% of swimmers found in Chapter 15 and in Kennedy et al. (1978) (Fowler, 1995); 23% of the swimmers with shoul- and Johnson et al. (1987). der pain experienced symptoms during recov- ery. This corresponds to a shoulder position Secondary impingement of forward flexion, abduction and internal rota- tion, allowing a subacromial impingement of Increased shoulder laxity has been shown to cor- supraspinatus and biceps tendons. Mechanical relate with symptoms of impingement (Warner abutment may occur as a result of degenerative et al., 1990). Increased capsular laxity exposes changes or a hooked acromion, causing mechani- the humeral head to increased upward transla- cal impingement of the subacromial structures. tion. Involuntary inferior and multidirectional Kennedy et al. (1978) believed that microtears instability have been recognized as causes of could occur in the avascular zone of the su- shoulder pain in swimmers (Johnson et al., 1987). praspinatus and biceps tendons and in turn Swimmers who exhibit signs and symptoms of produce an inflammatory response consisting of impingement that lessen with a relocation test oedema, tendinitis and subacromial bursitis. may actually present with primary anterior insta- bility (Johnson et al., 1987; Kvitne et al., 1995). signs and symptoms Radiographic analysis of the shoulder should include anteroposterior views in internal and external rotation, an axillary view and a west- Primary impingement point prone axillary view (Johnson et al., 1987). If the supraspinatus is primarily afflicted, tender- ness will be present at the greater tuberosity Shoulder instability insertion, a painful arc in abduction may be present and a positive impingement sign will Isolated anterior glenohumeral instability is seen exist (Kennedy et al., 1978). If the biceps tendon primarily in backstroke swimmers (Johnson et is involved, tenderness will be located over the al., 1987) and is termed ‘apprehension shoulder’. swimming 461

The swimmer may encounter frank subluxation to address training of those muscles active of the shoulder, particularly when entering the throughout the stroke cycle, particularly the backstroke flip turn. Besides the clinical appre- ‘scapular pivoters’ or scapular rotator muscles hension test, radiological assessment is man- (Pink & Jobe, 1991; Pink et al., 1991). Pink and datory for delineating the bony defect of the Jobe (1991) suggest a sequence of treatment of the anterior glenoid in cases of recurrent subluxation scapular muscles and glenohumeral protectors (Kennedy et al., 1978). (rotator cuff) be carried out first. Some of these exercises are done in various weight-bearing treatment and rehabilitation positions and thus may be especially advanta- geous for female swimmers with increased Treatment of painful shoulder conditions in the shoulder laxity or instability. Closed-chain posi- female swimmer essentially follows the guide- tion offers an opportunity for proprioceptive and lines for treatment of overuse injuries, consisting mechanoreceptor training, an area found defi- of relative rest and various modalities for pain cient in individuals with shoulder instability and inflammation as warranted by the phase (Forwell & Carnahan, 1996). Selected exercises of injury (Johnson et al., 1987; Fowler, 1995). The for scapular rotators are described in Table 31.2. majority of swimmers with shoulder pain The later phase of strengthening of gleno- respond well to conservative rehabilitation humeral positioners, the deltoid, pectoralis and measures. latissimus dorsi, requires caution during training The female swimmer may be more prone to of the supraspinatus. Worrell et al. (1992) found fatigue. Therefore, it is of the utmost importance that 100° abduction and ‘thumb up’ position

Table 31.2 Selected exercises for scapular muscle strengthening. (Based on Pink & Jobe, 1991; Moseley et al., 1992; Kenal & Knapp, 1996; Wilk et al., 1996)

Exercise Muscle emphasized Description

Scaption With external rotation Supraspinatus, upper and lower Elevation of arm in plane 30° anterior to With internal rotation trapezius, levator scapula, coronal plane (i.e. scaption), either with rhomboids, serratus anterior, thumb upwards (external rotation) or subscapularis thumb downwards (internal rotation)

Rowing Trapezius, rhomboids, levator Rowing machine in setting scapula Prone bench with hand-held weights in simulated rowing motion

Push up with a plus Pectoralis minor, pectoralis major, Push-up exercise done against wall or floor, latissimus dorsi or as bench-press drill plus full scapular protraction with elbows extended

Press up Serratus anterior Sitting press up. May be done single-handed or sideways for additional difficulty

Supine punches Supine (or in Trendelenberg position to minimize anterior deltoid effect) with hand- held weights for scapular protraction, or manually resisted punches, or punches with tubing 462 sport-specific injuries: prevention and treatment

(external rotation) elicited maximal electromyo- simulation techniques as well as various pro- graphic signals from the supraspinatus. Moseley grammes for strength training. These issues et al. (1992) agreed with this finding but cau- should be addressed when preventive strategies tioned against an inclusion of such a position are planned. Swimmers should be taught proper in an exercise programme. Abduction alone, to a stretching techniques such as proprioceptive position of <90°, was not considered a core exer- neuromuscular facilitation and careful partner cise by these authors. selection (McMaster et al., 1992; Fowler, 1995). Finally, concern has been voiced regarding the preventive strategies effect of weight training, particularly for the prepubescent swimmer (McMaster & Troup, Technical errors should be corrected. For 1993). A recent meta-analysis by Falk and Tenen- example, dropping of the elbows in the crawl baum (1996) suggests guidelines for strength during either pull-through or recovery phases training of the prepubescent athlete. increases shoulder external rotation, which then places the muscles of propulsion at a mechanical Back pain disadvantage. Crossing the hand towards the midline causes a ‘wringing out’ of the hypovas- Competitive swimming is an activity that con- cular area of the supraspinatus and biceps sists of many hours of training, both on land and tendons (Johnson et al., 1987). Correct position in the water, with the spine moving into extreme of hand entry consists of shoulder internal positions repeatedly. As such, it withstands con- rotation and forearm pronation. Decreased body siderable amounts of stress (Paris, 1990). It is our roll may cause increased abducted flexion and observation that back pain has become a growing extension. concern for swimmers in recent years. One study Subtle changes in technique may be detected reported a 37% rate of back pain among swim- and remedied by using assistive devices such as mers and rated back pain as the most frequent swim fins, which reduce strain on the shoulder complaint (Mutoh et al., 1988). In a retrospective musculature. An upper arm band may be used study we compared the prevalence of low back (Johnson et al., 1987), possibly making the biceps pain in current vs. past Israeli swimmers (Drori tendon a more effective humeral depressor and et al., 1996): 50% of present butterfly swimmers creating more space under the subacromial arch. reported back pain as opposed to 8% of past Scapular taping has also been considered to swimmers, while 47% of current breaststroke enhance optimal scapulohumeral kinematics swimmers reported back pain compared with (Host, 1995). However, assistive devices used by 27% of past swimmers. While taking into consid- swimmers may also contribute to shoulder pain. eration the shortcomings of a retrospective Hand paddles are used to increase the resistance questionnaire study, this trend warrants further through the water and also to lengthen the time consideration. Cameron et al. (1986) state, but spent in pull-through; thus the likelihood of without specific numbers, that the most frequent impingement is also increased. The use of a kick swimming-related complaint in their facility board may also exacerbate shoulder symptoms, was low back pain, particularly in butterfly as the arms are essentially held in the impinge- swimmers. ment test manoeuvre position (Johnson et al., Stress to the spine in swimming is incurred in 1987). three major areas: the cervicothoracic junction, The use of paired stretching in swimming is the thoracolumbar junction and the lower back very common and may pose special risks for the (Paris, 1990). The lower cervical region is the hypermobile female swimmer. Some swimmers junction of the mobile neck with the relatively use an isokinetic swim bench or other dry-land inflexible thoracic spine. The breaststroke swimming 463

Fig. 31.3 Butterfly stroke demonstrating extension of the lumbar spine.

swimmer who forces the neck back for a quick breath is at risk of developing neck pain. An increased load is also placed on the neck during the recovery phase as the arms are thrust forward or overhead (Paris, 1990). The thoracolumbar and lumbar regions are particularly prone to compressive strain of the posterior elements due to the hyperextension motions of the lumbar spine during strenuous training using the butter- fly stroke or the new breaststroke style (Kenal & Knapp, 1996) (Fig. 31.3). The same hyperexten- sion movement has been implicated in produc- ing a stress fracture in the pars interarticularis in gymnasts (Stinson, 1993). differential diagnosis Fig. 31.4 CT scan demonstrating bilateral spondylo- The differential diagnostic procedures for the lysis of L5 in a 13-year-old female breaststroke swimmer with a 6-month history of low back pain and swimmer include the following, as well as con- a positive bone scan. sideration of metabolic, neoplasmic and infec- tious aetiologies (Micheli, 1979). • Musculotendinous or musculoligamentous injuries, associated with postural faults such as a hyperlordotic or roundback posture. lation demonstrating some degree of spinal cur- • Localized injuries to the growth plate. These vature (Cailliet, 1975), the higher percentage may include Schmorl’s nodes, apophyseal ab- reported in swimmers may actually represent the normalities (usually at the anterior part of the practice of advocating swimming as a therapeu- ring apophysis) and Scheuermann’s disease tic activity for scoliosis. (Swärd, 1992; Micheli & Wood, 1995). • Discogenic back pain. diagnostic tests • Spondylolysis and spondylolisthesis may also cause low back pain in female swimmers Plain radiographic evaluation will detect frac- (Fig. 31.4). tures and subluxations. It should be remembered • Scoliosis has also been reported but not associ- that plain anteroposterior, lateral and oblique ated with back pain. Becker (1986) reported a views deliver 0.11Gy to the skin, a very high 16% incidence of functional scoliosis in swim- dose for an area close to the gonads (Harvey mers. With approximately 2% of the adult popu- & Tanner, 1991). Bone scans may help detect 464 sport-specific injuries: prevention and treatment

early malignancy or inflammatory processes and entirely absent in other swimming styles. In a when compared with oblique radiographs may large epidemiological survey, 73% of breast- help in identifying spondylolysis. Magnetic reso- stroke swimmers reported knee pain compared nance imaging visualizes the intervertebral disc with 48% among other styles (Vizsolyi et al., most accurately while avoiding radiation expo- 1987). In another study by Stulberg et al. (1980), of sure. However, findings must be strictly corre- 18 swimmers with patellar tenderness 12 were lated with the clinical picture because of the high female, lending support to the higher rates of rate of false-positive findings (Harvey & Tanner, patellofemoral pain in females reported else- 1991). Computerized tomography is also used to where (Arendt, 1994). evaluate possible discogenic pathologies, as well Kennedy et al. (1978) believe that the main as spinal fractures. offender in breaststroker’s knee is the tibial col- lateral ligament because it has been found treatment strategies to demonstrate dramatic increases in tension as the knee moves into extension, during valgus Treatment of the swimmer with musculotendi- stress and especially with terminal external rota- nous pain should include stretching shortened tion. Underwater photography confirmed this structures (lumbodorsal fascia, hamstrings), sequence of events during the performance of the strengthening (abdominal muscles and spinal whip kick (Fig. 31.5). Stulberg et al. (1980) identi- stabilization exercises) and limitation of activi- fied the medial facet of patella and the medial ties performed in painful range. Stress fractures femoral intercondylar ridge as common sites of of the pars or spondylolisthesis may require rest pain, in addition to the tibial collateral ligament. and protection of the area. A swimmer may They described the mechanical fault as excessive respond favourably to an antilordotic brace such abduction of the thighs as the knees and hips are as the Boston brace (Micheli, 1979). While reduc- flexed during recovery. Excessive valgus and ing stress resulting from excessive lordosis, the external rotation are, again, the incriminating brace allows continued participation in swim- factors. ming. Micheli (1979) also advocates the use of the Boston brace when dealing with persistent differential diagnosis discogenic pain. The main recommendation for the swimmer presenting with Scheuermann’s Pain and tenderness are typically localized to the disease is to focus their training on the back- medial aspect of the knee joint and may present stroke and freestyle. Training modifications as localized tenderness to the tibial collateral should be incorporated when appropriate, for ligament or as diffuse tenderness around the example avoidance of hand-held floats, which medial aspect of the patellofemoral joint. Knee increase lumbosacral strain (Cameron et al., effusion and patellofemoral crepitus have also 1986). Excessive kicking and the use of a flotation been reported (Johnson et al., 1987). Pain typi- device between the legs while pulling may cally appears in the breaststroke swimmer using promote excessive lordosis (Kenal & Knapp, the whipkick and at first is present only during 1996). Swimmers using a kickboard should be this activity, gradually worsening with contin- encouraged to keep the shoulders below the ued participation (Stulberg et al., 1980). Clinical water surface on all prone strokes in order to signs and symptoms and a physical examina- relieve excess stress on the lumbar region. tion are usually confirmatory. The differential diagnosis includes tibial collateral ligament stress syndrome, patellofemoral pain syndrome, Knee pain medial synovitis and plica syndrome (Kenal & Knee pain is the most frequent pain reported Knapp, 1996). Kennedy et al. (1978) suggest a by breaststroke swimmers, although it is not diagnostic sign of pain elicited when forced swimming 465

the middle of the kicking phase and should not achieve full extension until legs are together at the end of the kicking phase (Johnson et al., 1987). Finally, the symptomatic breaststroke swimmer should minimize the use of the whipkick in prac- tice at times of severe discomfort and attempt to find the ‘critical dosage’ allowing pain-free training.

Synchronized swimming Synchronized swimming has been recognized as an official Olympic event since the 1984 Olympic Games. Synchronized swimming requires flexi- bility, kinaesthetic awareness and an ability to perform repeatedly under anaerobic conditions with inadequate aerobic recovery time in between. Synchronized swimming is a relatively safe sport and most problems are similar to those seen in swimmers in general.

Injuries

Most of the injuries in synchronized swimming are overuse injuries, although the prevalence of these injuries has not been adequately studied. In Fig. 31.5 Rear view of the breaststroke kick demon- a study of 24 synchronized swimmers in Japan, strating the valgus position of the knee. one-third of them complained of injuries (Mutoh et al., 1988). In another study of injury rates, no injuries were recorded among the 200 synchro- nized swimmers participating in the Junior Olympic National Championships (Rovere et al., abduction plus external rotation with the knee in 1982). slight flexion causes pain. Plain X-rays (anterior, posterior, sunrise and tunnel view) may help in knee injuries determining any bony abnormality or malalign- ment of the patella. These injuries, caused by the eggbeater kick, include chondromalacia, chronic patellar ten- treatment donitis, subluxation of the patella and medial collateral ligament strain (Tucker, 1980; Wein- In addition to regular measures aimed at reduc- berg, 1986). ing inflammation and restoring muscle balance around the knee, treatment should focus on elim- shoulder injuries inating the source of stress. It is the coach’s task to instruct swimmers to recover with their knees Rotator cuff impingement syndrome is seen in together. Knees should be abducted no more synchronized swimmers as in competitive swim- than pelvic width during the recovery phase and mers (Tucker, 1980). In addition, synchronized 466 sport-specific injuries: prevention and treatment

swimmers can suffer from laxity of the anterior breath-holding and vigorous exercise (Davies capsule, anterior subluxation or dislocation due et al., 1995). Symptoms include dizziness, dis- to repeated support sculling. This manoeuvre orientation and even momentary blackout, stretches the anterior capsule at the point of especially when completing the underwater maximal external rotation (Weinberg, 1986). component of the free programme. It has been recommended to limit the underwater sequences back pain to 40–45s at most.

Low back pain was the most common injury Acknowledgements reported among synchronized swimmers in a study by Mutoh et al. (1988). Low back pain is fre- We would like to thank Dr Bareket Falk for her quently attributed to lordosis or to the hyperex- thoughtful professional assistance and Professor tension occurring in some of the positions (split, R.J.Z. Werblowsky and Mrs Dinah Olswang for knight, standing and walkout sequence). Other their invaluable help in editing the manuscript. injuries described by Mutoh et al. (1988) are wrist and neck injuries. References muscle cramps Allegrucci, M., Whitney, S.L. & Irrgang, J.J. (1994) Clini- cal implications of secondary impingement of the Cramping of muscles during workouts, practices shoulder in freestyle swimmers. Journal of Orthopedic and performances is common, especially in the Sports Physical Therapy 20, 307–318. toes, arch of the foot and calf because the ankles Arendt, E.A. (1994) Orthopaedic issues for active and are extended and toes pointed for long periods athletic women. Clinics in Sports Medicine 13, of time (Weinberg, 1986). The aetiology of these 483–503. Astrand, P.O., Eriksson, B.O., Nylander, L. et al. (1963) cramps is not understood. Girl swimmers. Acta Paediatrica Suppl. 147, 33–38. Bar-Or, O. & Inbar, O. (1992) Swimming and asthma: benefits and deleterious effects. Sports Medicine 14, Medical problems 397–405. The medical problems associated with pro- Barr, S. (1991) Relationship of eating attitudes to anthropometric variables and dietary intakes of longed exposure to chlorinated water, such as female collegiate swimmers. Journal of the American skin, ear and eye problems, have been discussed Dietetic Association 91, 976–977. earlier in this chapter. However, some specific Beach, M.L., Whitney, S.L. & Dickoff-Hoffman, S.A. concerns should be mentioned. (1992) Relationship of shoulder flexibility, strength • When ear tubes are installed, the use of ear and endurance to shoulder pain in competitive swimmers. Journal of Orthopedic Sports Physical moulds becomes problematic as it prevents the Therapy 16, 262–267. synchronized swimmer from hearing the Becker, T.J. (1986) Scoliosis in swimmers. Clinics in musical accompaniment. Sports Medicine 5, 149–159. • Near-sighted synchronized swimmers have a Bonen, A., Belcastro, A.N., Ling, W.Y. & Simpson, A.A. problem during competitions since they usually (1981) Profiles of selected hormones during men- strual cycles of teenage athletes. Journal of Applied must perform without goggles. Thus, swimmers Physiology 50, 545–551. with myopia should train without corrective Brooks-Gunn, J., Burrow, C. & Warren, M.P. (1988) Atti- lenses in order to develop their confidence and tudes toward eating and body weight in different to become accustomed to swimming without groups of female adolescent athletes. International accurate vision. Journal of Eating Disorders 7, 749–757. Cailliet, R. (1975) Scoliosis: Diagnosis and Management, • A problem unique to synchronized swimmers 1st edn, pp. 1–2. F.A. Davis, New York. is the danger of hypoxia that may develop Cameron, J.M., Goode, A.W., King, J.B. & Garrett, L.P. during competition due to the combination of (1986) Swimming Times Technical Supplement 13, 5–7. swimming 467

Cassell, C., Benedict, M. & Specker, B. (1996) Bone Hawley, J.A. & Williams, M.M. (1991) Relationship mineral density in elite 7- to 9-year-old female gym- between upper body anaerobic power and free- nasts and swimmers. Medicine and Science in Sports style swimming performance. International Journal of and Exercise 28, 1243–1246. Sports Medicine 12, 1–5. Constantini, N.W. (1985) Sexual development in Israeli Hawley, J.A., Williams, M.M., Vickovic, M.M. & girl swimmers. MD thesis, Hebrew University Handcock, P.J. (1992) Muscle power predicts Medical School, Jerusalem. freestyle swimming performance. British Journal of Constantini, N.W. (1994) Clinical consequences of ath- Sports Medicine 16, 151–155. letic amenorrhoea. Sports Medicine 17, 213–223. Heinrich, C.H., Going, S.B., Pamenter, R.W., Perry, Constantini, N.W. & Warren, M.P. (1994) Physical C.D., Boyden, T.W. & Lohman, T.G. (1990) Bone activity, fitness, and reproductive health in women: mineral content of cyclically menstruating female clinical observations. In C. Bouchard, R. Shephard resistance and endurance trained athletes. Medicine & T. Stephens (eds) Physical Activity, Fitness and and Science in Sports and Exercise 22, 558–563. Health, pp. 955–966. Human Kinetics Publishers, Hergenroeder, A.C. & Klish, W.J. (1990) Body composi- Champaign, Illinois. tion in adolescent athletes. Pediatric Clinics of North Constantini, N.W. & Warren, M.P. (1995) Menstrual America 37, 1057–1083. dysfunction in swimmers: a distinct entity. Journal Hirata, K. (ed.) (1979) Selection of Olympic Champions, of Clinical Endocrinology and Metabolism 80, 2740– Vol. 1. Institute of Environmental Stress, Santa 2744. Barbara, California. Costill, D.L., Maglischo, E.W. & Richardson, A.B. (eds) Host, H. (1995) Scapular taping in the treatment of (1992) Handbook of Sports Medicine and Science: Swim- anterior shoulder impingement. Physical Therapy 75, ming. Blackwell Scientific Publications, Oxford. 803–813. Cumming, D.C., Wall, S.R., Galbraith, M.A. & Belcas- Huang, S.W., Veiga, R., Sila, U., Reed, E. & Hines, S. tro, A.N. (1987) Reproductive hormone responses to (1989) The effect of swimming in asthmatic children: resistance exercise. Medicine and Science in Sports and participants in a swimming program in the city of Exercise 19, 234–238. Baltimore. Journal of Asthma 26, 117–121. Davies, B.N., Donaldson, G.C. & Joels, N. (1995) Do the Inbar, O. & Bar-Or, O. (1977) Relationship of anaerobic competition rules of synchronized swimming and aerobic arm and leg capacities to swimming per- encourage undesirable levels of hypoxia? British formance of 8–12-year-old children. In R.J. Shephard Journal of Sports Medicine 29, 16–19. & H. Lavallee (eds) Frontiers of Activity and Child Drori, A., Mann, G. & Constantini, N. (1996) Low back Health, pp. 283–292. Pelican, Quebec. pain in swimmers: is the prevalence increasing? Jacobson, P.C., Beaver, W., Grubb, S.A., Taft, T.N. & Program and Book of Abstracts, p. 75. 12th International Talmage, R.V. (1984) Bone density in women: college Jerusalem Symposium on Sports Injuries, Tel Aviv, athletes and older athletic women. Journal of Israel. Orthopaedic Research 2, 328–332. Falk, B. & Tenenbaum, G. (1996) The effectiveness of Johnson, J.E., Sim, F.H. & Scott, G.S. (1987) Muscu- resistance training in children: a meta-analysis. loskeletal injuries in competitive swimmers. Mayo Sports Medicine 22, 176–186. Clinical Proceedings 62, 289–304. Fauno, P., Kalund, S. & Kanstrup, I. (1991) Menstrual Keizer, H.A. & Rogol, A.D. (1990) Physical exercise and patterns in Danish elite swimmers. European Journal menstrual cycle alterations: what are the mecha- of Applied Physiology 62, 36–39. nisms? Sports Medicine 10, 218–235. Forwell, L.A. & Carnahan, H. (1996) Proprioception Kenal, K.A.F. & Knapp, L.D. (1996) Rehabilitation of during manual aiming in individuals with shoulder injuries in competitive swimmers. Sports Medicine instability and controls. Journal of Orthopedic Sports 22, 337–347. Physical Therapy 23, 111–119. Kennedy, J.C., Hawkins, R. & Krissoff, W.B. (1978) Fowler, P.J. (1995) Upper extremity swimming injuries. Orthopaedic manifestations of swimming. American In J.A. Nicholas (ed.) The Upper Extremity in Sports Journal of Sports Medicine 6, 309–321. Medicine, 2nd edn, pp. 851–861. Mosby–Yearbook, St Kvitne, R.S., Jobe, F.W. & Jobe, C.M. (1995) Shoulder Louis. instability in the overhead or throwing athlete. Frisch, R.E., Gotz-Welbergen, A.V., McArthur, J.W. et al. Clinics in Sports Medicine 14, 917–935. (1981) Delayed menarche and amenorrhea of college Lampe, R.M., Henderson, A.C. & Hansen, G.H. (1977) athletes in relation to age of onset of training. Journal Green hair. Journal of the American Medical Association of the American Medical Association 246, 1159–1163. 237, 2092. Harvey, J. & Tanner, S.C. (1991) Low back pain in young Lee, E.J., Long, K.A., Risser, W.L., Poindexter, H.B.W., athletes: a practical approach. Sports Medicine 12, Gibbons, W.E. & Goldzieher, J. (1995) Variations in 394–406. bone status of contralateral and regional sites in 468 sport-specific injuries: prevention and treatment

young athletic women. Medicine and Science in Sports differential diagnosis. American Journal of Sports and Exercise 27, 1354–1361. Medicine 7, 362–366. Lowensteyn, I., Signorile, J., Tremblay, L. & Salhanick, Micheli, L.J. & Wood, R. (1995) Back pain in young ath- D. (1992) Correlation of swimming speed with letes. Archives of Pediatric Adolescent Medicine 149, various power measurements using a modified arm 15–18. crank ergometer. Medicine and Science in Sports and Moseley, J.B., Jobe, F.W., Pink, M., Perry, J. & Tibone, I. Exercise 24, S185. (1992) EMG analysis of scapular muscles during a McMaster, W.C. & Troup, J. (1993) A survey of interfer- shoulder rehabilitation program. American Journal of ing shoulder pain in United States competitive Sports Medicine 20, 128–137. swimmers. American Journal of Sports Medicine 21, Mutoh, Y., Takamato, M. & Miyashita, M. (1988) 67–70. Chronic injuries of elite competitive swimmers, McMaster, W.C., Long, S.C. & Caiozzo, V.J. (1992) divers, water polo players and synchronized swim- Shoulder torque changes in the swimming athlete. mers. In B.E. Ungerechts & K. Reichte (eds) Swim- American Journal of Sports Medicine 20, 323–327. ming Sciences, 5th edn, pp. 333–337. Human Kinetics Maffuli, N., King, J.B. & Helms, P. (1994) Training in Publishers, Champaign, Illinois. elite young athletes (the training of young athletes Nichols, J.F., Spindler, A.A., LaFave, K.L. & Sartoris, (TOYA) study): injuries, flexibility and isometric D.J. (1995) Acomparison of bone mineral density and strength. British Journal of Sports Medicine 28, 123–136. hormone status of periadolescent gymnasts, swim- Magnusson, S.P., Constantini, N.W., McHugh, M.P. & mers, and controls. Medicine and Exercise Nutrition Gleim, G.W. (1995) Strength profiles and perfor- and Health 4, 101–106. mance in masters’ level swimmers. American Journal Paris, S.V. (1990) The spine and swimming. In S.H. of Sports Medicine 23, 626–631. Hochschuler (ed.) The Spine in Sports, pp. 117–125. Malina, R.M. (1978) Physical growth and maturity Hanley & Belfus, Philadelphia. characteristics of young athletes. In R.A. Magill, M.J. Pink, M. & Jobe, F.W. (1991) Shoulder injuries in ath- Ash & F.L. Smoll (eds) Children in Sport: A Contempo- letes. Clinical Management 11, 39–47. rary Anthology, pp. 79–101. Human Kinetics Publish- Pink, M., Perry, J. & Browne, A. (1991) The normal ers, Champaign, Illinois. shoulder during freestyle swimming. American Malina, R.M. (1983) Menarche in athletes: a synthesis Journal of Sports Medicine 19, 569–575. and hypothesis. Annals of Human Biology 10, 1–24. Potts, J. (1996) Factors associated with respiratory Malina, R.M. (1991) Darwinian fitness, physical fitness problems in swimmers. Sports Medicine 21, 256–261. and physical activity. In C.G.N. Mascie-Taylor & F.W. Reid, D.C. (1987) Current research of selected shoulder Laskor (eds) Application of Biological Anthropology to problems. In R. Donatelli (ed.) Physical Therapy of the Human Affairs, pp. 143–184. Cambridge University Shoulder, pp. 200–203. Churchill Livingstone, New Press, Cambridge. York. Malina, R.M. (1994a) Physical growth and biological Richardson, A.B., Jobe, F.W. & Collins, H.R. (1980) The maturation of young athletes. Exercise and Sport Sci- shoulder in competitive swimming. American Journal ences Reviews 22, 389–433. of Sports Medicine 8, 159–163. Malina, R.M. (1994b) Physical activity and training: Risser, W.L., Lee, E.J., Leblanc, A., Poindexter, H.B.W., effects on stature and the adolescent growth spurt. Risser, J.M.H. & Schneider, V. (1990) Bone density in Medicine and Science in Sports and Exercise 26, 759– eumenorrheic female college athletes. Medicine and 766. Science in Sports and Exercise 22, 570–574. Malina, R.M., Meleski, B.W. & Shoup, R.F. (1982a) Rose, K.J. & Carey, C. (1995) Intensive swimming: can Anthropometric, body composition, and maturity it affect your patients’ smiles? Journal of the American characteristics of selected school-age athletes. Pedi- Dental Association 126, 1402–1406. atric Clinics of North America 29, 1305–1323. Rosen, L.W., McKeag, D.B., Hough, D.O. & Curley, V. Malina, R.M., Mueller, W.H., Bouchard, C., Shoup, R.F. (1986) Pathogenic weight-control behavior in female & Lariviere, G. (1982b) Fatness and fat patterning athletes. Physician and Sportsmedicine 14, 79–86. among athletes at the Montreal Olympic Games, Rovere, G.D., Yates, S. & Miller, R. (1982) Junior 1976. Medicine and Science in Sports and Exercise 14, Olympic: sport medicine health and safety recom- 445–452. mendations. Physician and Sportsmedicine 10, 120– Marcus, R., Drinkwater, B. & Dalsky, G. (1992) Osteo- 133. porosis and exercise in women. Medicine and Science Russell, J.B., Mitchell, D., Musey, P.I. & Collins, D.C. in Sports and Exercise 24, S301–S307. (1984) The relationship of exercise to anovulatory Marcy, S.M. (1985) External otitis due to infection. Pedi- cycles in female athletes: hormonal and physical atric Infectious Disease 4 (Suppl. 3), S27–S30. characteristics. Obstetrics and Gynecology 63, 452– Micheli, L.J. (1979) Low back pain in the adolescent: 456. swimming 469

Sanborn, C.F., Martin, B.J. & Wagner, W.W. (1982) Is Swärd, L. (1992) The thoracolumbar spine in young athletic amenorrhea specific to runners? American elite athletes: current concepts on the effects of phys- Journal of Obstetrics and Gynecology 143, 859–861. ical training. Sports Medicine 13, 357–364. Shklar, A. & Dvir, Z. (1993) Isokinetics of the shoulder. Theintz, G. (1994) Endocrine adaptation to intensive In Z. Dvir (ed.) Isokinetics: Muscle Testing, Interpreta- physical training during growth. Clinical Endocrinol- tion and Clinical Applications, 1st edn, pp. 171–191. ogy 41, 267–272. Churchill Livingstone, New York. Tucker, M. (1980) Common orthopedic problems affect- Sinning, W.E. (1996) Body composition in athletes. In ing synchronized swimmers. In B.J. Wenz (ed.) Sports A.F. Roche (ed.) Human Body Composition, pp. Medicine Meets Synchronized Swimming, pp. 44–45. 257–273. Human Kinetics Publishers, Champaign, American Alliance for Health, Physical Education, Illinois. Recreation and Dance, Reston, Virginia. Stager, J.M. & Hatler, L.K. (1988) Menarche in athletes: Virant, F.S. (1992) Exercise induced bronchospasm: epi- the influence of genetics and prepubertal training. demiology, pathophysiology and therapy. Medicine Medicine and Science in Sports and Exercise 20, 369– and Science in Sports and Exercise 24(8), 851–855. 373. Vizsolyi, P., Taunton, J., Robertson, G. et al. (1987) Stager, J.M., Robertshaw, D. & Miescher, E. (1984) Breaststroker’s knee: an analysis of epidemiological Delayed menarche in swimmers in relation to age and biomechanical factors. American Journal of Sports and onset of training and athletic performance. Medi- Medicine 15, 63–71. cine and Science in Sports and Exercise 16, 550–555. Warner, J.J.P., Micheli, L.J., Arslanian, L.E., Kennedy, Stager, J.M., Wigglesworth, J.K. & Hatler, L.K. (1990) J. & Kennedy, R. (1990) Patterns of flexibility, laxity, Interpreting the relationship between age of menar- and strength in normal shoulders and shoulders che and prepubertal training. Medicine and Science in with instability and impingement. American Journal Sports and Exercise 22, 54–58. of Sports Medicine 18, 366–375. Stinson, J.T. (1993) Spondylolysis and spondylolisthe- Weinberg, S.K. (1986) Medical aspects of synchronized sis in the athlete. Clinics in Sports Medicine 12, swimming. Clinics in Sports Medicine 5, 159–167. 517–528. Wilk, K.E., Arrigo, C.A. & Andrews, J.R. (1996) Closed Stulberg, S.D., Shulman, K., Stuart, S. & Culp, P. (1980) and open kinetic chain exercise for the upper extrem- Breaststroker’s knee. Pathology, etiology and treat- ity. Journal of Sport Rehabilitation 5, 88–102. ment. American Journal of Sports Medicine 8, 164–171. Worrell, T.D., Corey, B.J. & York, S.L. (1992) An analysis Sundgot-Borgen, J. (1993) Prevalence of eating disor- of supraspinatus EMG activity and shoulder isomet- ders in elite female athletes. International Journal of ric force development. Medicine and Science in Sports Sports Nutrition 3, 29–40. and Exercise 24, 744–748. Chapter 32

Track and Field

AURELIA NATTIV

Introduction with or without anaemia, stress urinary inconti- nence while running, exercise-induced bron- Over the last few decades, women’s participa- chospasm, heat illness, gastrointestinal problems tion in track and field events has received and overtraining. increased recognition internationally. In the early Overuse injuries of the lower extremity are by 1960s there was a growing number of girls and far the most common injuries seen in the female women interested in competing in high-level track and field athlete (Watson & DiMartino, track and field events. At that time, however, 1987; Hoeberigs, 1992; Mechelen, 1992; Frederic- women were still excluded from many Olympic son, 1996). Although there is a lack of epidemio- events. According to many officials involved logical data on track and field injuries, the in the Olympic Movement, women were the majority appear to be related to participation in ‘weaker sex’ and some of the events were felt to the sport rather than to the gender of the athlete. be too strenuous for the female athlete. Though However, there are some musculoskeletal prob- the passage of Title IX in 1972 had a great impact lems that tend to occur more frequently in the on women’s participation in sport in the USA, it female track and field athlete, including was not until 1984 that the marathon became an patellofemoral syndrome (Arendt, 1994; Ireland, Olympic event for women. During the last 20 1994) and stress injury to bone (Barrow & Saha, years, women have had exposure to excellent 1988; Myburgh et al., 1990). The prevalence of coaching, strength and endurance training and these injuries, as well as other orthopaedic have excelled in track and field events, breaking injuries, varies by event: stress fractures and records and becoming stronger and faster. For patellofemoral syndrome are more commonly the female athlete, a unique interplay exists seen in the female distance runner; hamstring between mechanical, hormonal and nutritional strains are more often seen in sprinters and hur- factors that in some instances may result in pre- dlers; and patellar tendonitis is common in disposition to bone, ligament, muscle or tendon jumpers, especially high jumpers. Although injuries. female soccer and basketball players exhibit a higher prevalence of anterior cruciate ligament Medical and orthopaedic problems for (ACL) injuries compared with their male coun- the female track and field athlete terparts (Arendt & Dick, 1995), it is not known if this gender difference exists in female athletes The medical problems commonly encountered in competing in track and field events. the female track and field athlete include disor- dered eating, amenorrhoea and premature osteo- porosis (the female athlete triad), iron deficiency 470 track and field 471

clude that sex per se may not affect risk for stress Incidence and distribution of injuries fractures but that other factors, including diet, The incidence of injuries in track and field ath- menstrual history and bone density, may be more letes varies in the literature from 17.5% (Watson important determinants of risk. Some gender & DiMartino, 1987) to 76% (Bennell et al., 1996) differences have been noted for specific knee and has been difficult to determine for a number injuries, including a higher prevalence of of reasons. The ideal epidemiological study patellofemoral syndrome (Clement et al., 1981; includes denominator-based incidence rates Ciullo & Jackson, 1985; Arendt, 1994; Ireland, (Hoeberigs, 1992), where the number of new 1994) and iliotibial band syndrome (O’Toole, injuries observed in a defined period of time is 1992) in women runners. However, epidemiolog- related to the population of runners at risk. Many ical studies assessing gender differences in these of the studies on track and field injuries have injuries are lacking. assessed a defined group of track and field ath- The majority of injuries in female track and letes that does not necessarily reflect the entire field athletes are overuse in nature and involve track and field population. The definition of the lower extremities (Watson & DiMartino, ‘injury’ and the definition of ‘a runner’ also vary 1987; Macera, 1992; Bennell & Crossley, 1996), from one study to another, as does the observa- with the leg (Watson & DiMartino, 1987; tion period in which the athletes are studied. In D’Souza, 1994; Bennell & Crossley, 1996) and the addition, there are many studies on running knee (Clement et al., 1981; Kutsar, 1988) being the injuries in general that have sampled a variety of most common site in most studies depending on individuals, mostly recreational joggers or dis- the specific event. Many of the injuries in female tance runners, often at the time of a competitive track and field athletes are recurrent in nature race or fun run. In contrast, there are few studies (Bennell & Crossley, 1996; Bennell et al., 1996). that have assessed injuries in the specific events Sprinters, hurdlers, jumpers and multi-event of the track and field athlete. Exposure time is athletes report more acute injuries than middle- difficult to quantify in track and field because distance and distance runners (Bennell & Cross- many of the training regimens are individual- ley, 1996). The greatest proportion of injuries ized. For example, the National Collegiate Ath- occur during training rather than competition letic Association (USA) does not have injury data (D’Souza, 1994). for track and field, mostly due to the latter problem. Risk factors for running injuries In the literature the overall incidence of injury for track and field athletes does not appear to The most frequently reported risk factors for differ by gender (Macera, 1992; D’Souza, 1994; running injuries include running distance, Bennell & Crossley, 1996). However, when spe- sudden increases in running mileage or intensity, cific injuries are assessed most studies concur previous running injury and lack of running that female track and field athletes are at greater experience (Hoeberigs, 1992; Brill & Macera, risk than males for stress injury to bone (Barrow 1995). Running distance has been cited as the & Saha, 1988; Myburgh et al., 1990) and numer- most important risk factor in running injuries ous studies of military personnel have also (Macera et al., 1989; Hoeberigs, 1992; Brill & demonstrated a higher risk of stress fractures in Macera, 1995). Higher running speed has been female trainees (Protzman & Griffis, 1977; postulated to be a risk factor in some studies Kowal, 1980; Jones et al., 1989). In a recent 12- (Koplan et al., 1982; Jacobs & Berson, 1986; month prospective study of stress fractures in Lysholm & Wiklander, 1987) but not all (Blair et track and field athletes, Bennell et al. (1996) did al., 1987; Marti et al., 1988; Walter et al., 1989). A not find a difference in stress fracture rates higher performance level (Watson & DiMartino, between males and females. The authors con- 1987; D’Souza, 1994) has been correlated with a 472 sport-specific injuries: prevention and treatment

higher incidence of injury in male and female Sprinters and relay runners track and field athletes in some studies. In another study of competitive track and field ath- The sprint events include the 100m, 200m and letes, increasing age, greater overall flexibility 400m; the relay events include the 4¥100m and and menstrual disturbances were associated the 4¥400m. Each race event has four phases: with a greater likelihood of injury (Bennell & reaction time, acceleration, maximum speed and Crossley, 1996). D’Souza (1994) has reported that decreasing speed (Athletics Congress, 1989). more injuries occur during the beginning of the Reaction time is the time between firing of the season. gun and the start of the muscular reaction. Accel- Lack of proper warm-up exercise, stretching eration is the rate of speed increase from starting and cooling down have been proposed as risk position to maximum speed, while maximum factors for running injuries but studies are con- speed is the rapid repetition of neurophysiologi- flicting and inconclusive. The role of running cal actions and reactions. Decreasing speed shoes in shock absorbency and relationship to includes the component of the race where neuro- injury needs to be studied further. There has been muscular or metabolic fatigue causes decelera- little research assessing appropriate footwear for tion. The length of each of these phases will the female track and field athlete in various depend on the event as well as a number of other events. factors, including the competitive ability and Additional risk factors for stress fractures and experience of the athlete. Most injuries in the stress injury to bone in the female track and field sprint and relay events occur during the accelera- athlete include disordered eating, menstrual tion and maximum speed phases. dysfunction and low bone density (Barrow & Sprinters have a higher incidence of acute Saha, 1988; Myburgh et al., 1990). Intrinsic bone injuries (Fig. 32.1) compared with middle- geometric variables such as area moments of distance and distance runners, who have more inertia of the tibia may prove to be an important overuse injuries (Bennell & Crossley, 1996). The contributing variable to stress fracture risk, most common injuries in sprinters include although most of the studies to date have been in hamstring strains (Lysholm & Wiklander, 1987; male military recruits (Giladi et al., 1987; Kutsar, 1988; Jönhagen et al., 1994). This is most Milgrom et al., 1989). A narrower tibial width likely explained by the explosive nature of may provide an indicator of a biomechanically sprinting, in which the hamstring muscle group weaker structure that might be more likely to is of utmost importance. Garrett et al. (1989) used sustain a stress injury. Women have been found computerized tomography to show that ham- to have relatively narrower bones than men, string injuries are primarily localized proximally which may help explain their higher incidence of and laterally in the hamstring group, most com- stress fractures when exposed to similar training monly in the long head of the biceps. Tighter regimens. hamstrings have been noted in sprinters who sustained hamstring injuries compared with non-injured sprinters (Jönhagen et al., 1994). In Event-specific musculoskeletal this same study, injured sprinters had weaker injuries hamstrings when performing eccentric con- Track and field events primarily fall into events tractions at all velocities tested and weaker that have explosive power requirements and hamstrings and quadriceps when performing those that emphasize endurance. An under- concentric contractions at slow velocities, com- standing of the mechanics of each event is essen- pared with uninjured sprinters. tial to the understanding of the injuries that Yamamoto (1993) has demonstrated that a commonly occur in that event. bilateral imbalence of knee extension and hip track and field 473

can be helpful in preventing and treating these problems. Stress fractures of the tibia, metatarsals and fibula can also be seen in the sprinter and are discussed in more detail in the section on middle-distance and distance runners. Faulty running technique, sudden starting acceleration and excessive demands in weight and jumping training underlie many of the injuries seen in the sprinter (Kutsar, 1988). Avoid- ing block drills early in the season or on consecu- tive days during the season is a helpful preventive measure (Ciullo & Jackson, 1985). Hand and finger injuries can occur in relay events and can be minimized by practising co- ordination of baton exchange during training (Ciullo & Jackson, 1985).

Hurdlers

Hurdling is a rhythmic sprinting event and therefore the ability to perform the rhythmic pattern at speed is a critical factor for success. The techniques involved in hurdling include the start, the first strides, departure, action over the hurdle, touchdown, running between hurdles and the run-in off the last hurdle. Fig. 32.1 Sprinters have a higher incidence of acute lower limb injuries, hamstring strains being the most Hamstring injuries as well as quadricep strains common injury. are common in hurdlers. Adductor strains and pelvic avulsion fractures can also occur, espe- cially while stretching over the hurdle (Ciullo & flexion, hamstring strength and ratio of the flexor Jackson, 1985). Stretching exercises are important to extensor muscle groups were parameters in the hurdler, as a significant stretch is required related to the occurrence of hamstring injury. to clear the hurdle in both the lead leg and trail Although it has been theorized that female ath- leg (Fig. 32.2). Heel bruises are often sustained letes may have more of a discrepancy in their when the hurdler lands flat footed or on her heel hamstring to quadricep ratios, this has not been as opposed to the ball of the foot. If this occurs consistently demonstrated. It has also not been repetitively, a calcaneal fracture can occur. Heel shown that there is a gender difference in ham- cups can help prevent heel bruising. string injuries. Toe running, common in the sprinter, can pre- Jumpers dispose to musculotendinous injury of the poste- rior tibialis, flexor digitorum longus and flexor The jumping events include the long jump, triple hallucis longus. Achilles tendonitis, plantar jump, high jump and pole vault. The jumping fasciitis and metatarsalgia may also occur in events are characterized by a running approach the sprinter. Appropriate stretching, softer soles, phase, a take-off phase, an aerial phase and a rest, and correction of biomechanical problems landing phase. 474 sport-specific injuries: prevention and treatment

triple jump

The triple jump is a more difficult event. The greatest injury potential exists in the landing phase (Ciullo & Jackson, 1985; Kutsar, 1988). Ankle injuries are common, as the foot can often land in plantar flexion and inversion. Lateral ankle sprains and fractures of the tibia and fibula may be seen as well as calcaneal fractures. Injuries to the knee ligaments and menisci can occur due to compressive and rotatory forces if the landing is unbalanced. Patellar tendonitis can also be commonly seen in the jumper. Muscle strains are less common.

high jump

The high jump was introduced as an athletic event in one of the first Olympic Games. The ‘Fosbury flop’ was introduced in the 1968 Olympic Games and has been the most popular technique used in attaining greater heights. The ‘straddle’ technique is often used at the lower qualifying heights; however, ankle sprains are frequent with this approach (Ciullo & Jackson, Fig. 32.2 A significant stretch of the hamstring and 1985). Softer landing pits help to limit the spinal quadriceps muscle groups is required of the hurdler. trauma that may be associated with landing on Injuries to the myotendinous junction of these muscle the neck or back. Proper jumping and landing groups, as well as to the adductors, are common. techniques are very important (Fig. 32.3). Patellar tendonitis or ‘jumper’s knee’ is the most common injury seen in the high jumper long jump (Ciullo & Jackson, 1985) and is often the result of repetitive braking action in conversion of linear The long jump is one of the original events of the motion. Quadriceps tendon strains, hamstring ancient Olympic Games. Most long jump injuries strains and patellofemoral syndrome are other occur during competition rather than training problems that can be seen in the high jumper, in due to poor technique during the landing phase addition to low back strains. (Kutsar, 1988). The majority of injuries are to the knee, including meniscal injuries, ACL injuries pole vault and other ligament injuries. Ankle sprains are also common (Ciullo & Jackson, 1985; Kutsar, Pole vaulting is one of the most complex events 1988). Preventive measures include avoidance of in track and field. The fibreglass pole was intro- improper acceleration too early or too late in duced in 1960 and allows greater speeds. An the jump and adherence to proper landing effective plant of the pole is the most important techniques. technique for the pole vaulter. Injuries are fre- quent and often due to faulty landings and falls (Kutsar, 1988). Shoulder subluxation or acromio- track and field 475

Fig. 32.3 Proper technique is important in the avoid- Fig. 32.4 The successful thrower must be strong and ance of injuries for the high jumper. Patellar tendonitis flexible as body mechanics are used maximally to is the most common injury seen and can be avoided produce a powerful and effective throw. with proper jumping and landing technique.

clavicular joint sprains can occur if the vaulter an object through the air by using the arm and misses her plant. The vaulter must learn to decel- involves a sequence of segmental movements of erate slowly at the end of a long sprint in order the legs, trunk, upper arm, forearm and hand. to avoid injury to the ACL (Ciullo & Jackson, The purpose is to maximize the distance the 1985). Abdominal and hip muscles are utilized object is thrown. The success of the throw is while the athlete is crossing over the bar and dependent on how effectively the thrower uses falling to land on her back. Faulty technique can his or her body to produce the sequence of lead to injury. The pole vaulter should routinely mechanical events reflective of good throwing check her pole before each vault, avoid training technique (Fig. 32.4). The distance the object on a slippery track surface and practise single travels is determined by release parameters technique elements without spikes (Kutsar, (velocity, height, angle), the force of gravity, 1988). the aerodynamic characteristics (shape) of the implement, the environment (wind and air density), temporal patterns of the feet, and Throwers the ground reaction force (Athletics Congress, Throwing is an event in which the athlete propels 1989). 476 sport-specific injuries: prevention and treatment

shotput unbalanced. Excessive torquing can strain the cervical, thoracic and lumbar spine muscles. The Shotputting is a power event that uses bursts of most frequent injury is blistering or laceration of energy, since the shotput is pushed as opposed to the fingers. Aids to increase surface friction and thrown. The shotput weighs 7.25kg at the to secure the grip are necessary (Ciullo & Olympic and collegiate level, 5.45kg in high Jackson, 1985). Wrist injuries and de Quervain’s school and 3.65kg for the grade-school athlete tenosynovitis can also be seen when faulty tech- (Ciullo & Jackson, 1985). The rotational motion nique is used. used in the newer techniques produces tremen- dous torque. The common techniques in use hammer throw include the Feuerbach glide, the short–long and the spin (Athletics Congress, 1989). Flexibility The hammer thrower propels a shot weighing and strength are critical to the athlete’s success. 7.25kg forward. Strength of the back and legs is Four quick preliminary trials are necessary prior very important, as are flexibility, speed and coor- to qualification for semi-final or final events, dination. The goal is to transfer energy from the requiring a warm-up of the muscles of the shoul- leg and back muscles through the hips, shoulders der, leg and back. Sprinting, agility drills and and arms to the hammer. Paraspinous muscle running help develop the coordination and strain as well as transverse process fracture is not speed necessary for this event. The torquing uncommon if proper technique is not used. Hip techniques produce great stress on the knees, capsular sprain, abdominal muscle strain, iliotib- shoulder and back and repetitions should there- ial band syndrome and pubic symphisitis may fore be minimized during midseason. also occur with improper technique. Torque Injury is often due to error in technique. on the elbows may lead to medial or lateral Common injuries from faulty torquing tech- epicondylitis; practising swings without the niques include abdominal strain (external hammer can help prevent this from occurring. oblique or transverse abdominus muscles), Sudden movements using faulty technique can paraspinous muscle spasms and strain, and lead to rotator cuff problems, as well as rhom- gluteus or hip capsular strain. Faulty technique boid and levator scapulae strain (Ciullo & leading to internal rotation on the planted non- Jackson, 1985). Chronic injuries to the knee, dominant foot under the toe bar (used to stop ankle, shoulder and back can also occur with momentum and gain balance) can cause ACL faulty technique. Attention to equipment is also disruption. If faulty technique is used, lateral epi- important as broken wires and wire kinking can condylitis can also occur as the shotput is pro- lead to injury. Leather gloves can increase grip pelled forward. Proper progression of technique and decrease friction. The athlete must also be and form is essential to prevent injury. Wrist pain sure there are no other people within range of is common early in the season and can be pre- throws to prevent potentially devastating injury vented by wrist-strengthening exercises, avoid- to bystanders. ance of hyperextension techniques and taping (Ciullo & Jackson, 1985). javelin discus The javelin was the first field event in the first ancient Olympic Games. Throwing the javelin The discus is an athletic event dating back to 1300 involves not only the arm but also the legs and BC. The modern discus weighs 2kg. The tech- entire body. The most crucial factor in determina- nique of discus throwing involves considerable tion of throwing distance appears to be the veloc- torque, and injuries of the knee, ankle and shoul- ity of the javelin at the release point (Athletic der are not uncommon if the athlete becomes Congress, 1989). The elbow leads the hand into track and field 477

the throw. Medial epicondylitis at the elbow is the most common injury and can be prevented by practising proper technique. The throwing motion primarily involves muscle fibre activa- tion patterns of the deltoid, supraspinatus, infra- spinatus, teres minor and subscapularis. The most common shoulder injury in javelin throwers is impingement syndrome (Jackson, 1976). Maintaining rotator cuff strength, as well as flexibility of the shoulder and elbow, and using proper technique will prevent these common injuries. Weight training is also an inte- gral component of training as well as a means to help prevent injuries. Strain of back muscles and triceps, as well as fingertip lacerations due to rotation of the grip cord at the release, are also common. ACL injuries can also occur while turning inward on a planted and flexed knee if faulty technique is used.

Middle-distance, distance and Fig. 32.5 The high-performance middle-distance marathon runners runner has the speed of a sprinter and endurance of a distance runner. Overuse injuries, primarily of the Middle-distance running includes the 800m and lower extremity, are most frequently seen in these 1500m, whereas distance running typically female runners. includes the 3000m, 5000m and 10000m. The marathon is an endurance event covering 42.19 km (26 miles, 385 yards). The ideal middle- quent in females and is common in those women distance runner would have the speed of a with patellas that chronically subluxate (Insall et sprinter and the endurance of a distance runner. al., 1972). Patellofemoral syndrome is best In the off-season, the middle-distance runner treated with quadriceps and hip abductor often trains as a distance runner and injury strengthening exercises and hamstring, gastro- patterns are often similar (Fig. 32.5). There are cnemius–soleus and iliotibial band stretching. five basic components to distance training: Avoidance of full squats, stairs or hill running endurance, strength, flexibility, speed and and correction of underlying mechanical predis- running mechanics (Athletics Congress, 1989). posing factors, such as foot pronation or leg Injuries to middle-distance, distance and length discrepancies, can be helpful. Additional marathon runners are primarily overuse injuries. modification of training, such as decreasing total Studies report that knee injuries comprise weekly mileage, should also be addressed. 30–50% of all running injuries and are generally Stress injury to bone and stress fractures have due to overuse involving the extensor mecha- also been noted to occur more commonly in the nism (O’Toole, 1992). Patellofemoral syndrome is female runner compared with the male runner in more commonly seen in the female athlete with most studies (Clement et al., 1981; Barrow & alignment abnormalities, foot pronation, tibial Saha, 1988; Myburgh et al., 1990) but not all torsion and problems that create excessive lateral (Bennell et al., 1996), especially in the presence of forces on the patella (Arendt, 1994; Ireland, 1994). disordered eating, amenorrhoea and low bone Patella alta has been reported to be more fre- density in women (Fig. 32.6a,b). Medial tibial 478 sport-specific injuries: prevention and treatment

shown that tibial periosteal inflammation and tibial stress reactions can precede frank fracture. Magnetic resonance imaging can also be useful in management and follow-up of stress fractures and stress injury to bone, including the élite athlete with repetitive stress injury (Arendt & Griffiths, 1997). The tibia is the most common site for stress fractures in runners followed by the metatarsal bones. The most common metatarsal stress frac- ture in the runner is the second metatarsal. Current research in the area of stress injury to bone in the female athlete emphasizes the impor- tant interaction of mechanical, nutritional and hormonal factors on bone (Nattiv & Armsey, (a) 1997). A nutritional and menstrual history should be assessed as part of the medical work- up of all female runners with stress injury to bone. Preventive efforts include an assessment of these factors, ideally at the time of the pre-season physical examination. If disordered eating or menstrual dysfunction is identified, the athlete should have appropriate medical tests and follow-up. In most studies of distance runners, injuries to the foot, ankle and lower leg are the next most frequent after knee injuries (Mechelen, 1992; Rolf, 1995). In addition to stress fractures, common injuries about the leg include medial tibial stress syndrome, Achilles tendonitis and posterior tibial tendonitis (Watson & DiMartino, 1987; Kutsar, 1988; D’Souza, 1994). Plantar fasci- itis is the most common cause of heel pain in (b) runners and is often seen in conjunction with a Fig. 32.6 (a) Magnetic resonance imaging (MRI) of a tight Achilles tendon (Fredericson, 1996). A heel collegiate female distance runner with thigh pain cup or heel lift can be helpful in the treatment of reveals a stress fracture of the lesser trochanter of her plantar fasciitis, in conjunction with a stretching femur. She had a history of primary amenorrhoea and programme and correction of biomechanical low bone density (osteopenia) in her hip and spine. (b) problems. A flat foot or cavus foot can predispose The athlete continued to have hip pain despite rest and the MRI taken 3 months later shows a persistent stress to excessive stress in the origin of the plantar injury. This runner had a previous stress fracture in the fascia. Corrective orthotics may help in the same region in the previous year. prevention and treatment of this problem. Non-steroidal anti-inflammatory agents may be stress syndrome refers to the spectrum of stress helpful in decreasing inflammation. A cortico- injury to bone (Detmer, 1986; Fredericson et al., steroid injection can give significant relief of pain 1995; Fredericson, 1996). Using magnetic reso- in the athlete with recurrent symptoms. Low nance imaging, Fredericson et al. (1995) have back pain and hip problems, greater trochanteric track and field 479

bursitis and adductor tendonitis are also com- majority of runners. Conservative treatment, monly reported in the runner (Lysholm & Wik- including decreased training, non-steroidal anti- lander, 1987). inflammatory agents, stretching and rehabilita- Achilles tendonitis is a very common overuse tion techniques, usually provide only temporary injury in runners. Treatment strategies include relief. decreasing weekly running distance and cross- training, as well as local ice, non-steroidal anti- Multi-event athletes: decathletes inflammatory agents, massage, mobilization and heptathletes techniques, electrostimulation and strengthen- ing exercises with eccentric loading (Fredericson, The decathlon is the most complex track and 1996). A heel lift is also often helpful as well as field event. It has 10 events, with the 100m, long a medial arch support if the runner pronates jump, shotput, high jump and 400m on the first significantly. day of competition and the hurdles, discus, pole Illiotibial band syndrome is common in the vault, javelin and 1500m on the second day of distance runner and commonly results from competition. The heptathlon has seven events. recurrent friction of the iliotibial band over the The first day of competition comprises the lateral femoral epicondyle (Fredericson, 1996). hurdles, high jump, shotput and 200m, while on Messier et al. (1995) found that a higher total the second day the long jump, javelin and 800m weekly distance and training on the track were take place. predisposing factors to iliotibial band syndrome There is a lack of studies of injury rates and in runners. A comprehensive stretching pro- medical problems in multi-event athletes. Over- gramme for the iliotibial band and proximal hip training is a concern, as are the injuries associ- muscles is important in treatment of iliotibial ated with each event. Psychological stamina, band syndrome (Fredericson, 1996). motivation, dedication and competitiveness to Although chronic compartment syndrome overcome obstacles are key components of (CCS) is not common, the physician should be success for the multi-event athlete. Studies of familiar with this diagnosis in the runner as the élite decathlon performers have shown that these presenting symptoms can be subtle. CCS has athletes were outstanding young performers at been described as an exercise-induced compart- many events (Freeman, 1986; Athletic Congress, ment syndrome that has been recognized in all 1989). fascial compartments of the leg but most com- monly in the anterior and deep posterior com- Common medical problems partments (Detmer, 1985; Rorabeck et al., 1988). Symptoms of consistently recurring aching, Female athlete triad tightness or weakness in the leg usually begin within 20min of running and resolve shortly The problems of the female athlete triad (disor- after cessation of running, although in some dered eating, amenorrhoea and osteoporosis) are cases pain persists for a longer time. Numbness discussed in Chapters 25–27. Distance runners in the distribution of the involved nerve (often in have been the most frequently studied group the first web space for anterior compartment syn- that has demonstrated significant decreases in drome) is often noted. Symptoms may be bilat- bone mineral density at multiple skeletal sites eral. Compartment pressure measurements are a (Rencken et al., 1996), as well as an increase in reliable method of assessment of CCS. Magnetic stress fracture risk (Barrow & Saha, 1988; resonance imaging has also recently been used in Myburgh et al., 1990). Given the repetitive aiding the diagnosis of CCS (Amendola et al., mechanical forces on bone in these athletes, low 1990). Fasciotomy is the only treatment that bone mineral density can set the stage for a stress provides permanent relief of symptoms in the fracture especially if there is a history of disor- 480 sport-specific injuries: prevention and treatment

dered eating and amenorrhoea. A menstrual muscles (Nygaard et al., 1990). Those with hypo- history should be obtained for any female athlete oestrogenic amenorrhoea and oligomenorrhoea presenting with a stress fracture. should be assessed for treatment with hormone replacement. Anatomical defects, such as poste- rior urethrovesical angle, should be assessed if Iron-deficiency anaemia the problem persists despite treatment. Several studies have demonstrated chronically low serum ferritin levels in endurance athletes, Exercise-induced bronchospasm especially long-distance runners (Ehn et al., 1980; Clement & Asmundson, 1982; Dickson et al., One of the most common medical conditions in 1982; Colt & Heyman, 1984; Lampe et al., 1986; the track and field athlete is exercise-induced Balaban et al., 1989), although it is has not been bronchospasm, an attack of asthma or bron- shown that the prevalence of iron-deficiency chospasm characterized by airway inflammation anaemia in female runners is greater than in the and hyperresponsiveness that is induced by general female population. exercise. The athlete often experiences this as Most studies in female athletes conclude that shortness of breath during running, chest pain or a low ferritin level in the absence of anaemia is tightness, wheezing, or coughing. The symptoms not associated with a decrease in performance. will often occur after 5–10min of running or However, a low ferritin level with anaemia can other form of exercise. One of the hallmarks of affect athletic performance and in this situation exercise-induced bronchospasm is that the iron supplementation is beneficial to the female symptoms often get worse shortly after exercise athlete. Routine screening of all female athletes commences and usually resolve within 15– by assessing serum ferritin has not been found to 30min following cessation of exercise (Cypcar & be cost-effective. However, screening in some Lemanske, 1994). Athletes with a history of aller- high-risk groups, including endurance runners gies or asthma are at higher risk for exercise- with a history of nutritional deficiency, a history induced asthma. No gender predominance has of anaemia or with symptoms of fatigue and been identified. decreased performance, may prove beneficial. The fact that 11% of the 1984 USA Olympic For a complete discussion of iron-deficiency team had exercise-induced bronchospasm yet anaemia see Chapter 21. won 41 medals illustrates that with adequate recognition and treatment exercise-induced bronchospasm can be prevented or minimized Stress urinary incontinence and need not impair performance (Pierson & Stress urinary incontinence is experienced as Voy, 1988). Preventive efforts include avoidance involuntary loss of urine during physical activity of known allergens that may precipitate the by some athletes. It is commonly seen in female asthma, a warm-up period approximately 30– athletes in running and jumping sports, as 60min prior to prolonged running or exercise well as in gymnastics (Nygaard et al., 1990). and avoidance of exercise in cold and dry envi- The mechanism involves an increase in intra- ronmental conditions. Schnall and Landau (1980) abdominal pressure during exercise. Additional reported that multiple sprints of 30s duration, risk factors include multiparity and hypo- 2min apart, performed 30min prior to pro- oestrogenic amenorrhoea and oligomenorrhoea. longed running had a protective effect and may Treatment includes avoidance of excessive reduce the symptoms of exercise-induced bron- fluid ingestion prior to events (tailored to sport chospasm. This strategy takes advantage of the and weather conditions to avoid dehydration), refractory period that 40–50% of individuals the wearing of sanitary napkins during the event with exercise-induced bronchospasm experience and Kegel exercises to strengthen pelvic floor and is defined as the time during which less than track and field 481

half of the initial response is provoked by a bulb globe temperature (WBGT) index and lack second challenge (Cypcar & Lemanske, 1994). In of acclimatization. Female gender itself does not other words, a mild attack of asthma makes the appear to be a risk factor for heat injury. Wells athlete less responsive (refractory) to an identical (1977) studied the heat response of women exercise task performed within 1 hour. The use of during different phases of the menstrual cycle nasal breathing or the wearing of a scarf or surgi- and did not find differences in sweat rates cal mask to warm and humidify the inspired air or evaporative heat loss throughout the men- during outdoor running in the cold winter strual cycle. Drinkwater et al. (1977) demon- months or using an indoor track may also be strated that there was a resistance to heat injury helpful in the prevention of exercise-induced from physical conditioning in female marathon bronchospasm. runners. Pharmacological prevention and treatment Prevention of heat illness in the track and field includes prescription inhalers used 15–20min athlete includes attention to the environmental prior to running. The most commonly prescribed conditions prior to a track meet or race. The inhalers include the b2-adrenergic agonists, WBGT index is the most useful measure of heat which have been effective in preventing symp- stress. Physicians and organizers of race events toms of exercise-induced bronchospasm in 90% should be familiar with the potential hazards of of patients. The b2 agonists can also be used in exercising in environments with a high WBGT acute bronchospasm. For those individuals unre- index and be prepared to cancel events if condi- sponsive to the b2 agonists, cromolyn sodium tions are hazardous to the athlete’s well-being inhalers may be helpful as a preventive treat- (Bracker, 1992; American College of Sports ment for exercise-induced bronchospasm. Corti- Medicine, 1997). Gradual acclimatization to costeroid inhalers are not used in the sports the environmental conditions is important and setting acutely, unless the individual is found to avoidance of running during peak humidity is have chronic asthma in addition to exercise- essential. In severe cases of heat exhaustion with induced asthma or bronchospasm. In the heat stroke, intravenous fluids should be admin- individual with chronic asthma, inhaled cor- istered as well as cooling techniques and the ticosteroids and other medications for chronic athlete should be transferred to an emergency asthma can help to treat the underlying inflam- facility immediately. matory disorder and airway obstruction and reduce the incidence of exercise-induced bron- Gastrointestinal problems chospasm. These inhaled agents (b2-adrenergic agonists, cromolyn sodium and inhaled cortico- upper gastrointestinal problems steroids) are presently approved by the US Olympic Committee and the International Gastrointestinal problems are common in the Olympic Committee for use by athletes when track and field athlete, especially in distance and accompanied by a physician note or statement of marathon runners. Symptoms such as heartburn, need. loss of appetite, nausea and vomiting appear to be more prevalent during and after intense work- outs, suggesting a dose–response relationship Heat illness (Keefe et al., 1984; Riddoch & Trinick, 1988). One of the most serious conditions for the track Symptoms have also been found to be more and field athlete is heat injury. Heat injuries prevalent in the female runner and the inexperi- include heat cramps, heat exhaustion and heat enced runner (Keefe et al., 1984; Riddoch & stroke. Predisposing factors include previous Trinick, 1988). Gastro-oesophageal reflux and heat injury, inadequate hydration, prolonged decreased gastric emptying appear to be the exercise in humid environments with a high wet main mechanisms responsible for the upper gas- 482 sport-specific injuries: prevention and treatment

trointestinal symptoms in the runner (Green, of occult gastrointestinal bleeding; non-steroidal 1992). anti-inflammatory drugs do not appear to Measures to minimize upper gastrointestinal increase the incidence (Baska et al., 1990). Strenu- symptoms in the runner include reduction in the ous exercise has been found to cause a redistribu- intensity of the workout and avoidance of fatty tion of blood flow and reduction of visceral foods and high-calorie meals prior to exercise. In perfusion. Ischaemic colitis of the caecum and addition, low-osmolar cold drinks that are more proximal colon have been noted in runners and readily emptied by the stomach may be help- may represent the main source of lower gastroin- ful (Green, 1992). The use of pharmacological testinal bleeding in the endurance runner (Moses agents, such as histamine H2 blockers, needs et al., 1988). further study in the prevention of exercise- A complete medical history and examination associated upper gastrointestinal problems in is necessary to evaluate occult bleeding in the the runner. runner, especially if anaemia is associated with blood loss. Preventive measures include use of lower gastrointestinal problems histamine H2 blockers in those athletes without underlying disease. However, the small amount Lower gastrointestinal problems are also of bleeding that usually occurs in the runner has common in the runner. In fact, the term ‘runner’s not been shown to have a detrimental effect on trots’ has been used to explain the well-known health or performance. complaint of diarrhoea associated with running (Fogoros, 1980). Lower abdominal cramping, Overtraining increased frequency of bowel movements, diar- rhoea and the urge to defecate are the most Overtraining can occur in the competitive female common lower gastrointestinal complaints expe- track and field athlete and is probably the most rienced while running. As is the case with upper common cause of depression and fatigue in high- gastrointestinal problems, symptoms are usually level athletes (Puffer & McShane, 1992). The heightened with increased intensity of exercise. competitive athlete, driven to excel and faced The most likely aetiology of lower gastroin- with decreased success and performance, may testinal problems in runners is relative ischaemia drive herself even harder to perform better and of the gastrointestinal tract during intense may become involved in a vicious cycle leading exercise. Preventive measures include proper to the phenomenon of overtraining. hydration early in exercise to prevent cramping, Studies in athletes exposed to a significant preferably with cold solutions with low osmolar- increase in training load have demonstrated ity, and decreasing exercise intensity if possible. increases in pressure, anger, fatigue, global mood Avoidance of exacerbating foods or drugs, disturbances and a reduction in a general sense including caffeine, is important, as is the con- of well-being as measured by the Profile of Mood sumption of lower residue foods before activity States (Morgan et al., 1988). Muscle biopsies in (Green, 1992). Pharmacological agents, such as these athletes have demonstrated markedly antispasmodics, should be discouraged and diminished muscle glycogen in those athletes have not been adequately studied in the runner. with the greatest changes in their Profile of Mood States scores (Costill et al., 1988). occult gastrointestinal bleeding Preventive measures include adequate dietary carbohydrates and sound nutrition and psycho- Occult gastrointestinal bleeding has been noted logical support for the athlete. When the diagno- to be a frequent event in athletes, especially in the sis of overtraining is made, treatment should endurance runner (Baska et al., 1990). The inten- focus on a significant decrease in the intensity sity of exercise appears to increase the prevalence and frequency of training and appropriate psy- track and field 483

chological intervention. It is important to rule venting these problems. Maximal performance out other causes of depression and fatigue in the and enjoyment from sports participation can be female athlete, as a number of other medical achieved in a safe and healthy manner for the problems in addition to overtraining can con- competitive track and field athlete. Most of the tribute to these symptoms. A complete and thor- problems reviewed here are preventable and ough medical history and appropriate physical can be avoided by careful screening, education examination, as well as laboratory testing, may and counselling during the pre-season physical be needed prior to making the diagnosis of examination or during other encounters with the overtraining. athlete and her multidisciplinary team.

Recommendations for future research Acknowledgements Although there is a wealth of information on Sincere gratitude is given to Coach Dick running injuries in the recreational athlete or in Kampmann at Pepperdine University for his cross-sectional studies of athletes competing in assistance. certain events, there is a lack of sound research assessing the medical and orthopaedic problems References seen in the various events of the track and field athlete. More injury surveillance research is Amendola, A., Rorabeck, C., Vellett, D., Vezina, W., needed in order to assess gender differences in Rutt, B. & Nott, L. (1990) The use of magnetic injury patterns in male and female track and field resonance imaging in exertional compartment syn- dromes. American Journal of Sports Medicine 18, 29–34. athletes. Although it appears that there is a American College of Sports Medicine (1997) Position higher incidence of stress fractures in the female statement on prevention of thermal injuries during track and field athlete, there is a need for more distance running. Physician and Sportsmedicine 12, 7. prospective studies to assess this finding better, Arendt, E. (1994) Orthopaedic issues for active and ath- as well as to explore the interrelationship of letic women. Clinics in Sports Medicine 13, 483–503. Arendt, E. & Dick, R. (1995) Knee injury patterns mechanical, hormonal and nutritional factors on among men and women in collegiate basketball and bone, ligament, muscle and tendon injury in the soccer. NCAAdata and review of literature. American female athlete. Journal of Sports Medicine 23, 694–701. Arendt, E. & Griffiths, H. (1997) The use of MR imaging in the assessment and clinical management of stress Conclusion reactions of bone in high-performance athletes. Clinics in Sports Medicine 16, 291–306. There are many more girls and women com- Athletics Congress (1989) The Athletics Congress’s Track peting in track and field than ever before. and Field Coaching Manual, 2nd edn. Leisure Press, Improvements in coaching, equipment and exer- Champaign, Illinois. cise science over the last few decades have pro- Balaban, E., Cox, J., Snell, P., Vaughan, R. & Frenkel, E. (1989) The frequency of anemia and iron deficiency duced female athletes who continue to improve in the runner. Medicine and Science in Sports and Exer- in strength and speed. Some medical and cise 21, 643–648. orthopaedic problems have potentially serious Barrow, G. & Saha, S. (1988) Menstrual irregularity and health consequences for the female track and stress fractures in collegiate female distance runners. field athlete and these have been discussed in American Journal of Sports Medicine 16, 209–216. Baska, R., Moses, F., Graeber, G. & Kearney, G. (1990) this chapter. The physician and healthcare Gastrointestinal bleeding during an ultramarathon. provider need to be aware of the medical and Digestive Diseases and Sciences 35, 276–279. orthopaedic problems commonly encountered in Bennell, K. & Crossley, K. (1996) Musculoskeletal the female track and field athlete during training injuries in track and field: incidence, distribution and and competition and to work together with the risk factors. Australian Journal of Science and Medicine in Sport 28, 69–75. athlete and her multidisciplinary team in pre- Bennell, K., Malcolm, S., Thomas, S., Wark, J. & 484 sport-specific injuries: prevention and treatment

Brukner, P. (1996) The incidence and distribution of Diagnosis, rehabilitation and prevention. Sports Med- stress fractures in competitive track and field ath- icine 21, 49–72. letes. A twelve-month prospective study. American Fredericson, M., Bergman, A., Hoffman, K. & Dilling- Journal of Sports Medicine 24, 211–217. ham, M. (1995) Tibial stress reaction in runners. Cor- Blair, S., Kohl, H. & Goodyear, N. (1987) Rates and risks relation of clinical symptoms and scintigraphy with for running and exercise injuries: studies in three a new magnetic resonance imaging grading system. populations. Research Quarterly for Exercise and Sport American Journal of Sports Medicine 23, 472–481. 58, 221–228. Freeman, W. (1986) Decathlon performance success: Bracker, M. (1992) Environmental and thermal injury. progress and age factors. Track Technique 96, 3050– Clinics in Sports Medicine 11, 419–436. 3052. Brill, P. & Macera, C. (1995) The influence of running Garrett, W. Jr, Rich, F., Nikolaou, P. & Vogler, J. III (1989) patterns on running injuries. Sports Medicine 20, Computed tomography of hamstring muscle strains. 365–368. Medicine and Science in Sports and Exercise 21, 506–514. Ciullo, J. & Jackson, D. (1985) Track and field. In R.C. Giladi, M., Milgrom, C., Simkin, A. et al. (1987) Stress Schneider, J.C. Kennedy & M.L. Plant (eds) Sports fractures and tibial bone width. A risk factor. Journal Injuries: Mechanisms, Prevention and Treatment, pp. of Bone and Joint Surgery 69B, 326–329. 212–246. Williams & Wilkins, Baltimore. Green, G. (1992) Gastrointestinal disorders in the Clement, B. & Asmundson, R.C. (1982) Nutritional athlete. Clinics in Sports Medicine 11, 453–470. intake and hematological parameters in endurance Hoeberigs, J. (1992) Factors related to the incidence runners. Physician and Sportsmedicine 10, 37–41. of running injuries. A review. Sports Medicine 13, Clement, D., Taunton, J., Smart, G. & McNicol, K. (1981) 408–422. A survey of average running injuries. Physician and Insall, J., Goldberg, V. & Salvati, E. (1972) Recurrent Sportsmedicine 9, 47–58. dislocation and the high-riding patella. Clinical Colt, E. & Heyman, B. (1984) Low ferritin levels in Orthopaedics and Related Research 88, 67–69. runners. Journal of Sports Medicine and Physical Fitness Ireland, M.L. (1994) Special concerns of the female 24, 13–17. athlete. In F.H. Fu & D.A. Stone (eds) Sports Injuries: Costill, D.L., Flynn, M.G., Kirwan, J.P. et al. (1988) Mechanism, Prevention, and Treatment, 2nd edn, pp. Effects of repeated days of intensified training on 153–187. Williams & Wilkins, Baltimore. muscle glycogen and swimming performance. Medi- Jackson, D. (1976) Chronic rotator cuff impingement in cine and Science in Sports and Exercise 20, 249–254. the throwing athlete. American Journal of Sports Medi- Cypcar, D. & Lemanske, R. Jr (1994) Asthma and exer- cine 4, 231–240. cise. Clinics in Chest Medicine 15, 351–368. Jacobs, S. & Berson, B. (1986) Injuries to runners: a Detmer, D. (1985) Chronic compartment syndrome: study of entrants to 10,000 meter race. American diagnosis, management, and outcomes. American Journal of Sports Medicine 14, 151–155. Journal of Sports Medicine 13, 162–170. Jones, B., Harris, J., Vinh, T. & Rubin, C. (1989) Exercise- Detmer, D. (1986) Chronic shin splints. Classification induced stress fractures and stress reaction of bone: and management of medial tibial stress syndrome. epidemiology, etiology and classification. Exercise Sports Medicine 3, 436–446. and Sport Sciences Reviews 17, 379–472. Dickson, D., Wilkinson, R. & Noakes, T. (1982) Effects Jönhagen, S., Németh, G. & Eriksson, E. (1994) Ham- of ultra-marathon training and racing on hemato- string injuries in sprinters. The role of concentric and logic parameters and serum ferritin levels in well- eccentric hamstring muscle strength and flexibility. trained athletes. International Journal of Sports American Journal of Sports Medicine 22, 262–266. Medicine 3, 111–117. Keeffe, E., Lowe, D., Goss, J. & Wayne, R. (1984) Drinkwater, B., Kupprat, J., Denton, J. & Horvath, S. Gastrointestinal symptoms of marathon runners. (1977) Heat tolerance of female distance runners. Western Journal of Medicine 141, 481–484. Annals of the New York Academy of Sciences 301, Koplan, J., Rothenberg, R. & Jones, E. (1982) The 777–792. natural history of exercise: a 10-yr follow-up of a D’Souza, D. (1994) Track and field athletics injuries: a cohort of runners. Medicine and Science in Sports and one-year survey. British Journal of Sports Medicine 28, Exercise 27, 1180–1184. 197–202. Kowal, D. (1980) Nature and causes of injuries in Ehn, L., Calmark, B. & Hoglund, S. (1980) Iron status in women resulting from an endurance training athletes involved in intense physical activity. Medi- program. American Journal of Sports Medicine 8, cine and Science in Sports and Exercise 12, 61–64. 265–269. Fogoros, F. (1980) Runner’s trots. Journal of the American Kutsar, K. (1988) An overview of common injuries in Medical Association 243, 1743–1744. track and field events. Modern Athlete and Coach Fredericson, M. (1996) Common injuries in runners. (Australia) 26, 3–6. track and field 485

Lampe, J., Slavian, J. & Apple, F. (1986) Poor iron status O’Toole, M. (1992) Prevention and treatment of injuries of women runners training for a marathon. Interna- to runners. Medicine and Science in Sports and Exercise tional Journal of Sports Medicine 7, 111–114. 24, S360–S363. Lysholm, J. & Wiklander, J. (1987) Injuries in runners. Pierson, W. & Voy, R. (1988) Exercise-induced bron- American Journal of Sports Medicine 15, 168–171. chospasm in the XXIII Summer Olympic Games. Macera, C. (1992) Lower extremity injuries in New England and Regional Allergy Proceedings 9, runners. Advances in prediction. Sports Medicine 13, 209–213. 50–57. Protzman, R. & Griffis, C. (1977) Comparative stress Macera, C., Pate, R., Powell, K., Jackson, K., Kendrick, J. fracture incidence in males and females in an equal & Craven, T. (1989) Predicting lower-extremity training environment. Athletic Training 12, 126–130. injuries among habitual runners. Archives of Internal Puffer, J. & McShane, J. (1992) Depression and chronic Medicine 149, 2565–2568. fatigue in athletes. Clinics in Sports Medicine 11, Marti, B., Vader, J., Minder, C. & Abelin, T. (1988) On the 327–328. epidemiology of running injuries. The 1984 Bern Rencken, M., Chestnut, C. III & Drinkwater, B. (1996) Grand-Prix study. American Journal of Sports Medicine Bone density at multiple skeletal sites in amenor- 16, 285–294. rheic athletes. Journal of the American Medical Associa- Mechelen, W. (1992) Running injuries: a review of the tion 276, 238–240. epidemiological literature. Sports Medicine 14, Riddoch, C. & Trinick, T. (1988) Gastrointestinal distur- 320–335. bances in marathon runners. British Journal of Sports Messier, S., Edwards, D., Martin, D. et al. (1995) Etiol- Medicine 22, 71–74. ogy of iliotibial band friction syndrome in distance Rolf, C. (1995) Overuse injuries of the lower extremity runners. Medicine and Science in Sports and Exercise 27, in runners. Scandinavian Journal of Medicine and 951–960. Science in Sports 5, 181–190. Milgrom, C., Giladi, M., Simkin, A. et al. (1989) The area Rorabeck, C., Bourne, R., Fowler, P., Finlay, J. & Nott, L. moment of inertia of the tibia: a risk factor for stress (1988) The role of tissue pressure measurement in fractures. Journal of Biomechanics 22, 1243–1248. diagnosing chronic anterior compartment syn- Morgan, W., Costill, D., Flynn, M., Raglin, J. & O’Con- drome. American Journal of Sports Medicine 16, nor, P. (1988) Mood disturbance following increased 143–146. training in swimmers. Medicine and Science in Sports Schnall, R. & Landau, L. (1980) Protective effects of and Exercise 20, 408–414. repeated short sprints in exercise-induced asthma. Moses, F., Brewer, T. & Peura, D. (1988) Running- Thorax 35, 828–832. associated proximal hemorrhagic colitis. Annals of Walter, S., Hart, L., McIntosh, J. & Sutton, J. (1989) The Internal Medicine 108, 385–386. Ontario cohort study of running-related injuries. Myburgh, K., Hutchins, J., Fataar, A., Hough, S. & Archives of Internal Medicine 149, 2561–2564. Noakes, T. (1990) Low bone density is an etiologic Watson, M. & DiMartino, P. (1987) Incidence of injuries factor for stress fractures in athletes. Annals of Inter- in high school track and field athletes and its relation nal Medicine 113, 754–759. to performance ability. American Journal of Sports Nattiv, A. & Armsey, T. (1997) Stress injury to bone in Medicine 15, 251–254. the female athlete. Clinics in Sports Medicine 16, Wells, C. (1977) Sexual differences in heat stress 197–224. response. Physician and Sportsmedicine 5, 78. Nygaard, I., DeLancey, J., Arnsdorf, L. & Murphy, E. Yamamoto, T. (1993) Relationship between hamstring (1990) Exercise and incontinence. Obstetrics and strains and leg muscle strength. Journal of Sports Med- Gynecology 75, 848–851. icine and Physical Fitness 33, 194–199. Chapter 33

Rowing

JO A. HANNAFIN

Introduction while in sculling each athlete uses two smaller sculls. Rowing was introduced as an Olympic sport for The phases of the rowing stroke are demon- heavyweight women at the 1976 Olympic Games strated in Fig. 33.2. This is the only Olympic sport in Montreal and expanded to include lightweight in which the participating athletes do not face the women’s rowing at the 1996 Olympic Games in start or finish line. The athletes sit on a sliding Atlanta. Participation by high-school, club, élite seat facing the stern of the boat with their feet and masters rowers has grown rapidly over the anchored in shoes attached to the foot stretcher. last 20 years as opportunities for participation on The athlete begins at the finish, with the legs fully local, national and international levels have con- extended and the oar or sculls at waist height. tinued to expand. The recovery or slide phase then begins, with The majority of injuries sustained in rowing coordination of trunk and arm movement as the are overuse injuries related to an abrupt change hands extend away from the body toward the in training level, alteration in technique or boat, stern of the boat and the legs slowly begin to or the increasingly high volume of training seen bend until a compressed position of approxi- at the national and international level. In order to mately 130° is reached. During this phase, poten- understand better the injuries that occur in tial energy is stored in the legs, lower back and rowing, it will first be necessary to review the arms in preparation for the catch, when the oar weight classes, types of boats and specifics con- enters the water, and the drive, when the legs and cerning equipment and training that may affect back extend propelling the boat through the the development of these overuse injuries. water. In sweep rowing, considerable trunk rota- Oarswomen are characterized by the type of tion occurs at the catch and early phase of the boat in which they row, whether they use a single drive in addition to the compression of the spine oar (sweep rowing) or two nars (sculling) and the seen in both sweep rowing and sculling. weight class in which they compete. Figure 33.1 There are two weight classes for women in demonstrates the differences between sweep Olympic rowing. The heavyweight or open class rowing and sculling and the variety of boats has no height or weight restrictions for athletes. rowed in competition. The current Olympic In international competition, athletes competing events for women include the heavyweight in the vomen’s heavyweight events range in single sculls (F1¥), double sculls (F2¥), quadru- height from 175 to 185cm in height and from 68 ple sculls (F4¥), pair (2–), eight (F8+) and the to 90kg in veight. The coxswain of the women’s lightweight double (FPL 2¥). In sweep rowing, eight must weigh a minimum of 50kg. The light- each athlete uses a single oar that enters the weight class has been in existence in interna- water on the port or starboard side of the boat, tional competition since 1984 when lightweight 486 rowing 487

Single scull (1x)

Double scull (2x)

Quadruple scull (4x)

Pair without coxswain (2–)

Pair with coxswain (2+)

Four without coxswain (4–)

Four with coxswain (4+)

Eight with coxswain (8+)

Stern Bow

Fig. 33.1 The sweep events for women include the pair without coxswain (2 –), four without coxswain (4 –) and the eight (8 +). Sculling events for women include the single sculls (1 ¥), double sculls (2 ¥) and quadruple sculls (4 ¥).

events for women were included as exhibition related to on-water training, towing ergometer events at the Lightweight World Championships training, weight lifting or land cross-training. It in Montreal, Canada. Women participating in the is also important to have a knowledge of the lightweight class must weigh no more than 57kg mechanics of the rowing stroke and to elicit and are generally 170–180cm in height. symptoms that may be referable to specific phases of the rowing stroke. The physical examination before participation Rowing injuries should be general and should evaluate range of Overuse injuries are seen most frequently in the motion, strength and flexibility necessary for knee, lower back, rib cage and upper extremity successful competition in rowing, while evalua- and occur with maximum frequency during tion for an acute or overuse injury will be more periods of intense training and racing secondary specific and focused on the regional problem. to the high level of training that is perfnrmed Because of the complexity of the rowing stroke (Hosea et al., 1989; Hickey et al., 1997). When an and the interrelationship of the arms, trunk, back athlete presents with an injury it is critical to and legs, the joints proximal and distal to the ascertain a description of recent training in order injury should be carefully assessed. It may also to determine if the injury occurred during be useful to evaluate the injury via simulation of sculling or sweep rowing and if the injury was the rowing technique on an ergometer in order to 488 sport-specific injuries: prevention and treatment

of training or to modify the type of work being performed. In mild overuse injuries it may be possible to continue to train with a decreased workload or duration of exercise while applying principles of stretching, strengthening, ice and anti-inflammatory medications. Alternatively, it is possible to alter the equipment being used by the athlete in order to diminish the load, to alter the functional range of motion or to modify the (a) stress seen by the athlete (port vs. starboard). The load placed on the oar can be modified by chang- ing the length or stiffness of the oar or by alter- ation of the inboard–outboard ratios. The height and position (toe-in vs. toe-out) of the foot stretchers can be modified to diminish rotational forces at the hip and knee. Rotational stresses on the thoracic and lumbar spine can be modified by moving an athlete from a port to a starboard position in a sweep boat. If these modifications fail, it may be necessary to discontinue on-water

(b) training if symptoms are not improving or are worsening with continued training. It may also be necessary to discontinue on-water or ergome- ter training at the time of diagnosis for more severe injuries, including lumbar disc disease vith radiculopathy or stress fractures of the ribs. The principle of ‘active rest’ or cross-training must be applied in this driven and demanding group of athletes. It is virtually impossible to tell an oarswoman to stop exercising in the face of an injury. Rather it is important to educate the (c) athlete and to provide viable alternatives to the Fig. 33.2 The phases of the rowing stroke. An athlete is provocative activity in order to facilitate rapid shown at (a) the catch, (b) the drive and (c) the finish of resolution of symptoms and return to sport. the rowing stroke in a sweep boat. Bracing and physical therapy remain essential components of successful treatment. determine whether a correctable biomechanical Thoracic spine and rib abnormality may be responsible for the injury being evaluated. Thoracic disc herniations in oarswomen are The treatment of specific injuries has been out- uncommon but can nccur. The majority of tho- lined in previous chapters and is not discussed in racic injuries seen are costochondritis, costover- detail here. However, alterations in training or tebral joint dysfunction and stress fractures of the technique specific to the sport of rowing are ribs. Costochondritis can present with single or reviewed in the treatment of specific injuries. For multiple joint involvement and is most com- injuries related to on-water or ergometer training monly seen in the joints of the outside arm (e.g. it is frequently necessary to decrease the intensity the right costochondral junction in a starboard rowing 489

athlete). This syndrome is thought to result from athlete presenting with focal chest wall pain with repetitive overcompression of the costochondral activity. In the early stage, pain may only be junction seen with trunk torsion and outside present with high-level activity but vill rapidly arm cross-chest adduction in sweep rowing. appear with deep inspiration, coughing or sneez- Treatment is based on the principles outlined ing. A bone scan is diagnostic if performed after previously including ice, anti-inflammatory symptoms have been present for 5 days (Fig. medication and active rest. It may be possible for 33.3). the athlete to continue to train in a sculling boat, The posterolateral rib at the serratus insertion on an ergometer or on the opposite side of the is the most common site of stress fracture, boat (port vs. starboard) if symptoms allow. although fractures at other sites have been repn- Stress fractures of the ribs are an increasingly rted (Brukner & Khan, 1996). Successful manage- common and serious injury in the élite oars- ment of a stress fracture involves cessation of all woman. First reported by Holden and Jackson rowing and upper body weight training for a (1985) in three élite female rowers, these injuries minimum of 4 weeks, althnugh athletes should have increased in frequency during the last continue to cross-train in order to maintain car- decade. This increase is thought to be related to diovascular fitness. A gradual transition to on- the intensity of both on-water and ergometer water rowing and upper body weight training is training and may also be related to design allowed at 4 weeks if the athlete is asymptomatic. changes of the rowing blade from tulip to hatchet Upon initial return to on-water training, mileage shape, which results in a heavier load at the and speed work must be catch. The incidence of stress fractures of the ribs curtailed to avoid reinjury but can be gradually was previously thought to be higher in female and steadily increased. A careful assessment of rowers secondary to differences in upper body rowing technique is important with the return to strength, as described by Holden and Jackson on-water training in order to correct abnormal (1985). Data collected by physicians from the stroke mechanics and to avoid reinjury. It may be Canadian Rowing Association (R. Bachus, necessary to decrease the load on the nar for unpublished observations) and the United States athletes participating in team boats so that they Rowing Association (Karlson, 1998) do not can train without overloading the healing rib. demonstrate any increased risk of stress fractures in sweep rowing vs. sculling or in male vs. Shoulder female rowers competing at an élite level. It is estimated that 10–15% of all élite rowers will Impingement syndrome is the most common sustain a rib stress fracture at some point in their shoulder injury in oarswomen and can be related competitive careers. The roles of gender, focal to technique, training errors and abnormalities in strength deficits and training on the incidence of the strength and flexibility of the shoulder and stress fractures of the ribs in the club, college or periscapular musculature. Impingement syn- pre-élite oarswoman have not been studied. drome can also result from excessive gleno- Although stress fractures of the ribs are seen with humeral laxity, which is more common in the similar frequency in men and women, it is still female athlete. Over-reaching at the catch critical to screen any female athlete presenting with increased glenohumeral forward flexion, with a stress fracture for abnormalities in eating coupled with excessive scapular protraction, patterns and to assess the nutritional and men- may result in the development of impingement strual status of the athlete. syndrome. Asymmetric strengthening of the Stress fractures of the ribs are often initially deltoid without concomitant strengthening of misdiagnosed as intercostal muscle pulls and the the rotator cuff and the periscapular musculature athlete is allowed to continue to train. A high during land-based strength training may also be index of suspicion must be maintained in any provocative. Treatment of impingement syn- 490 sport-specific injuries: prevention and treatment

Fig. 33.3 A 99Tc bone scan of an Olympic female single sculler demonstrates multiple sites of increased uptake consistent with stress fractures of the ribs.

drome includes the use of non-steroidal anti- 33.4a) and is related to a premature break in the inflammatory medications, ice and physical extended elbow during the drive, resulting in therapy, including a well-designed strength and compensatory hyperflexion of the wrist and flexibility programme for the rotator cuff, rhom- overload of the flexor–pronator origin. Lateral boids, serratus and latissimus. Modification of epicondylitis is seen more commonly in sweep the height of the rigger and inboard–outboard rowing, particularly in the inside hand, and is ratios may be helpful in allowing the athlete to related to repetitive dorsiflexion of the wrist continue to train and compete. Athletes should required to feather the oar at the end of each be monitored in order to reduce errors in tech- stroke (Fig. 33.4b). This injury may be related to nique, including over-reaching or inadequate the size of the oar handle, placing the female scapular stabilization at the catch allnwing athlete with a smaller grip area at increased risk. excessive transmission of load to the rotator cuff Recent advances in oar handle size and grip sur- and glenohumeral joint. faces have made this injury uncommon in the élite athlete, although it is seen frequently in the collegiate or club oarswoman secondary to train- Elbow and wrist ing errors or equipment misfit. Medial and lateral epicondylitis are uncommon Extensor tenosynovitis was first described in a in the élite female rower but can be seen in club group of élite oarsmen by Williams (1997) but and collegiate rowers. The most common cause occurs with equal frequency in male and female of these overuse injuries is a change in technique rowers. This extensor tenosynovitis or ‘cross- or size of the oar handle. Medial epicondylitis over tendonitis’ involves the first and second appears to be more common in scullers (Fig. dorsal compartment of the wrist where the rowing 491

and increased incidence of ligamentous laxity. The sport of rowing places high loads on the patellofemoral joint secondary to repetitive flexion–extension during on-water and ergo- meter training as well as land training, which fre- quently involves hill running, Olympic-style (a) lifting and plyometric training for the lower extremities. Compressive patellofemoral pain and lateral facet syndrome will often present fol- lowing transition to winter land training or fol- lowing the initiation of on-water speed work. Iliotibial band friction syndrome is most com- monly seen during distance endurance training but can also be seen with any significant increase in the intensity of training. Genu valgum, femoral anteversion and external tibial torsion may predispose to both compressive patello- (b) femoral pain and lateral facet syndrome, while genu varum and a tight iliotibial band may pre- Fig. 33.4 The hand position and grip necessary for (a) sculling and (b) sweep rowing. dispose to iliotibial band friction syndrome. Ath- letes should be carefully evaluated to determine the flexibility and strength of the hamstrings, quadriceps and hip flexors, and focal deficits abductor pollicis longus and extensor pollicis should be systematically addressed. Treatment is brevis cross. It presents with crepitus and pain, directed to reversal of abnormal patterns of and symptoms can be reproduced with repetitive muscle weakness or inflexibility. It may also be wrist dorsiflexion. Treatment includes the use necessary to modify training and decrease squat- of ice, functional wrist splinting, iontophoresis ting, open-chain knee extension exercises, hill or phonnphoresis, and non-steroidal anti- running and stair climbing. Patellar taping or inflammatory medications. Adaptive splinting bracing may be helpful in cases of lateral mal- may be used to allow the athlete to continue to tracking or lateral facet syndrome. It is often pos- train, but must be carefully designed and padded sible to continue on-water or ergometer training to avoid skin breakdown. Local corticosteroid with modification of training intensity or of injection may be helpful in the athlete who does equipment. The foot stretcher can be altered in not respond to conservative treatment as out- order to decrease knee flexion (by raising the lined above. Surgical intervention has been height of the foot stretcher) or to decrease func- described by Williams (1997) but is infrequently tional knee valgus or varus by increasing toe-in needed. It is not often necessary to remove or toe-out of the shoes on the foot stretcher. Front the athlete from on-water training if appro- or back stops can also be placed on the track of priate splinting and technique modification is the sliding seat in order to alter the arc of knee undertaken. flexion and extension.

Knee Lumbar spine

The female athlete is thought to be more prone Injuries to the lumbar spine are common in to injuries invnlving the patellofemoral joint rowing secondary to the large forces transmitted because of the increased Q-angle, wider pelvis from the legs through the spine to the upper 492 sport-specific injuries: prevention and treatment

Fig. 33.5 The New Zealand double sculls team at the Barcelona Olympics nearing the end of the drive phase of the rowing stroke. (© Allsport / Botterill.)

extremities and the oar. In a study of lightweight aggressive evaluation, including a myelogram élite female rowers Howell (1984) described an using magnetic resonance imaging or computed 82% incidence of low back pain compared with tomography. Central disc syndromes without an age- and sex-matched incidence in the general radiculopathy will often benefit from conserva- population of 20–30%. Hosea et al. (1989) have tive treatment. Addition of epidural steroid demonstrated that significant compressive loads treatment may be necessary if the athlete is non- are placed on the lumbar spine during the drive responsive to conservative treatment or if time is phase of the rowing stroke (Fig. 33.5). In female of the essence. It may be necessary to stop all rowers, these compressive forces approach 6.85 rowing for a period of 4–6 veeks if symptoms times body weight at L4 during mid-drive. persist in spite of appropriate conservative treat- In addition, sweep rowing results in signifi- ment. Disc herniation with sensory loss may cant torsional forces across the lumbar and tho- worsen if the athlete is allowed to continue to racic spine that may differentially load the disc train. Athletes may be allowed to compete in space and facet joints. Poor technique or inequal- important events if monitored carefully and edu- ity of the strength of the leg and back muscula- cated as to the risk of progression of the neuro- ture may predispose to lumbar spine injuries. logical symptoms. Athletes presenting with Evaluation of the oarswoman presenting with lumbar disc disease and motor loss must stop all low back pain must include a thorough examina- rowing activities and must be evaluated by a tion of the spine, sacroiliac joints and hips; an physician skilled in the conservative and opera- assessment of the flexibility of the hip, abdomi- tive management of lumbar disc disease. nal and spine musculature; and a thorough neu- Epidural steroid and physical therapy may be rological examination. The athlete presenting extremely beneficial, although surgical interven- with pain without radicular symptoms can be tion may be warranted in specific cases. Early treated initially with active rest (swimming), consultation with a spine surgeon is advis- physical therapy designed to address posture, able. Élite athletes have returned to ruccessful muscle strength and flexibility, and modification international competition following lumbar disc or discontinuation of ergometer or nn-water surgery. training. In the élite athlete, persistence of Spondylolysis or spondylolisthesis is uncom- radicular symptoms for longer than 1 week or mon in the skeletally mature oarswoman but can development of radiculopathy warrants more be seen in junior team candidates. This injury rowing 493

should be suspected when the pain is localized Gloves are not generally worn as the propriocep- lateral to the midline and is exacerbated by tive sense of oar position in the hand is critical in extension rather than flexion. Lateral and oblique fine control of the position of the blade in the radiographs will confirm the diagnosis of an water. established spondylolysis or spondylolisthesis, The design of the tracks on which the seat while a bone scan may be required for diagnosis glides, in combination with calf muscle hypertro- of an acute pars interarticularis stress fracture. phy, can predispose the rower to ‘track bite’. Athletes with an acute stress fracture of the pars Track bite presents with focal skin loss where the are required to stop all rowing and extension calves and the tip of the tracks come into direct exercises until resolution of the injury. contact. These can easily become infected and should be treated with aggressive local care and padding when needed. Skin ulceration can also Exercise-induced bronchospasm occur in the gluteal crease secondary to repetitive Exercise-induced bronchospasm is seen in chafing during the rowing stroke. Careful atten- 15–20% of élite oarsmen and oarswomen. There tion to personal hygiene and early treatment of is no known gender influence and the treatment focal skin irritation is successful in the manage- in rowers is similar to the treatment in any ment of these problems. athlete. Environmental factors may play an increased role in the rower as rapid changes in References temperature can occur while the athlete is train- ing on the water. In addition, these athletes may Brukner, P. & Khan, K. (1996) Stress fracture of the neck be at some distance from medical personnel of the seventh and eighth ribs: a case report. Clinical during competition and must therefore be well Journal of Sports Medicine 6, 204–206. Hickey, G., Fricker, P. & McDnnald, W. (1997) Injuries to educated in the early recognition of symptoms elite rowers over a 10-yr period. Medicine and Science and the preventive use of inhaled medications. in Sports and Exercise 29, 1567–1572. Inhaled b2 agonists are permissible in interna- Holden, D. & Jackson, D. (1985) Stress fractures of the tional rowing competition but must be registered ribs in female rowers. American Journal of Sports Med- in advance of competition. icine 13, 342–348. Hosea, T., Boland, A., McCarthy, K. & Kennedy, J. (1989) Rowing injuries. Postgraduate Advances in Dermatological problems Sports Medicine 3, 1–16. Howell, D. (1984) Musculoskeletal profile and inci- Rowers can develop a dermatological problem dence of musculoskeletal injuries in lightweight involving the skin of the hands, calves and but- female rowers. American Journal of Sports Medicine 12, 278–282. tocks. Significant callosities will develop on the Karlson, K. (1998) Rib stress fractures in elite rowers: a palms and fingers in response to training. If these case series and propnsed mechanism. American callosities are allowed to become hypertrophic Journal of Sports Medicine 26(4), 516–519. they will slough, resulting in full-thickness skin Williams, J. (1997) Surgical management of traumatic loss that can significantly affect training. Athletes non-infective tenosynovitis of the wrist extensors. Journal of Bone and Joint Surgery 59B, 408–410. must be reminded to maintain optimal thickness of these calluses with the use of a pumice stone. Chapter 34

Gymnastics

ANGELA D. SMITH

Introduction jective judging parameters include body car- riage, expressiveness and music interpretation. Both spectators and the press exult at the athletic The judges also observe and mark the gymnast’s feats of female gymnasts. Simultaneously, aesthetic qualities, such as body shape, leanness however, they deplore the unhealthy behaviours and overall ‘look’. apparently practised by many of the most suc- cessful gymnasts, behaviours recommended or Changes in recent history even required by their coaches (Rosen & Hough, 1986; Roeper, 1996). The gravity-defying skills of body type female artistic gymnasts led to a death from a vaulting injury that occurred during competi- Before the 1970s, élite artistic female gymnasts tion. An eating disorder killed another élite could usually be described as being of average gymnast after she barely missed qualifying for height, slender, lithe and graceful. The success in the Olympic Games. Gymnastics may give a 1972 of the incredibly popular gymnast Olga young woman self-confidence and strength or it Korbut ushered in a new era of gymnasts with may stunt her growth and cause long-term acrobatic skills, such as back flips on the balance health problems. beam, and new feats of flexibility that required All élite sport requires particular body types, excessive lumbar spine mobility. The media often careful diet, intense training and remarkable described Korbut as ‘pixie-ish’ and lauded her commitment and focus. None the less, women’s girlish, pig-tailed figure that enabled her to gymnastics has been singled out as a sport that perform such daring acrobatic stunts. In 1976, may be particularly abusive of its élite partici- Nadia Comaneci, a prepubertal 14-year-old, pants (Tofler et al., 1996). These young women increased the skills necessary to be a champion are highly motivated and eager to please the gymnast by a quantum leap, performing succes- adult coaches and judges who govern their lives. sive back tucks on the beam and twisting double Sometimes the adults seem to fail the gymnasts back flips in her floor exercises. Completion of in their charge. For example, many questioned these types of rotational skills was very difficult the failure of coaches and officials to stop Kerri for a woman who was 165cm tall, so champi- Strug’s second vault after she had already sus- onships were increasingly won by small girls tained a serious ankle injury in the 1996 Olympic with prepubertal bodies and superb acrobatic Summer Games (O’Connor & Lewis, 1997). skills. The top two medallists in the all-around Both artistic and rhythmic gymnasts are competition at the 1992 Olympic Summer Games judged on objective markers such as skill were 138cm tall and weighed 31kg (Ryan, 1995). difficulty and excellence of skill completion. Sub- Although the gymnastics community and the 494 gymnastics 495

public appreciated the amazing acrobatic feats, demonstrated by Comaneci in 1976 remain the they missed the grace and maturity generally standard for world and Olympic competition. exhibited by older gymnasts. Many female gym- Nevertheless, in 1976 Comaneci was the only nasts and their coaches planned a gymnastic competitor to complete all the very difficult skills career to last only until age 16 years or so and perfectly; now most of the top competitors expect tried to avoid longitudinal growth and develop- to perform these moves successfully. In order to ment of the normal adult female body contours accomplish these feats, younger children perform as long as possible. This was generally accom- increasingly difficult moves and spend a greater plished by long hours of training and minimal number of training hours working on them. energy intake. At the 1996 Olympic Summer Games, Olympic disciplines observers were pleased to see a few mature gym- nastic champions who were over 16 years of age artistic gymnastics and had the experience, grace and artistic pres- ence of women. In fact, five of the seven women Artistic gymnasts perform routines in four dif- on the gold medal team were 18 years or older ferent disciplines. The floor exercise is performed (Normile, 1996). None the less, 18-year-old Kerri to music and includes sequences of: (i) acrobatic Strug, the final gymnast to compete for the USA skills, such as handsprings, flips and twisting team as they won the gold medal, was only flips; (ii) dance steps that express the music; and 145cm tall and weighed less than 36kg (Roeper, (iii) balance skills, such as handstands and scales 1996). Recent rule changes now require female (arabesques). Similar skills are performed on the gymnasts to be at least 16 years of age during 10-cm wide balance beam but without music. the calendar year of a world championship or The uneven parallel bars require great upper Olympic Summer Games in order to compete body and abdominal strength: the gymnast (Forbes, 1996). Of course, great strength, small swings around each bar, flies between them with stature and a very lean body composition are still release moves and then ends with a flying dis- necessary. mount. For the vault exercise, female gymnasts The body habitus of rhythmic gymnasts has sprint to a springboard, punch the board for take- perhaps been even more stereotyped than that off, touch the vault with their hands and then of artistic gymnasts. Virtually all international, land on a padded mat after performing one of female, rhythmic gymnastic competitors are several possible combinations of twisting and extremely slender, with even more aesthetic lithe somersaulting manoeuvres. body lines than artistic gymnasts. Anecdotal reports of energy consumption indicate extreme rhythmic gymnastics limitation of food intake. The changes in élite body type have perhaps been less obvious than A rhythmic gymnast performs to music on a flat for the artistic gymnasts since rhythmic gymnas- platform. She uses apparatus such as a ball, tics was not added to the Olympic schedule until hoop, rope, clubs or ribbon while performing 1984. acrobatic skills and dance steps. Extreme flexibil- ity, beautiful line and graceful interpretation of skills the music, along with creative and successful use of the apparatus, determine her score. Olga Korbut’s revolutionary skills at the 1972 Olympic Summer Games are now routinely General concerns accomplished by young club-level gymnasts. Somewhat less rapid change in acrobatic skills In the last few years, both the gymnastics and has occurred over the last decade as many moves medical communities have expressed increasing 496 sport-specific injuries: prevention and treatment

concern about the health of young gymnasts need for extreme thinness is driven by both the (Tofler et al., 1996; O’Connor & Lewis, 1997). Both perception of improved performance and the physical and mental health issues have been subjective component of judging. As they strive discussed. Concerns raised include possible for the leanest bodies possible, gymnasts may stunting of normal growth (Theintz et al., 1993; resort to unhealthy behaviours. A study of 42 Lindholm et al., 1994), unhealthy retardation of collegiate gymnasts found that two-thirds had puberty with potential long-term health implica- been told to lose weight by their coach or trainer tions (Lindholm et al., 1994), other problems and that three-quarters of these young women related to inadequate nutrition (Lindholm et al., resorted to dangerous methods of weight 1994), emotional abuse by coaches and/or loss, such as recurrent vomiting and/or diuretic parents (Tofler et al., 1996), inappropriate com- or laxative abuse (Rosen & Hough, 1986). Nutri- ments by officials that lead gymnasts to further tional deficits appear to be common among malnutrition (Ryan, 1995) and eating disorders. rhythmic gymnasts as well as artistic gymnasts Comments such as ‘If I could, I’d take half a point (Sundgot-Borgen, 1996). off just because of that fat hanging off your butt’, made by a gymnastics official to a very lean ado- Menarche lescent a year before she became Olympic cham- pion (Ryan, 1995), are most unlikely to encourage Until recently, élite gymnasts were thought to healthy eating habits. have delayed menarche primarily because of The International Gymnastics Federation has their severe training schedules and inadequate responded to these challenges by increasing the nutrition. Although recent studies have indi- minimum age for world gymnastics competition cated that the most important factor determining to 16 years. USA Gymnastics has instituted the 5- menarche for athletes in most sports is heredity Star Gym Program that rewards gymnastics (Malina, 1994), the overriding factor determining clubs for providing attention to their gymnasts’ menarche among young gymnasts may be nutrition, hydration, training schedules and undernourishment for extended periods of time. injury prevention techniques in the hope that this Virtually all studies have noted significantly strategy will allow healthy gymnasts to be ade- delayed menarche among competitive artistic quately nourished in order to train and compete gymnasts compared with other athletes who at optimal levels and develop as normally as pos- train at similar volume and intensity. For sible. Of course, parents must also be willing to example, in one study the average age at menar- help their children follow this approach. One che was 14.3 years for gymnasts, 13.3 years for trainer, cautioning the mother of an undernour- swimmers and 13.2 years for tennis players ished young gymnast about potential bone and (Baxter-Jones et al., 1994). Estimated median age growth concerns, was told ‘We want to keep her at menarche for gymnasts calculated from a this way [small and undernourished]’ (Ryan, meta-analysis of other studies was 15.6 years 1995). compared with 13.2 years for a national sample of Flemish girls (Beunen & Malina, 1996). Growth and development Stature Nutrition At an early age successful gymnasts have shorter Although scientific data concerning the average and lighter parents than children in other sports energy intake and expenditure of competitive (Theintz et al., 1989). However, when older gym- gymnasts are rare, anecdotal evidence suggests nasts are examined, discrepancies between gym- that many female gymnasts regularly consume nasts and other groups increase. Benardot and less energy than they expend. The perceived Czerwinski (1991) studied 146 junior élite gym- gymnastics 497

nasts aged 7–14 years and found a drop from the attributes of short stature and great strength and 48th percentile for height and weight among the speed. It seems likely that the drive to be the youngest athletes to the 20th percentile among leanest, lightest athlete possible—by eating too the older gymnasts. The height–weight ratio little to support intense training, as well as func- remained stable, at approximately the 50th per- tions such as menses and growth—markedly centile. These authors believed that the age- delays the normal prepubertal growth spurt and related decrease could be related to inadequate may permanently decrease stature from the nutrition, sport-specific selection that favours height predicted for the athlete. retention of small powerful gymnasts or a combi- nation of these factors. From age 6 years on, Bone mineral density studies by several authors have found female gymnasts to be below the 50th percentile for both Early disquiet about the incidence of disordered height and weight for age. Most clustered near eating and amenorrhoea among gymnasts raised the 10th percentile range. The gymnasts in the further concerns about their bone mineral more recent studies were the shortest and light- density, the third aspect of the female athlete est (Malina, 1994). triad. Fortunately, the bone of competitive Although some investigators believe that the female gymnasts seems to be preserved despite short stature of gymnasts is mainly inherited the nutritional and menstrual abnormalities (Malina, 1994; Beunen & Malina, 1996), heredity (Kirchner et al., 1995; Lindholm et al., 1995; may not account for the entire discrepancy. In a 5- Robinson et al., 1995). Slemenda and Johnston year longitudinal study of 22 females involved in (1993) hypothesized that the very high impact élite gymnastics training, Lindholm et al. (1994) forces on both the upper and lower extremities of found that no distinct growth spurt was seen these athletes leads to maintenance of normal compared with a control group who did have the bone density for age. In support of this hypothe- normal prepubertal growth spurt as expected. sis, Robinson et al. (1995) found that the gym- All gymnasts were followed until menarche nasts they studied had greater lean body mass except for one athlete who still had primary than either runners or the control group and that amenorrhoea at age 18 years. Theintz et al. (1993) the gymnasts had greater strength of quadriceps, also found no discernible growth spurt among biceps and hip adductor muscles. gymnasts training at least 18 h·week–1; in addi- Among eumenorrhoeic collegiate gymnasts, tion, they noted ‘marked’ stunting of leg growth an increase in both serum osteocalcin (a hormone in the gymnasts. associated with bone deposition) and lumbar Skeletal age correlates well with chronological bone mineral density was found after only a 27- age from 6 to 10 years of age, lags somewhat from week training period, even though the athletes 11 to 12 years and begins to fall more than a year started the study with much higher bone density behind chronological age by 13 years. Even by 17 values than a heavier, sedentary control group years of age, female gymnasts in three studies (Nichols et al., 1994). had not reached a skeletal age of 14.5 years (Malina, 1994). The great energy demands and Training low nutritional intake could well be implicated as a major cause of the marked delay in matura- Élite gymnasts train up to 40 h·week–1. Even pre- tion and the possible permanent stunting of élite gymnasts may train long hours: a national growth. None the less, according to Beunen and team gymnast reported training 4 h·day–1 when Malina (1996) heredity explains 94% of the vari- she was only 4 years old (Ryan, 1995). There has ance for skeletal maturation. Undoubtedly, most been speculation about the relationship between élite gymnasts are able to achieve the highest intense gymnastics training and menarche, levels of competition because of their genetic growth, emotional distress and injuries. Most 498 sport-specific injuries: prevention and treatment

studies find difficulty discriminating the effects pate in epidemiological studies), one Olympic of training intensity from nutritional deficits and champion’s memoirs may provide some useful other factors. Several authors have attempted insight into the difficulties faced by epidem- to establish a safe threshold for the number of iological investigators. Mary Lou Retton men- training hours that are unlikely to cause injury tions several serious injuries. She competed only or possibly stunt growth. Absence of growth a week following a concussion and sprained her spurt and apparent stunting of leg growth was wrist during the event. An injury to the wrist that noted in gymnasts training at least 18 h·week–1 appeared to be a stress fracture of the scaphoid (Theintz et al., 1993), but only absence of growth was treated with only 4 weeks of cast immobi- spurt without decreased leg growth was seen lization instead of the 8–12 weeks recommended. among gymnasts training less than 18 h·week–1 ‘When you’re training with Bela and you have (Lindholm et al., 1994). big competitions coming up, you’re not going to Among pre-élite, élite, national and Olympic stay out that long’ (Retton et al., 1986). A cartilage gymnasts, increased training intensity and train- injury of the knee required surgery only 6 weeks ing more than 15 h·week–1 were found to corre- before she won the Olympic all-around title late with spinal injury (Goldstein et al., 1991). Of (Retton et al., 1986). 21 gymnasts with wrist pain and tenderness One study found female gymnasts training localized to the distal radial physis (growth and competing with an injury during 71% of all plate), 17 trained at least 36 h·week–1 (Roy et al., exposures, training sessions or competitions 1985). Among world-class gymnasts, there was (Sands, 1993). This finding makes it difficult to no relationship between overgrowth of the distal interpret the true incidence of injury. Few investi- ulna and weekly training volume or years of gators have employed daily or even weekly training, although gymnasts at that level would examination, interview and/or questionnaire be anticipated to train extensively (Claessens et methods to check for injuries that do not com- al., 1996). However, gymnasts who trained less pletely preclude training or competing, so the than 10 h·week–1 have been reported to exhibit actual incidence of injury may be greater than osteochondritis dissecans of the elbow (Chan et indicated in most of the investigations summa- al., 1991). Therefore, although it seems likely that rized below (Sands, 1993). gymnasts who train longer hours and with greater intensity are more likely to sustain injury, Incidence even those who train fewer than 10 h·week–1 are not immune from serious repetitive trauma that Among club gymnasts, an injury rate of may cause permanent problems. 3.6–3.7/1000hours has been found (Caine et al., 1989; Backx et al., 1991). Actual injury rates are probably higher, since in one of these studies Injuries injury was defined as missing a complete prac- You catch your fingers on the bars, bend them tice or meet (Caine et al., 1989) and in the other back, break them, and dislocate them so you study injuries were only counted if a student have to pull them out…you can bang up your reported it to a teacher (Backx et al., 1991). More ribs so badly that it hurts to breathe. That advanced gymnasts may sustain injuries at a happens every day. You turn ankles and sprain higher rate. Gymnasts in a highly ranked and wrists and pull muscles (Retton et al., 1986). closely monitored collegiate programme were Gymnasts generally train while they are injured found to sustain a new injury during 9% of since they can often perform some of their usual exposures (Sands, 1993). However, among 178 activities without significantly aggravating the competitive female gymnasts monitored less rig- injury. Since some individual athletes prefer not orously the rate was only 0.52/1000hours, with to report their injuries (even when they partici- the lowest rates found among the most advanced gymnastics 499

competitors (Lindner & Caine, 1990). Similarly, the body part most frequently sustaining acute at one national training centre with readily avail- injury (Caine et al., 1989). Although less attention able medical coverage, artistic gymnasts sus- has been given to facial injury, 7% of gymnasts in tained only two new injuries each per year on one study had experienced injury to the ‘hard’ average (Dixon & Fricker, 1993). Injuries to com- tissues of the mouth during the previous year petitive gymnasts are often serious as gauged by (Bayliss & Bedi, 1996). time lost from training and competition. A prospective study of eight Division I college Soft-tissue overuse teams found that more than 50% of the women could not train or compete for at least 8 days, and Repetitive motion and repetitive blunt trauma 17% missed more than 21 days at least once lead to soft-tissue overuse injury. Repetitive during a competitive season (Petrie, 1992). microtrauma may eventually cause tendinitis, muscle strain or localized tissue abnormality related to recurrent bleeding. New injury vs. reinjury

Approximately 60% of new injuries to collegiate tendinitis gymnasts (Sands, 1993; Wadley, 1993) and club gymnasts (average age 12.6 years) were caused In gymnasts the anatomical areas prone to ten- by a single acute traumatic event (Caine et al., dinitis include the tendons crossing the wrist and 1989). However, only about 40% of all injuries, elbow and the patellar and Achilles tendons. including reinjuries, were acute (Caine et al., Treatment of tendinitis in these regions is diffi- 1989; Sands, 1993). In prospective investigations cult since a gymnast’s skills require full range of approximately 20–30% of injuries were recur- motion at these joints. A circumferential counter- rences (Caine et al., 1989; Wadley, 1993). Among force brace, made either of slightly elastic mater- club gymnasts most reinjuries were to the low ial or of inelastic strapping with a compressible back, which accounted for 83% of all reinjuries; air bladder against the skin, may alter the forces these were of the overuse or chronic type (Caine on an injured tendon sufficiently to allow activ- et al., 1989). ity. Wrist flexor tendons can be protected by a semi-flexible dorsal wrist splint that limits exten- sion beyond the pain-free arc of motion. Apparatus The ideal treatment of tendinitis includes rela- Nearly 30% of injuries to collegiate gymnasts tive rest until symptoms completely resolve. occurred during tumbling or during a floor exer- However, a competitive gymnast may be unable cise, while 10% occurred on the uneven bars or unwilling to rest from all activities that aggra- (Sands, 1993). A similar incidence was noted for vate the injury for the length of time required for club gymnasts, with 35% of injuries occurring complete resolution. Additional methods for during a floor exercise, 23% on the balance beam decreasing symptoms include local application and 20% on the uneven bars (Caine et al., 1989). of ice, alternating warm–cold therapy, oral anti-inflammatory medication, ultrasound or phonophoresis (with corticosteroid gel) therapy, Anatomical location and electrical stimulation or iontophoresis (with Injury to the lower back was seen most fre- corticosteroid gel) therapy. Therapeutic injection quently, followed by injury to the shoulder, shin, of corticosteroid into the sheath of the injured ankle and wrist (Sands, 1993). Among overuse or tendon may be considered. However, steroid gradual-onset repetitive motion injuries, the injection weakens tendon tissue, so the athlete lower back, wrist and ankle were most com- must protect the injected area for at least 2–3 monly affected (Caine et al., 1989). The ankle was weeks following injection. Injection into the 500 sport-specific injuries: prevention and treatment

tendon itself is contraindicated because of the is application of ice to the injured area. The area significant risk of tendon rupture following should be protected from further blunt trauma treatment. until pain and swelling have resolved. Appropri- ate padding may allow an injured gymnast to repetitive microstrain continue her usual training programme with minimal risk of further injury. However, if the Muscle strain typically occurs at or near the mus- injury is severe and padding impractical because culotendinous junction, generally in the same of injury location, then she should avoid activi- anatomical regions as tendinitis. In addition, the ties that could lead to further injury until pain rotator cuff and deltoid muscles of the shoulder and swelling have resolved. and the posteromedial muscles of the lower leg may be affected by overuse muscle strain. Sprains and strains Delayed-onset muscle soreness is caused typi- cally by excessive eccentric muscle contraction. ankle sprain For example, a gymnast is likely to develop delayed-onset muscle soreness if she performs Ankle sprains are probably the most frequent 15min of plyometric exercise, repetitively acute injury of female gymnasts. Gymnasts must jumping down from 50-cm boxes and contract- perform with toes pointed, the least stable posi- ing the calf muscles as they lengthen, without tion of the ankle, and land on padded surfaces ever having done similar activity at similar inten- that are necessary to absorb landing forces but sity for a similar period of time. Overuse muscle which provide a variably stable platform for the strain injury may be treated in the same way as feet. tendinitis, but corticosteroid injection is gener- The treatment of ankle sprains is complicated ally not indicated. by the inability of gymnasts to train with sup- portive shoes. The commonly used air-stirrup repetitive contusion braces plus a supportive athletic shoe function to lock the hindfoot into place to prevent ankle Repetitive blunt trauma can damage skin and inversion or eversion. A lace-up ankle brace with subcutaneous fat, muscle, nerve or blood vessel. semi-rigid stays placed medially and laterally Fat necrosis occurs more often from a single also has drawbacks. The heel of the brace must be episode of blunt trauma than from repetitive covered by a soft gymnastic shoe or similar mate- contusion, although the earlier traumatic injury rial so that the gymnast does not slip on mats. may predispose the injured area to more signifi- However, there are then two layers of material cant and visible fat necrosis with subsequent between the gymnast’s heel and the apparatus, contusion. Similarly, a relatively mild muscle decreasing her sensation and jeopardizing contusion with no visible ecchymosis followed proprioception and performance. Taping or by a second contusion to the area soon after the strapping may be useful, although the efficacy of first results in moderate pain and swelling. Sub- taping decreases markedly after about 20min of sequent reinjury may cause marked pain, dis- activity (Greene & Hillman, 1990; Shapiro et al., coloration and muscle fibrosis. 1994). If the gymnast has enough plantar flexion Meralgia paraesthetica, injury to the lateral to train or perform well in an ankle-protective femoral cutaneous nerve, has been reported device, then she probably has enough mobility to in two gymnasts, presumably from repetitive allow reinjury. striking against the uneven bars (Macgregor & Moncur, 1977). Similar repetitive injury is pos- knee ligament rupture sible involving the superficial veins, mainly of the hand/wrist and foot/ankle. Anterior cruciate ligament injury is endemic Initial treatment for repetitive contusion injury among élite female artistic gymnasts (L. gymnastics 501

Krivickas, personal communication, 1990). Gym- sion and maintaining the muscle in a lengthened nasts are also prone to medial collateral ligament position are useful. Oral anti-inflammatory med- sprains and patellar dislocations (Andrish, 1985). ication may speed the initial resolution of pain The combination of all three of these injuries and swelling, but probably slows the later phases should be considered in any female gymnast of the healing process (Mishra et al., 1995). Physi- who has sustained any one of the three injuries. cal therapy modalities such as electrical stimula- Each of the three structures (anterior cruciate tion may also decrease early pain and swelling. ligament, medial collateral ligament and/or The injured gymnast should avoid activities that medial patellar retinaculum) may be injured cause pain during the healing phase, while main- when a gymnast’s foot is planted and she rotates taining as much strength and flexibility of the away from the foot while flexing her knee muscle as possible. slightly. This manoeuvre is likely to occur repeat- edly whenever a gymnast is learning a twisting Stress fractures and osteochondroses move. If her foot becomes stuck in the padded mat, she is likely to injure at least one of these wrist knee structures, depending on the amount of speed and force at landing. Additional injured Among non-élite club gymnasts, 86% of females structures may include the meniscal cartilages, were recently reported to have wrist pain articular cartilage or bone. (DiFiori et al., 1996). Albanese et al. (1989) reported three cases of apparent premature shoulder dislocation growth plate closure of the distal radius in young gymnasts. Additional stress-related changes of Shoulder dislocation among gymnasts com- the distal radial physis have included widening prises two general types: the acute traumatic and irregularity of the physis and cystic change. lesion that typically includes ligament tear or Stress-related changes were found in 10% of the fracture; and the minimally traumatic disloca- skeletally immature artistic gymnasts at the tion related to joint hypermobility and muscle world championships in 1987 (De Smet et al., weakness or fatigue. Young female athletes with 1994). Among the skeletally mature gymnasts, dislocations related to hypermobility and fatigue 71% had positive and 29% neutral ulnar vari- caused by minimal trauma, such as swinging ance; this is significantly different from the usual from high to low bar in the usual manner, are situation, where the distal end of the radius is rel- often successfully treated simply with a directed atively longer than the distal ulna (De Smet et al., strengthening programme. 1994). Study of the skeletally immature gymnasts found that 80% of them fell within the 95% confi- muscle strain dence limits for normal ulnar variance based on a large reference group. The taller, heavier, more Acute muscle strains most often affect muscles muscular gymnasts were more likely to have that cross at least two joints. For gymnasts, these abnormal ulnar variance. In the authors’ opinion, include the biceps, triceps and wrist flexors and the findings concerning possible premature extensors in the upper extremity. Abdominal distal radius growth arrest were ‘less dramatic muscles may be strained, especially near the than originally stated’ in previous case reports or insertions on to the ilium. Paraspinous muscles small series (Claessens et al., 1996). are injured both in the upper back and the A study of Chinese opera students who prac- lumbar region. In the lower extremity, the ilio- tised floor exercise activities for 12h·week–1 psoas, rectus femoris and hamstrings are fre- brought to light two worrisome findings. A bony quently strained despite the great flexibility of bridge suggestive of premature physeal closure these muscles in élite gymnasts. was found in an asymptomatic 12-year-old girl. Following acute muscle strain, ice, compres- Also, occult injury was seen on magnetic reso- 502 sport-specific injuries: prevention and treatment

nance imaging (MRI) of some wrists that had treatment of all but one elbow, the average exten- normal plain radiographs (Shih et al., 1995). MRI sion lost was 10°. Only one gymnast was able to findings include horizontal metaphyseal frac- continue competing (Jackson et al., 1989). The tures and extension of physeal cartilage into the inability of athletes with osteochondritis disse- metaphysis, suggesting that physeal widening cans of the capitellum or radial head to continue actually occurs secondary to metaphyseal injury. competitive gymnastics has been found by others Vertical fracture lines and bony bridges indica- who studied groups consisting of both male and tive of premature physeal closure have also been female gymnasts (Chan et al., 1991). At least one found on MRI (Shih et al., 1995). study has found that radiographically visible The presence of radiographic changes may osteochondritis dissecans is unlikely to be found predict slower resolution of symptoms. Roy et al. among asymptomatic high-performance female (1985) found that gymnasts (19 of 21 were gymnasts training 20–25h·week–1, with no cases female) with wrist pain and distal radial changes found among 43 asymptomatic athletes (Jackson on plain X-ray took at least 3 months to recover; et al., 1989). five actually took more than 6 months to return Traction apophysitis of the olecranon may also to gymnastics. Those without radiographic occur, with fragmentation of the epiphysis and changes recovered within an average of 4 weeks. widening of the growth plate. Gymnasts with A single case of osteonecrosis of the capitate this problem are able to return to their previous bone of a 19-year-old collegiate gymnast has level of competition (Maffulli et al., 1992b). been reported (Murakami & Nakajima, 1984). Since this athlete began having pain when she osteochondritis dissecans of was not doing any active athletic training and the knee this is the only case apparently reported in the English literature, the relationship between Osteochondritis dissecans may affect the femoral gymnastics and the pathology remains unclear condyles of young gymnasts. Although heredity (Murakami & Nakajima, 1984). seems to be a factor in this disorder, repetitive high-impact trauma is thought to play a signifi- elbow cant role (Mubarak & Carroll, 1981). Rest from high-impact activities or surgical drilling of the Osteochondritis dissecans, usually of the capitel- lesion may allow healing to occur, although lum or the radial head, may limit a gymnast’s internal fixation of the lesion may be preferred ability to compete. Surgical removal or internal treatment for the high-performance gymnast. fixation of loose fragments may be necessary. Internal fixation is generally indicated for Although relatively rare, osteochondritis disse- unstable lesions as well. cans of the elbow represented nearly 1% of all gymnastics injuries seen over a 12-year period by spondylolysis Maffulli et al. (1992a). Six of the injured were girls, all but one 14 or 15 years old. All had limited At one élite national training centre, where the elbow extension and only one of the 12 (including average duration of scholarship for female gym- the boys) was able to continue competing at the nasts was 2.2 years, the incidence of sympto- same level. In another study similar problems matic spondylolysis was 9.5% during the period were found among seven high-performance of scholarship (Dixon & Fricker, 1993). The true female gymnasts, three of whom had both elbows incidence remains unknown as an MRI study affected by osteochondritis dissecans of the found one asymptomatic case of spondylolysis capitellum. These athletes trained 20–25h·week–1 among 17 female gymnasts of wide-ranging and all had trained for at least 5 years. Despite competitive levels who used many different conservative physical therapy in all, and surgical training regimens (Tertti et al., 1990). Another gymnastics 503

MRI study of 33 female gymnasts, from pre-élite been treated successfully with an anti-lordotic to world-class athletes, found spinal abnormali- Boston brace (Micheli et al., 1980; Steiner & ties consisting of spondylolysis in five gymnasts Micheli, 1985). They can even train in the brace, and disc abnormalities in seven additional gym- although it limits their ability to perform certain nasts, with the incidence related to competitive activities such as back tucks and back hand- level and weekly training hours; 80% of the gym- springs (L.J. Micheli, personal communication, nasts with abnormalities on MRI trained at least 1984). 15h·week–1, while 87% of the gymnasts who –1 trained less than 15h·week had normal MRI iliac apophysitis scans (Goldstein et al., 1991). Gymnasts with spondylolysis (Fig. 34.1) have The growth plate of the iliac crest may become inflamed from blunt trauma or from repeated traction injuries. Gymnasts sustain both types of trauma frequently. Treatment is rest from aggra- vating activities and consideration of physical therapy modalities such as ultrasound or phonophoresis.

Acute fractures and dislocations

The most devastating injuries in gymnastics are catastrophic injuries to the head and spine, pos- sibly resulting in paralysis or even death. According to statistics from the National Centre for Catastrophic Sports Injury Research, the highest risk of head and spine injury among (a) common school sports is found in American football, gymnastics, ice hockey and wrestling (Cantu, 1995). Although 18 acute head and neck injuries occurred during a 10-year period (0.11 per athlete per year) at a national élite gymnas- tics training centre, none were catastrophic (Dixon & Fricker, 1993). The most frequently occurring fractures and dislocations among gymnasts involve the fingers and toes. However, other upper and lower extremity fractures are not uncommon, particu- larly due to missed moves from the uneven bars. Figures 34.2 and 34.3 illustrate injuries in two female gymnasts seen by the author within a 2- week period, both caused by missed moves; the (b) pre-élite 7-year-old sustained bilateral elbow fractures after missing her hold on the high bar. Fig. 34.1 (a) Spondylolysis, a defect in the pars interar- ticularis of the vertebra (arrow), related to repetitive lumbar flexion and extension. (b) This athlete had bilat- Long-term sequelae eral pars interarticularis defects, as seen on the lateral view (arrow tip is in the defect). A study of 24 national-team artistic gymnasts 504 sport-specific injuries: prevention and treatment

Fig. 34.2 Injury to a female gymnast caused by a missed move: severely displaced growth plate fracture of the proximal humerus. who had completed their competitive careers Inability to continue competing was confirmed found that seven continued to have the low back in another group of seven high-performance pain that had been present while they competed. female gymnasts, who lost an average of 10° of Lumbar radiographs of many of the gymnasts elbow extension (Jackson et al., 1989). showed significant abnormalities at the lum- A prospective study of gymnasts through their bosacral junction: bilateral L5 spondylolysis in 4 years of college, with follow-up interviews six gymnasts, unilateral L5 spondylolysis in 10–70 months after they retired from competi- one and L5–S1 spondylolisthesis in three (Koner- tion, presented a relatively bleak prognosis for mann & Sell, 1992). However, a comparison of female gymnasts in the first few years after retire- former élite gymnasts with an age-matched ment. These women were still bothered by 45% control group found no difference in subjective of the injuries that they had reported during their rating of back pain between the two groups and competitive years. The anatomical areas that no difference in posture (Tsai & Wredmark, hampered them most frequently were the lower 1993). back, ankle, great toe, shoulder and knee. In 29% Of 12 gymnasts (six female and six male) who of the women, sport activity was limited by their sought medical attention for osteochondritis previous injuries. Only one of the 22 gymnasts dissecans of the elbow, only one was able to available for follow-up reported no residual continue competing. At follow-up 6 months to 11 problems (Wadley, 1993). years later, the elbow symptoms of two former gymnasts interfered with their work, and three Prevention had been counselled not to follow their planned careers in physical education because of their decreased training hours elbow disability. The loss of elbow extension became even worse between the initial and It is difficult to establish a safe threshold for the follow-up examinations (Maffulli et al., 1992a). number of training hours unlikely to cause injury gymnastics 505

(aii)

(ai)

(bi) (bii)

Fig. 34.3 Injury to a pre-élite 7-year-old female gymnast who sustained bilateral elbow fractures after missing her hold on the high bar: (ai) anteroposterior and (aii) lateral views of severely displaced left supracondylar humerus fracture, with vascular injury that caused loss of the radial and ulnar pulses; (bi) anteroposterior and (bii) lateral views of right supracondylar humerus fracture. 506 sport-specific injuries: prevention and treatment

or possibly to stunt growth. Micheli, comment- most gymnastic moves use all parts of the body. ing on a study of spinal injuries in female gym- Therefore, the safest course would often be nasts, stated that ‘15h·week–1 may be an upper simply to perform conditioning and flexibility level for safe training for female gymnasts before work that would not aggravate the injury. Highly incurring spinal injury’ (Goldstein et al., 1991). competitive gymnasts do not seem to heed such However, studies of other injuries have found recommendations judging by the studies and problems related to overuse in gymnasts training memoirs discussed above. as little as 4.5h·week–1 (Chan et al., 1991). Theintz –1 et al. (1993) suggested 15–18h·week as a train- complete rehabilitation ing threshold when there are concerns about growth restriction. However, Lindholm et al. In other sports, reinjury has been reported as a (1994) found evidence of growth abnormality major source of time lost from training or compe- among gymnasts who trained on average only 10 tition. Among female gymnasts, a reinjury rate of h·week–1. Therefore, it seems most likely that 33% has been reported (Caine et al., 1989). Both training hours are only one variable in the aetiol- complete healing of the injury and complete ogy of injury and growth anomaly. Other factors, rehabilitation of the injured region are important such as intensity of training and nutrition, must in preventing reinjury. be considered. positive emotional outlook decreased training when growing rapidly A retrospective study of 83 female club gymnasts found that the athletes who reported more Rapidly growing gymnasts have approximately injuries scored higher on measures of anxiety twice the injury rate of gymnasts in a stable and tiredness, lower on composure and feeling phase of growth as determined by Tanner energetic, and higher on cognitive anxiety. The staging and menarcheal status (Caine et al., 1989). question of whether these mood variables were Among non-élite club gymnasts of average age the cause or the result of the injuries was not 12.3 years (SD=2.0), the most important factors determined in this survey (Kolt & Kirkby, 1994). related to wrist pain were found to be intensity of A prospective study of female competitive club training as related to age and later age of starting gymnasts found an increased incidence of injury training, perhaps due to the gymnast’s attempt after an athlete had been practising a discipline to attain the skill level of her same-age peers for an extended time and the authors surmised (DiFiori et al., 1996). This study also suggests that that loss of focus or concentration might be a training should be less intense during times of cause for these injuries (Lindner & Caine, 1990). rapid growth. Of course, muscle fatigue could be implicated at least equally with mental fatigue. decreased training when injured A prospective study of collegiate gymnasts did find that life stress in the preceding year, when A gymnast who trains before a significant injury coupled with poor current social support, pre- has healed risks sustaining overuse injuries, as dicted incidence of injury (Petrie, 1992). Since other structures must compensate for the weak- injury in a previous year would undoubtedly ened part. In addition, if she misses a move contribute to life stress, it may be impossible to because the injured part gives way or because sort out the contributions of previous injury, she buckles due to pain, she is likely to sustain a inadequate rehabilitation and poor focus from new acute injury. Although it is reasonable to depression or anxiety not related to these other practise moves that do not use the injured part, factors predisposing to injury. gymnastics 507

Bayliss, T. & Bedi, R. (1996) Oral, maxillofacial and Conclusion general injuries in gymnasts. Injury 27, 353–354. Benardot, D. & Czerwinski, C. (1991) Selected body Although research in the past 15 years has con- composition and growth measures of junior elite tributed to our understanding of the potential gymnasts. Journal of the American Dietetic Association nutritional, developmental and musculoskeletal 91, 29–33. problems among competitive artistic gymnasts, Beunen, G. & Malina, R.M. (1996) Growth and biologi- very few investigators have published work con- cal maturation: relevance to athletic performance. In G. Beunen & R.M. Malina (eds) The Child and Adoles- cerning rhythmic gymnasts. Although the nutri- cent Athlete, pp. 3–24. Blackwell Science, Oxford. tional and developmental issues may be similar, Caine, D., Cochrane, B., Cain, C. & Zemper, E. (1989) injury patterns may be quite different. An epidemiologic investigation of injuries affecting Despite a high incidence of menstrual young competitive female gymnasts. American Jour- abnormalities among gymnasts during their nal of Sports Medicine 17, 811–820. Cantu, R.C. (1995) Head and spine injuries in youth competitive years, anecdotal evidence sug- sports. Clinics in Sports Medicine 14, 517–532. gests that menarche is eventually attained and Chan, D., Aldridge, M.J., Maffulli, N. & Davies, A.M. fertility unlikely to be impaired permanently. (1991) Chronic stress injuries of the elbow in Growth may be permanently stunted among young gymnasts. British Journal of Radiology 64, 1113– those gymnasts who train long hours and 1118. Claessens, A.L., LeFevre, J., Beunen, G., De Smet, L. & consume inadequate diets. However, additional Veer, A.M. (1996) Physique as a risk factor for ulnar investigation is needed to confirm both the variance in elite female gymnasts. Medicine and findings and the possible causes of growth Science in Sports and Exercise 28, 560–569. abnormalities. De Smet, L., Claessens, A., Lefevre, J. & Beunen, G. Gymnastics is clearly one of the most danger- (1994) Gymnast wrist: an epidemiologic survey of ulnar variance and stress changes of the radial physis ous sports practised by large numbers of girls in elite female gymnasts. American Journal of Sports and young women. Fortunately, there have been Medicine 22, 846–850. few cases of paralysis or death. However, the DiFiori, J.P., Puffer, J.C., Mandelbaum, B.R. & Mar, S. studies cited suggest that most competitive (1996) Factors associated with wrist pain in the gymnasts can expect years of musculoskeletal young gymnast. American Journal of Sports Medicine 24, 9–14. problems related to injuries sustained during Dixon, M. & Fricker, P. (1993) Injuries to elite gymnasts their gymnastics careers. Long-term follow-up of over 10 yr. Medicine and Science in Sports and Exercise these athletes is needed to determine the severity 25, 1322–1329. and extent of these disabilities. Forbes, L. (1996) Physical and emotional problems of elite female gymnasts (letter). New England Journal of Medicine 336, 140–141. References Goldstein, J.D., Berger, P.E., Windler, G.E. & Jackson, D.W. (1991) Spine injuries in gymnasts and swim- Albanese, S.A., Palmer, A.K., Kerr, D.R., Carpenter, mers. An epidemiologic investigation. American C.W., Lisi, D. & Levinsohn, E.M. (1989) Wrist pain Journal of Sports Medicine 19, 463–468. and distal growth plate closure of the radius in gym- Greene, T.A. & Hillman, S.K. (1990) Comparison of nasts. Journal of Pediatric Orthopedics 9, 23–28. support provided by a semirigid orthosis and adhe- Andrish, J.T. (1985) Knee injuries in gymnastics. Clinics sive ankle taping before, during, and after exercise. in Sports Medicine 4, 111–121. American Journal of Sports Medicine 18, 498–506. Backx, F.J.G., Beijer, H.J.M., Bol, E. & Erich, W.B. (1991) Jackson, D.W., Silvino, N. & Reiman, P. (1989) Injuries in persons in high-risk sports: a longitudinal Osteochondritis in the female gymnast’s elbow. study of 1818 school children. American Journal of Arthroscopy 5, 129–136. Sports Medicine 19, 124–130. Kirchner, E.M., Lewis, R.D. & O’Connor, P.J. (1995) Baxter-Jones, A.D., Helms, P., Baines-Preece, J. & Bone mineral density and dietary intake of female Preece, M. (1994) Menarche in intensively trained college gymnasts. Medicine and Science in Sports and gymnasts, swimmers and tennis players. Annals of Exercise 27, 543–549. Human Biology 21, 407–415. Kolt, G.S. & Kirkby, R.J. (1994) Injury, anxiety, and 508 sport-specific injuries: prevention and treatment

mood in competitive gymnasts. Perceptual and Motor Retton, M.L., Karolyi, B. & Powers, J. (1986) Mary Lou: Skills 78, 955–962. Creating an Olympic Champion. McGraw-Hill, New Konermann, W. & Sell, S. (1992) The spine: a problem York. area in high performance artistic gymnastics. Aretro- Robinson, T.L., Snow-Harter, C., Taaffe, D.R., Gillis, D., spective analysis of 24 former artistic gymnasts of the Shaw, J. & Marcus, R. (1995) Gymnasts exhibit higher German A team. Sportverletz Sportschaden 6, 156–160. bone mass than runners despite similar prevalence Lindholm, C., Hagenfeldt, K. & Ringertz, B.M. (1994) of amenorrhea and oligomenorrhea. Journal of Bone Pubertal development in elite juvenile gymnasts. and Mineral Research 10, 26–35. Effects of physical training. Acta Obstetricia et Gyneco- Roeper, R. (1996) Gymnastics: triumph or tragedy? logica Scandinavica 73, 269–273. Chicago Sun-Times. Lindholm, C., Hagenfeldt, K. & Ringertz, H. (1995) Rosen, L.W. & Hough, D.O. (1986) Pathogenic weight- Bone mineral content of young female former gym- control behaviors of female college gymnasts. Physi- nasts. Acta Paediatrica 84, 1109–1112. cian and Sportsmedicine 16, 140–146. Lindner, K.J. & Caine, D.J. (1990) Injury patterns of Roy, S., Caine, D. & Singer, K.M. (1985) Stress changes female competitive club gymnasts. Canadian Journal of the distal radial epiphysis in young gymnasts. A of Sport Science 15, 254–261. report of twenty-one cases and a review of the litera- Macgregor, J. & Moncur, J.A. (1977) Meralgia paraes- ture. American Journal of Sports Medicine 13, 301–308. thetica: a sports lesion in girl gymnasts. British Ryan, J. (1995) Little Girls in Pretty Boxes: The Making and Journal of Sports Medicine 11, 16–19. Breaking of Elite Gymnasts and Figure Skaters. Double- Maffulli, N., Chan, D. & Aldridge, M.J. (1992a) day, New York. Derangement of the articular surfaces of the elbow in Sands, W.A. (1993) Women’s gymnastics injuries: a 5- young gymnasts. Journal of Pediatric Orthopedics 12, year study. American Journal of Sports Medicine 21, 344–350. 271–276. Maffulli, N., Chan, D. & Aldridge, M.J. (1992b) Overuse Shapiro, M.S., Kabo, J.M., Mitchell, P.W., Loren, G. & injuries of the olecranon in young gymnasts. Journal Tsenter, M. (1994) Ankle sprain prophylaxis: an of Bone and Joint Surgery 74B, 305–358. analysis of the stabilizing effects of braces and tape. Malina, R.M. (ed.) (1994) Physical growth and biologi- American Journal of Sports Medicine 22, 78–82. cal maturation of young athletes. Exercise and Sport Shih, C., Chang, C.Y., Penn, I.W., Tiu, C.M., Chang, T. & Sciences Reviews 22, 389–434. Wu, J.J. (1995) Chronically stressed wrists in adoles- Micheli, L.J., Hall, J.E. & Miller, M.E. (1980) Use of cent gymnasts: MR imaging appearance. Radiology modified Boston brace for back injuries in athletes. 195, 855–859. [Published erratum appears in Radiol- American Journal of Sports Medicine 8, 351–356. ogy 1995, 197, 319.] Mishra, D.K., Friden, J., Schmitz, M.C. & Lieber, R.L. Slemenda, C.W. & Johnston, C.C. (1993) High intensity (1995) Anti-inflammatory medication after muscle activities in young women: site specific bone mass injury: a treatment resulting in short-term improve- effects among female figure skaters. Bone and Mineral ment but subsequent loss of muscle function. Journal 20, 125–132. of Bone and Joint Surgery 77A, 1510–1519. Steiner, M.E. & Micheli, L.J. (1985) Treatment of symp- Mubarak, S.J. & Carroll, N.C. (1981) Juvenile osteo- tomatic spondylolysis and spondylolisthesis with chondritis dissecans of the knee: etiology. Clinical the modified Boston brace. Spine 10, 937–943. Orthopaedics and Related Research 157, 200. Sundgot-Borgen, J. (1996) Eating disorders, energy Murakami, S. & Nakajima, H. (1984) Aseptic necrosis of intake, training volume, and menstrual function in the capitate bone in two gymnasts. American Journal high-level modern rhythmic gymnasts. International of Sports Medicine 12, 170–173. Journal of Sports Nutrition 6, 100–109. Nichols, D.L., Sanborn, C.F., Bonnick, S.L., Ben-Ezra, V., Tertti, M., Paajanen, H., Kujala, U.M., Alanen, A., Salmi, Gench, B. & DiMarco, N.M. (1994) The effects of T.T. & Kormano, M. (1990) Disc degeneration in gymnastics training on bone mineral density. Medi- young gymnasts. A magnetic resonance imaging cine and Science in Sports and Exercise 26, 1220–1225. study. American Journal of Sports Medicine 18, 206–208. Normile, D. (1996) Where is women’s gymnastics Theintz, G.E., Howald, H., Allemann, Y. & Sizonenko, going? International Gymnastics 38, 46–47. P.C. (1989) Growth and pubertal development of O’Connor, P.J. & Lewis, R.D. (1997) Physical and emo- young female gymnasts and swimmers: a correlation tional problems of elite female gymnasts (letter). New with parental data. International Journal of Sports England Journal of Medicine 336, 140–141. Medicine 10, 87–91. Petrie, T.A. (1992) Psychosocial antecedents of athletic Theintz, G.E., Howald, H., Weiss, U. & Sizonenko, P.C. injury: the effects of life stress and social support on (1993) Evidence for a reduction of growth potential female collegiate gymnasts. Behavioral Medicine 18, in adolescent female gymnasts. Journal of Pediatrics 127–138. 122, 306–313. gymnastics 509

Tofler, I.R., Stryer, B.K., Micheli, L.J. & Herman, L.R. mobility, and subjective rating of back problems in (1996) Physical and emotional problems of elite former female elite gymnasts. Spine 18, 872–875. female gymnasts. New England Journal of Medicine Wadley, G.H. (1993) Women’s intercollegiate gymnas- 335, 281–283. tics: injury patterns and ‘permanent’ medical disabil- Tsai, L. & Wredmark., T. (1993) Spinal posture, sagittal ity. American Journal of Sports Medicine 21, 314–320. Chapter 35

Figure Skating

JANE M. MORAN

Introduction a need in modern figure skating for well- coordinated and focused research programmes Ice skating originated in northern Europe as to identify optimal methods of training and an important means of transportation on frozen injury management. rivers, canals, lakes and ponds, and secondarily became an activity of recreational and social The sport importance. As a sport, figure skating was recog- nized as a unique combination of art and athleti- The sport of figure skating includes five disci- cism. It was also one of the few sports considered plines: compulsory figures, free (singles) skating, ‘lady-like’ and so could be enjoyed by both pairs, dance and precision (team skating). The women and men. Figure skating emerged as a ability to care for figure skaters properly requires form of entertainment for the European nobil- at least a basic understanding of the unique ity and royalty during the 18th century. The skills, demands and risks of each of the five International Skating Union (ISU) was founded disciplines. in July 1892 at Scheveningen, The Netherlands. Today figure skating is recognized, practised and Compulsory figures regulated in 55 nations around the world. In this century, figure skating has enjoyed Each compulsory figure requires the skater to ever-increasing popularity in the recreational, perform, or ‘trace’, two or three superimposed competitive and professional arenas. The associ- circles that form a variation of the figure 8. There ated proliferation of indoor skating facilities has are a total of 41 figures of increasing degrees of provided year-round access to high-quality ice difficulty. In each figure, the skater must demon- surfaces. There are increasing demands on ath- strate control of the edge of the skate blade by letes at the competitive and professional levels to tracing, with a bent knee, each circle of the figure perform more and more difficult elements. This as exactly as possible over the initial tracing. The steady expansion of the ‘performance envelope’ skater traces each figure twice on each foot. This has placed greater demands on those who assist exercise demonstrates a skater’s mastery of athletes in gaining and maintaining the competi- skate blade edges in controlling motion, speed, tive edge: the coaches, who manage the complex balance and precision of movement. process of performance enhancement, and the health professionals, who prevent and manage Free skating performance-threatening injury. Increased per- formance demands, increased training complex- In this discipline, a single skater performs jumps, ity and a broadening spectrum of injury point to spins and stroking (footwork) depending on the 510 figure skating 511

skater’s level of technical ability. It is particularly the skater begins to perform double, triple or important to understand the physical demands quadruple jumps, increasingly greater rotational of jumps in order to advise the skater which ele- stresses are placed on the landing leg. When ments he or she is ready to return to after injury. landing a jump, the skater must control the rota- Figures 35.1 and 35.2 illustrate the various jumps tional component as well as absorbing the impact and identify the approach, take-off and landing force when the blade contacts the ice. In control- phases. ling the rotational component during a spin or When ‘approaching’ a jump, a skater will be on jump, the skater pushes both arms and free leg an inside or outside edge of one skate. The take- away from the axis of rotation. This increases the off is from the blade of one skate (inside or moment of inertia and reduces rotational speed. outside edge) or from the blade with an assist In this manner most of the rotational force is from the toe-piece of the other skate blade. Single eliminated before the skater lands or changes feet jumps or jumps of one and a half rotations do not and exits from the spin. In jumps, this manoeu- produce significant torque on the take-off or vre must be timed perfectly so that the arms and landing leg. As the level of skill increases and legs open immediately before landing. If the

Outside edge 12 Outside edge

(a) Toe pick

Outside edge

(b) Inside edge

Outside edge Outside edge (c)

Fig. 35.1 Technique of figure skating jumps: approach, flight and landing for (a) the toe loop, (b) the salchow and (c) the loop. (From Official Guide Book, Nagano, 1998.) 512 sport-specific injuries: prevention and treatment

Inside edge

Outside edge

Toe pick

(a) Outside edge

Outside edge Outside edge (b)

Fig. 35.2 Technique of figure skating jumps: approach, flight and landing for (a) the flip or Lutz and (b) the triple axel. (From Official Guide Book, Nagano, 1998.) rotational forces are not controlled and dissi- apart, their movements should be synchronized. pated just before landing, the rotational force is During spins about a common axis or side by transmitted to the landing leg. When learning a side in unison, the skaters are vulnerable to lacer- multi-revolution jump, the skater will quite often ations from the blade of the partner’s skate. over-rotate or under-rotate. This subjects the The lifts in pairs skating are becoming ever skater’s landing leg to repeated impact and rota- more daring and are increasingly the cause of tional forces and can lead to overuse injury. fall-related injury. There are two kinds of lifts: the During spins, rotation speeds are faster than overhead lift and the twist lift. In the overhead during jumps but there is no landing impact for lift, the male partner maintains physical con- the skater to absorb. Spin direction is determined tact with the female except momentarily during by the ‘footedness’ of the skater: right-footed change in her position or during dismount. The skaters rotate anticlockwise; left-footed skaters male performs a one- or two-handed lift, raising clockwise. The skater rotates with arms and legs the female partner overhead by her hips, axillae close to the body, usually in a tighter position or hands. He supports her overhead with one or while spinning than during a jump. both of his hands with his arms fully extended while he skates forward, backward or rotates on the ice. The female must maintain her balance Pairs and centre of gravity once in the lifted position. Pairs skating combines free skating elements The position of the female partner during the lift performed in unison by a pair of skaters, with can be upright, horizontal or head down. The other elements performed together such as lifts, male partner must then check his position or throw jumps and coordinated and ‘common- rotation before lowering her smoothly to the ice. axis’ spins. Whether the partners are together or In twist lifts (Fig. 35.3), the male lifts the female figure skating 513

Fig. 35.3 Pair’s twist lift: Shelby Lyons and Brian Wells Fig. 35.4 Pairs throw jump: Marina Elstova and Andrei of the USA at Skate America 1996. (Photo courtesy of Bushkov of Russia at Skate Canada 1996. (Photo cour- ISU Media and Allsport.) tesy of ISU Media and Allsport.)

partner overhead and tosses her in the air. While tance covered is far greater than any jump she airborne, she performs a half or full rotation could perform individually. The forces of impact before he catches her and lowers her to the ice. on landing are consequently magnified, as are The couple may fall at any time during the execu- any errors in correcting the rotational forces dis- tion of these lifts because of tripping, mistiming cussed in the previous section. or fatigue. There is potential for serious injury if the female partner falls from the height of the lift Ice dancing or the male partner fails to catch her during the twist lift. Fortunately, in the majority of lifts, the Ice dancing is based on the various aspects of male partner is often able to offer some assistance dance and emphasizes rhythm, interpretation partially to break the force of the female partner’s of music, precise steps, speed and carriage. It fall. includes varied dance holds, intricate footwork, Throw jumps (Fig. 35.4) are another very excit- deep edges, and small lifts and spins. The ice ing aspect of pairs skating that have an associ- dancer’s skate blades have shorter tails in order ated risk of injury to the female partner. In throw to avoid becoming entangled with a partner’s jumps, the male partner throws the female into skates during the close footwork (Fig. 35.5). the air and across the ice while she completes two However, because of the intricate and at times or three revolutions in the air. Her height and dis- rapid and entwined footwork, falls still occur, 514 sport-specific injuries: prevention and treatment

Fig. 35.5 Ice dancing: Shae Lynn Bourne and Victor Kraatz of Canada at Skate Canada 1996. (Photo courtesy of ISU Media and Allsport.)

often at high skating speeds, causing lacerations for example, reported that muscular power, flexi- and other injuries. bility, aerobic and anaerobic fitness all increase over the course of an individual skater’s devel- opment, but body composition remains essen- Precision skating tially unchanged. The developing physiological Precision skating, also known as team skating, is profile of the competitive figure skater has in characterized by complex formations and intri- turn formed the basis for monitoring and train- cate transitions performed by teams of 12–24 ing programmes for skaters that address aerobic skaters. The precision teams perform manoeuv- power, anaerobic power, muscular power, flexi- res such as circles, lines, wheels, intersections bility and body composition. and blocks (skaters lined up in more than two Competitive figure skaters train for ap- lines) (Fig. 35.6). The emphasis is on unison, proximately 10–11months per year. Training fre- accuracy of formations and synchronization of quency, duration and intensity of on-ice and the team. Skaters are in close proximity to each off-ice training time parallels an increase in the other and one fall frequently causes a domino technical calibre of the skater. Kjaer and Larsson effect, resulting in more than one injury. (1992) showed that figure skaters have oxygen requirements comparable with those athletes whose sports are endurance related. When moni- Physiological profile of skaters toring heart rates during the long programme Figure skating is a physically demanding sport it was demonstrated that skaters are at their that requires a unique combination of artistic maximal heart rates within the first minute of the ability and speed, agility, flexibility and power programme. While skaters have above-average (Fig. 35.7). The increasing technical difficulty maximal oxygen consumption, their aerobic of figure skating has resulted in heightened capacity is generally lower than many competi- demands on physical fitness. International study tive athletes (Provost-Craig, 1997). The skater of figure skaters has helped to develop a physio- must therefore be maximally conditioned, logical profile of these athletes. Gledhill (1997), both aerobically and anaerobically, in order to figure skating 515

Fig. 35.6 Line formation in synchronized skating. (Photo courtesy of ISU Media and Allsport.)

Fig. 35.7 Denize Biellman of Switzerland performing her famous spin, shown from two different sides. (Photo courtesy of Michel Perret, Foulis 4, CH-1260 Nyon.) (a) (b) perform continuously at a high level throughout the mean age at puberty of male and female a modern free skating programme, maintaining skaters (Tanner stage 3) was 14±1.73 years. Lock- sufficient strength and cardiovascular fitness wood (1997) and Niinima et al. (1979) reported to perform difficult jumps and maintain speed that the mean starting age of competitive train- to the end. Now that the competitive season ing has become significantly younger. Whereas extends throughout the year, it is particularly senior skaters began training at a mean age of important that skaters plateau at the peak of 7.7years, juvenile skaters today begin training at physical fitness. an average age of 5.85years. Not only are athletes Ross et al. (1976) demonstrated that both male training and competing at a younger age, but the and female figure skaters matured later than the physical demands of the sport have also changed average population. This corresponds with the dramatically, particularly jumping. Current study by Lockwood (1997) who reported that figure skaters are generally shorter and leaner 516 sport-specific injuries: prevention and treatment

than skaters in the past. The increased and earlier studies that document what effects training at emphasis on the performance of triple jumps has this young age will have on the musculoskeletal given younger, leaner skaters a competitive system in the years to come. advantage and allowed them to surpass the jumping performance of the more physically Equipment mature senior skaters. In these young skaters, the vigorous physical demands of training and As in any sport, the equipment necessary to par- of impact loading are being superimposed on the ticipate plays an integral part in safety, enjoy- biological demands of normal growth and devel- ment and performance. In the case of figure opment. There are few research studies that skating, equipment issues focus on the skate. The document the ability of the developing human components of a modern skate are illustrated in body, and specifically the musculoskeletal Fig. 35.8. Injuries to the figure skater can be system, to respond to these increased forces related to both boot components and blade and stresses. Slemenda and Johnston (1993) and placement. Lockwood (1997) have reported that high- impact, repetitive load-type training affects bone Boots mineral density at the specific loaded sites. Lock- wood (1997) reported a significant difference in The skate boot is made of leather and is con- bone mineral density between the dominant and structed around a steel shank that runs down the non-dominant lower extremity of figure skaters centre of the boot sole. This steel shank forms the in the prepubertal, pubertal and postpubertal compound curve of the sole and holds the other populations. However, there are no longitudinal boot components in place. The top portion of the

Inside Outside ABC 3–4 mm A both edges on the ice B right foot leans to Cross-section right so skater uses of right blade right outside edge C right foot leans to left so skater uses right inside edge

Inside edge

Outside edge Rocker Toe rake of spinning and jumping Fig. 35.8 Parts of a skate. figure skating 517

boot surrounding the leg is lower at the back to blades mounted is not recommended as it allows allow some degree of plantar flexion. A dancer’s flexion of the forefoot, a movement that does not boot may be modified by a ‘danceback stay’: a normally occur during skating. Also, this could notch is cut in the rear of the boot and the lining predispose the midsole and outsole of the boot to extended and rolled over for softness, thus separate from the central shank. Feet should be allowing for greater knee bends and toe points. regularly checked for any pressure areas and Boots can be obtained from stock or custom the corresponding part of the boot padded or made. Boots purchased off the shelf are generally punched out. Manoeuvres such as stroking, back made of thinner leather and vary greatly in crossovers and knee bends allow the skater to quality and price. Custom boots, while generally adjust to the feel of the boot and allow proper more expensive, are available for skaters who boot motion to be obtained. New boots should require a closer fit and increased support. There not be laced too tightly; instead, the skater is a spectrum of boot strength or stiffness, and it should unlace and lace the boots frequently as is important to match the boot to the skater’s age, they soften. weight, technical level and frequency of skating. A consensus statement developed at the 1997 All skaters require a boot that fits well and offers International Congress in Medicine and Science adequate support. Overly stiff boots require of Figure Skating (sponsored by the ISU) recom- excessive breaking-in times and also place the mends that a boot should: skater at risk for injury. Conversely, if the boot is • be lightweight; not stiff enough, the skater does not have the • be aesthetically pleasing; required support to perform the more demand- • allow plantar flexion and dorsiflexion; ing jumps, and the boot breaks down quickly. • limit inversion and eversion; This also places the skater at risk for injury. The • fit well and adapt to the shape of the skater’s boot strength equation is therefore modified by foot easily; the uniqueness of each skater. For example, the • accommodate a device to balance the foot beginner, who is younger with less weight and within the boot such as an orthotic; muscular force, requires a boot pliable enough to • be dry inside; allow for ankle and knee bends, while the skater • be made of materials with characteristics as performing triple jumps requires a heavily re- good as or better than leather. inforced boot for increased support on landing. Further research to develop a boot that meets Because the shape of the foot is unique to every these criteria will hopefully aid in the prevention skater and in order to avoid injuries to the feet of boot-related injuries. and ankles, the boot must be constructed to afford enough space for the foot and yet fit Blades snugly so as not to cause any movement of the foot in the boot. In order to avoid soft tissue The skate blade is purchased separately and injuries as well as stress fractures, the boot must selected according to intended use (e.g. free skate be adaptable in order to allow corrections to or dance). In coronal section the blade is approxi- accommodate irregular feet or to allow the use of mately 3–4mm in width, with the contact surface orthotics. grooved convexly upward so that there is a There are a variety of methods for softening hollow between the medial or inside edge and the leather of new boots. Some time should be lateral or outside edge. The blade is also curved spent with the feet in new boots before wearing along its length, referred to as the rocker (see Fig. the skates on the ice. Wearing boots around the 35.8). Therefore at any time the skater should be house (e.g. while watching TV and doing home- balanced on either an outside or inside edge, work) with blades mounted and guards in place with only a small portion of the total blade in is a common method. Wearing boots without the contact with the ice. In the figure skating disci- 518 sport-specific injuries: prevention and treatment

plines the blades vary in the degree of rocker or Injuries curvature of the blade, the depth of the hollow, and the number, size and distribution of toe- Documentation of trends in the type and fre- picks. Figures blades have a greater rocker, while quency of injury encountered in figure skating dance blades usually have a shorter tail to permit will require marked improvements in, and stan- close footwork with a partner. dardization of, reporting. The following section The blade is either riveted or screwed to the is intended as a summary of the available infor- sole of the boot. The skater is very sensitive to mation on figure skating injuries. placement of the blade: small adjustments can The frequency and spectrum of injury in figure have an inordinate effect on balance when per- skating appear to be increasing. There are many forming complex elements. Inappropriate blade aspects of the sport contributing to this increase: placement can also lead to overuse injuries in the (i) figure skating has experienced a rapid growth lower extremities as a result of overcorrecting an in popularity; (ii) the number of participants and edge on landing jumps. As a rule, the skate blade the hours of training have increased; (iii) since should line up just medial to the front toe seam figures were dropped from the competitive and directly midline on the heel. The skater aspect of skating in 1991, skaters spend more should make frequent checks to ensure that the time training in free skating than compulsory blade is securely fixed to the sole in order to figures; (iv) there has also been rapid growth in prevent injury when landing with an unstable the technical and physiological demands of the blade mount. free skating programmes; and (v) there has been a trend for children to begin training seriously at younger ages (Niinima et al., 1979; Zauner et al., Skate fit 1989; Lockwood, 1997). When the boot is laced, the foot should fit snugly Notwithstanding the above, there are a in the heel, arch and ball areas in order to provide number of reasons why it is difficult to document optimal support. The toes should be able to the incidence, severity and aetiology of figure wiggle freely, but not slide from side to side. The skating injuries. To begin with, there are few heel should not move out of the back cup of the acceptable studies that address this issue. Those boot when bending the knees. The foot should studies that are available may not reflect the true fit in the boot locked in a neutral position (Podha- incidence of injuries due to under-reporting. Like jsky, 1997). other athletes, skaters may not report an injury if Because figure skaters begin skating at an early they feel it will affect their chances of selection age, boot fit is critically important. Young skaters for competitions. Athletes may also perceive that spend long hours on the ice perfecting both they would appear weak or disadvantaged to free skating and compulsory figures. Boots are their competitors or to the judges. Figure skaters selected to fit snugly, with only a skating leotard who do continue to train and compete with over the foot. This fit may be perfect at first, overuse-type injuries may be excluded from a but as the young skater’s foot grows the study if the injury is of insufficient severity to boot remains the same size. The average skater curtail practice or competition. Finally, as changes boots about once per year and perhaps illustrated by Kjaer and Larsson (1992), athletes less frequently than ideal (often due to the cost may simply forget an injury. The subjects in of new boots). If not closely monitored in the their prospective study only recalled 83% of young skater, the feet may become increasingly their injuries at the end of a 1-year period. This cramped leading to the development of hammer- is particularly relevant when reviewing the toes, corns, calluses and other pressure-related literature on figure skating injuries as the injuries. majority of published information is derived figure skating 519

from questionnaires administered retrospec- and 16 élite ice dancers. The élite senior female tively to skaters. pairs skaters and female ice dancers sustained The injury rate in figure skating relative to the highest injury rate. Of the 49 injuries other sports is largely unknown. Studies by reported, 33 were serious enough significantly to Brock and Striowski (1986), Smith and Luding- alter or interrupt training for at least 7 days. The ton (1989) and Kjaer and Larsson (1992) report a types of injury were similar to those seen in lower injury rate in figure skaters compared with the study by Brown and McKeag (1987), and that reported in a study by Lowry and Leveau included concussions, lacerations, fractures, dis- (1982) on gymnasts, athletes who spend similar locations, haematomas and muscle strains. Smith amounts of time in practice and performance. and Ludington (1989) also showed that lower Figure skating injuries can be classified into extremity injuries predominated in both pairs acute (due to episodic macrotrauma) and and ice dancing, and that the number of overuse (due to repetitive microtrauma) injuries. acute injuries (mostly lift-related) outnumbered Several studies have reported the proportion of overuse injuries. A smaller sample of 14 pairs acute and overuse injuries and the predominance skaters studied by Brown and McKeag (1987) of lower extremity injuries in figure skaters. showed less involvement of the lower extremity Table 35.1 shows the number of injuries com- and a higher prevalence of injuries in the upper pared with the number of participating skaters, extremities and axial region. Table 35.2 the types of injuries sustained and In a retrospective study by Garrick (1982), Table 35.3 the anatomical location of the reported females had more overuse than acute injuries; injuries. In a retrospective study by Brock and again, the lower extremity predominated, the Striowski (1986), 50% of reported injuries were knee, foot and ankle being the common sites of acute, including fractures, sprains and cartilage injury. The predominance of injury to the lower tears, while 43% were overuse injuries, including extremity is a recurrent theme in the studies by tendonitis, shin splints and chondromalacia Smith and Micheli (1982), Brock and Striowski patellae. A retrospective study of 14 skaters by (1986), Brown and McKeag (1987), Smith and Brown and McKeag (1987) showed that acute Ludington (1989) and Kjaer and Larsson (1992). injuries (muscular strains, ligamentous sprains, The commonest injuries in these studies include fractures, haematomas) accounted for the largest joint sprains, muscle strains, patellofemoral pain, proportion of injuries in singles skating, and that tendonitis, tibial periostitis, haematomas, lacera- the lower extremities were the site of two-thirds tions and fractures. of all injuries. Tight, unyielding boots have been implicated Smith and Ludington (1989) reported a 9- in the aetiology of many lower extremity injuries. month prospective study that examined the inci- Jumping sports depend not only on the knee, hip dence, severity and cause of injuries sustained by and thigh but also on the ankle and calf to gener- 48 skaters, of whom 32 were élite pairs skaters ate the forces and counter-forces necessary to

Table 35.1 Number of figure skating injuries compared with the number of participating skaters

Smith & Brock & Brown & Smith & Kjaer & Micheli (1982) Striowski (1986) McKeag (1987) Ludington (1989) Larsson (1992)

No. of skaters 19 60 14 48 8

No. of injuries 52 28 39 singles 49 18 9 pairs 520 sport-specific injuries: prevention and treatment

Table 35.2 Types of figure skating injuries

Smith & Brock & Brown & Smith & Kjaer & Micheli (1982) Striowski (1986) McKeag (1987) Ludington (1989) Larsson (1992)

Concussion 3 (5.8%) Singles, 3 (8%) 2 (4%) Pairs, 3 (33%) Fracture 3 (8%) 1 (3.6%) Singles, 8 (21%) 4 (8%) Pairs, 2 (22%) Lacerations 2 (3.8%) Singles, 2 (5%) 5 (10%) Pairs, 1 (11%) Periostitis 5 (9.6%) 1 (2%) 2 (11%) Joint strain 9 (17.3%) 6 (21%) Singles, 3 (8%) 8 (16%) 9 (50%) Pairs, 1 (11%) Muscle sprain 9 (17.3%) Singles, 12 (31%) 13 (28%) 2 (11%) Soft tissue, 8 (15.3%) 8 (28.5%) Singles, 3 (8%) 1 (5.6%) non-specific Haematoma/ 2 (3.8%) Singles, 6 (15%) 5 (10%) contusion Pairs, 2 (22%) Bursitis 6 (11.5%) 4 (8%) Tendon 5 (9.6%) 10 (37.5%) Singles, 1 (3%) 7 (14%) 4 (22.2%) Nerve Singles, 1 (3%) Teeth 1 (3.6%) Non-skating 2 (7.1%)

Table 35.3 Anatomical location of figure skating injuries*

Smith & Brown & Smith & Kjaer & Micheli (1982) McKeag (1987) Ludington (1989) Larsson (1992)

Foot 6 (12%) 3 (6%) 6 (12%) 1 (6%) Ankle 10 (19%) 3 (6%) 7 (14%) 7 (39%) Leg 9 (17%) 3 (6%) 3 (6%) 2 (11%) Knee 6 (12%) 11 (23%) 10 (20%) 5 (28%) Thigh 1 (2%) 4 (8%) Hip/buttock 6 (12%) 9 (19%) 5 (10%) Low back 6 (12%) 4 (8%) 4 (8%) 2 (11%) Upper back 2 (4%) 2 (4%) Chest/rib 1 (2%) 1 (2%) 1 (2%) Head 4 (8%) 6 (13%) 2 (4%) Shoulder/arm 1 (2%) 4 (8%) 1 (2%) Elbow/forearm 1 (2%) Wrist 1 (2%) 1 (2%) Hand 2 (4%) 3 (6%) 1 (6%) Total 52 48 49 18

*The studies reviewed did not use standardized inclusion criteria; therefore, although it is possible to obtain a general impression of the relative frequency of injury to various anatomical areas, these proportions should be interpreted with caution. Figures are number of reported injuries to that anatomical area. Figures in parentheses represent percentage of total reported injuries; total may exceed 100% due to multiple areas of injury in a particular skater. figure skating 521

obtain maximum jump height and to absorb the more effectively to attenuate the forces generated impact of landing. Figure skating is the only at impact on landing. Smith and Ludington jumping sport that limits the ankle joint and calf (1989) identified 21.2% of injuries as related to muscles by the use of rigid boot support. The the boot, while Brock and Striowski (1986) noted high heel and inflexible ankle portion of the boot a comparable incidence of 14.3%. Davis and do not allow skaters to use their ankles effec- Litman (1979) noted the foot as a primary site of tively in plantar flexion during jump take-offs or lower extremity discomfort and injury among 45 to cushion their landings. Lockwood (1996) per- female skaters aged 9–18 years. Figure 35.9 illus- formed a kinematics analysis of the landing trates the primary areas of the foot affected by the phase of two technically different types of single, boot but does not include all the possible sec- double and triple jumps performed on ice. The ondary overuse-type injuries incurred as a result results indicated that both knee and hip flexion of altered ankle biomechanics. increased with additional revolutions but that Rapid growth may contribute to injuries only minimal ankle flexion occurred. This was related to muscle flexibility or boot fit. Achil- attributed to the stability of the boot, which pro- les tendonitis is a very common boot-related vided a mechanical block to increased ankle problem. The boot has a slight heel raise so that flexion. The lack of dorsiflexion flexibility in the the foot is slightly plantar flexed, which leads to skating boot may cause increased forces to be relative shortening of the gastrosoleus muscle transmitted higher up the leg on landing. The and the Achilles tendon. This lack of flexibility force absorbed by the knee extensor mechanism seems to have a strong relationship with devel- during landing contributes to the development opment of Achilles tendonitis. The Achilles of anterior knee pain and overuse injury. Smith tendon is also subject to pressure from the proxi- et al. (1991) reported on anterior knee pain in mal rim of the boot and may be injured during adolescent figure skaters. They examined 46 repeated toe jumps where the foot is maximally skaters, 14 (30%) of whom had anterior knee plantar flexed in the boot. pain syndromes, including patellar tendonitis, Ankle sprains are a common injury reported Osgood–Schlatter disease and patellofemoral in the majority of articles on skating injuries. pain syndrome. The female-to-male ratio of ante- Authorsen et al. (1997) and Danowski (1997) rior knee pain was 2:1. In the study by Brown found that the foot and ankle incur the largest and McKeag (1987) more than half the skaters number of injuries in the figure skater. Danowski reported knee pain. Richards and Henley (1996) (1997) described a foot instability syndrome in stated that the ankle plays an important role in which skaters spend so much time (several hours jumping and landing, and that a significant per day since childhood) in a reinforced boot portion (>30%) of the impact at landing is attenu- that they lose strength and proprioception about ated by the ankle. Richards et al. studied ground the ankle joint. The skater’s conditioning pro- reaction forces, limb kinematics and limb kinet- gramme should therefore incorporate exercises ics for backward drop jumps from a height of 30 to maintain and improve on the ankle joint’s cm in skaters wearing a rigid boot and those inherent proprioception and stability. Although wearing a boot with an articulation to allow free less directly related to the boot, groin strain motion of the ankle in the sagittal plane. They and plantar fasciitis are common, especially in found that ground reaction forces were 23% less, skaters with high arches and tight calf muscles. ankle range of movement in the sagittal plane Of the overuse injuries reported by Smith and was about 25% greater and the knee angle was Micheli (1982) in 19 competitive skaters, low significantly straighter at impact in the articu- back pain was the most frequent complaint. lated boot. Considering these findings it was Lumbar strain was also reported by Smith and concluded that the increased mobility afforded Ludington (1989) and Kjaer and Larsson (1992) the ankle in the sagittal plane enabled the skaters and is associated with the repeated hyperexten- 522 sport-specific injuries: prevention and treatment

Tibial periostitis Tibialis anterior Superficial erosions tendonitis

Malleolar bursitis Fifth metatarsal prominence

Metatarsal stress fractures Navicular contusions and stress fractures

Bunions

(a)

Achilles tendonitis Corns/callus/ Flexor hallux longus hammer toes tendonitis Peroneal tendonitis Flexor digitorum longus tendonitis Retrocalcaneal Fig. 35.9 Principal areas of the Posterior tibialis tendonitis bursitis skater’s foot affected by the boot Haglund's deformity fit: (a) front and (b) back of the (b) foot. sion and disc-loading of the low back during fre- skater. In the case of acute injury, it is difficult to quent jumping and landing. decrease the numbers of lacerations, contusions, Precision team skating is just developing into a fractures and concussions that occur in a sport recognized competitive sport and there are no with some inherent risk. However, microtrauma published data available with regard to injuries. or overuse syndromes, unlike acute injuries, are However, the potential for injury during compe- largely preventable through effective training tition or practice is great because of the number programmes and education. Brock and Striowski of skaters in close proximity on a limited ice (1986) documented the time lost due to acute and surface. A review of injuries sustained at the ISU overuse injuries and found that the potentially World Challenge Cup in 1996 (374 skaters par- preventable overuse injuries kept skaters off the ticipating in 14 teams) revealed 109 reported ice longer than acute injuries. injuries (C.F. McCarthy, personal communica- Figure skating has drawn on the experience of tion, 1996) (Table 35.4). other sports that suggest proper conditioning reduces overuse injuries and thereby decrea- Injury prevention ses training time lost due to these injuries. Aleshinsky et al. (1988) state that strengthening Figure skating injuries occur as a result of and conditioning programmes are essential to episodic macrotrauma (acute) or recurrent continued success in figure skating because they microtrauma (overuse), or a combination of maximize performance and reduce injury. Smith these, to the musculoskeletal structure of the et al. (1991) showed a direct relationship between figure skating 523

Table 35.4 ISU World Challenge Cup 1996: injuries by anatomical location. (Data from C.F. McCarthy, personal communication, 1996)

Fracture/ Concussion dislocation Soft-tissue injury

Head 5 Nasal 2 Coccyx 2 Vertebrae 3 Clavicle 4 Finger 7 6 Wrist 9 1 Forearm/arm 4 Elbow 2 Shoulder 2 2 Toe/foot 2 1 Ankle 6 20 Patella 1 Knee 2 8 Lower leg 3 2 Neck 2 Low back 5 Other Muscle tear 2 Tendonitis 4 Tendon laceration 2 Total 5 49 55

hamstring and quadriceps muscle tightness and advice about weight training, preseason medical knee pain. Lack of flexibility in the quadriceps advice and examinations, boot checks, ballet and causes an increased load to be placed on the sports psychology. Over this time there was a quadriceps mechanism, leading to overuse marked reduction in injuries. The decreased syndromes such as traction apophysitis, patel- injury rate was attributed to increased strength, lofemoral symptoms and patellar tendonitis. flexibility and knowledge, which led to earlier Lack of quadriceps strength results in decreased intervention and decreased emotional stress ability to absorb forces through the knees, which in the course of injury. Yu (1996) supports the in turn leads to lateral patellar compression. concept that the incidence of injury decrea- Ferstle (1979) described the use of off-ice training ses dramatically with increased flexibility and for the prevention of injuries. McMaster et al. routine stretching regimes. (1979) published a 3-month programme which Good postural alignment, adequate flexibility showed that graduated on-ice interval training and sufficient strength are basic requirements for and off-ice weight training and flexibility the athletic and artistic components of figure improved cardiovascular fitness and enhanced skating. Correct biomechanics, graduated train- performance. Smith (1996) conducted a 4-year ing time and intensity, and progression of muscle longitudinal study of 48–52 skaters aged 11–29 strength and flexibility are the keys to avoiding years. Over the 4-year period various training overuse injuries. The areas that predomi- adjuncts and recommendations were introduced nantly require increased flexibility are the lower to the skaters at the training camps, including extremity (quadriceps, gastrosoleus complex, 524 sport-specific injuries: prevention and treatment

hamstrings, hips), trunk (extension, flexion and throws and jumps can be avoided by off-ice lumbodorsal fascia) and upper extremity training. Moskvina (1997) advocates practising (shoulders). The areas that require strength- these techniques in a gym in order to develop ening include the primary muscles for jumping strength, timing, height and lean in the air, and (gluteus maximus, gluteus medius, hamstrings, recommends that acrobatic manoeuvres be per- quadriceps, gastrosoleus, tibialis anterior). Trunk formed using a rubber or foam mat in order to stability, including stabilization of the spine decrease the impact on landing. This allows through abdominal strengthening, is very skaters to learn increasing control of the lift, the important in jumping. Better jumpers have larger number of revolutions in the twist lift and to differences between their moments of inertia correct landing technique before attempting the (degree of ‘openness’) at the instant of take-off same elements on the ice. Injuries due to falls and the most closed position during flight. This from heights can be avoided if the female partner requires good upper body strength, particularly practises the necessary movements of a lift on the all the shoulder girdle muscles (abductors, floor or gymnastics bar. Practising the motor adductors and internal rotators) (Aleshinsky components of a lift with the male lying on the et al., 1988). Upper body strength is particularly floor or sitting in a chair eliminates both the risk important in pairs skaters in order to prevent of falls for the female partner and the risk of back injuries during lifts. In the male partner, upper injury for the male partner. Practising lifts as a body and trunk strengthening should include pair off the ice improves strength and technique a weight programme that incorporates the and improves confidence when the manoeuvres manner in which the lifts are performed on the are transferred to the ice. ice. Improved strength of the arm and leg adduc- Although figure skaters invest many hours of tor muscles improves the quality of a skater’s daily training, only a small portion of this time spin. incorporates activities that enhance condition- Acute injuries such as contusions and ing. Skating is a highly anaerobic and moder- haematomas can be decreased by wearing ately aerobic activity in which the skater touchdown pants, which have padding over the performs with a maximal heart rate for 2–5min. buttock and lateral thigh to cushion bony promi- Off-ice training allows the skater to train at the nences during falls. Acute ankle injuries can be supramaximal cardiovascular levels reached · prevented by incorporating strengthening and while doing difficult jumps. A high VO2max in proprioception exercises into off-ice condition- conjunction with an ability to tolerate high levels ing programmes. Authorsen et al. (1997) reported of lactic acid is recognized as a competitive that off-ice testing of the ankles of élite skaters advantage in figure skating. indicated poorly developed strength of the In response to the gradually emerging body of ligaments and peroneal muscles stabilizing the research specific to their sport, figure skaters ankle. Figure skaters should therefore increase have gradually expanded off-ice training in strength and proprioception training of the ankle order to enhance overall conditioning and per- in order to develop and maintain the active mus- formance and to decrease training time lost to cular stability and response time of the ankle. injury. Off-ice conditioning must be incorporated Not only will this help to prevent inadvertent into the training programme so that it does not ankle injuries away from the ice, which affect the interfere with the on-ice component but rather ability to return to skating, but will also protect supplements it. A comprehensive training pro- the skater from ankle injury on the ice as the gramme must be focused as closely as possible passive stability inherent in new boots progres- on the skater’s stated goals and should be based sively lessens throughout the season. on the results of physiological testing, biome- Some of the acute injuries that occur in pairs chanical alignment and present level of technical skating because of the risks inherent in the lifts, ability. figure skating 525

Medical concerns Nutrition Competitive success in figure skating demands Exercise-induced bronchospasm grace, strength, flexibility and endurance, as Exercised-induced bronchospasm (EIB) results skaters are judged on both technical and artistic in airflow obstruction that typically occurs 5– performance. It is extremely important for the 15min after strenuous exercise. Symptoms may skater to satisfy the energy requirements for include shortness of breath or wheezing, training and competition while maintaining although occasionally the only symptom may be optimum weight and body composition for the coughing after exercise. EIB has been docu- artistic aspect of the sport, and nutrition is there- mented in 70–80% of athletes with asthma fore a vital component of performance enhance- and 40% of people who have allergies (Schroeck- ment and injury avoidance. enstein & Busse, 1988; McCarthy, 1989). Athletes The aesthetic quality a skater presents to the at risk for EIB include those with a past history of judges often adds to the artistic merit of the asthma or environmental allergies and those performance, although this aspect should not with a history of coughing or wheezing after overshadow other factors in achieving success strenuous exercise. EIB can be exacerbated when (technical ability, training, mental preparedness). competing in a cold, dry environment. Con- It is imperative that a skater does not succumb to versely, the severity of the bronchospasm associ- pursuing a set weight for aesthetic reasons that, ated with exercise can be decreased by a long in the long run, adversely affects her health and warm-up prior to the event. performance. Nutritional deficiencies result in Provost-Craig et al. (1996) studied 100 competi- reduced exercise capacity, increased heart rate, tive skaters to determine the incidence of EIB in decreased oxygen uptake, decreased work competitive skating. In this study, pulmonary tolerance, a weakened immune system and an function tests completed at rink-side showed an increased risk of overuse injury. Coaches, fami- overall incidence of EIB of 30–38%. Screening lies, skaters and the medical profession all have for EIB in youths participating in physically a part to play in preventing eating disorders in demanding, cold-weather sports such as figure athletes. skating is necessary for proper identification and Generally, most trained athletes have a lower treatment. With appropriate treatment, athletes body fat content than non-athletic subjects of can improve their performance as well as their similar age and maturity. Several nutritional enjoyment of the sport. Education is important in studies have been conducted on competitive both identification and treatment. Early identifi- female figure skaters. Ziegler (1996) noted that in cation depends on education of athletes, parents both males and females aged 11–18 years caloric and coaches. An effective treatment programme intakes were below the recommended daily should communicate the knowledge that EIB allowance for age and energy output, especially is an exaggerated, reversible airway response to for females. He also reported that the iron and exercise that occurs in many athletes and that can folic acid status, as well as the endurance, of be successfully managed in most cases. Athletes figure skaters varied with the seasons and must be aware that using an inhaler for EIB were significantly lower during the competitive does not necessarily mean that they have season. asthma. Treatment compliance with non- It is often difficult for competitive skaters and pharmacological and pharmacological interven- coaches to eat properly. At rink-side, in hotel tions is improved through education. Athletes restaurants and at competitions in foreign coun- who exhibit a reduction in peak expiratory flow tries, healthy nutritional choices are sometimes rates of >10% after exercise are candidates for limited. Proper nutrition promotes effective treatment (Pierson, 1988). weight control, allows the individual to be com- 526 sport-specific injuries: prevention and treatment

fortable with her appearance, improves physical on the injury and the goals of rehabilitation. and mental performance, and improves the per- Throughout the rehabilitation programme, con- ception of health and well-being. All of this helps stant re-evaluation and modification are neces- to improve self-esteem. Skaters who are well sary to accommodate the athlete’s progress and nourished can train effectively, with increased graduated return to full participation. Overall, concentration and decreased stress, in order to the goal is safely to return the athlete to her previ- perform more consistently to their full potential. ous level of participation as soon as possible by maximizing function and minimizing reinjury. The general sports medicine rehabilitation Psychological stress approach and the treatment of soft-tissue injuries Some skaters experience significant psychosocial has been well delineated in other sports medi- stresses at very young ages compared with non- cine texts. The following therefore only outlines skating, non-competitive counterparts. Stress those techniques of specific use in the recovery of can be increased if the skater lives away from figure skaters. home and lacks the support of the family envi- Like all athletes, injured skaters are reluctant to ronment. Parents and other family members may give up their sport for any period of time. Even if sacrifice time and money, which sometimes the skater is following an off-ice conditioning increases the pressures on the skater to attain and rehabilitation programme, she will become unrealistic goals. In addition to these sources of isolated. The medical personnel responsible for stress, there is also the social isolation from non- the rehabilitation of a skater should make every skating peer groups imposed by the time require- attempt to keep the skater on the ice in some ments of rigorous training schedules. capacity. In this regard it is important that physi- A supportive family and a good working rela- cians and therapists treating an injured skater tionship with a sensitive coach are two ele- have an understanding of the various aspects of ments necessary for success in competitive figure skating so that they can advise the skater about skating. Success for a particular skater is repre- ‘relative rest’ and protection of the injured body sented by the achievement of a common goal part while maintaining some on-ice train- arrived at through discussions with the skater, ing. Assuming this knowledge of the sport, the other family members and the coach. In pursuit medical team can provide guidance to the skater, of this goal, competitive skaters can benefit coach and often the parent as to the ability of the from effective stress management training, psy- injured area to tolerate the stresses of the various chosocial skills enhancement and motivational skating elements. Uninterrupted association interventions. with the arena of competitive endeavour main- tains the psychological health and commitment of the serious or competitive skater. Injury management (rehabilitation) Almost all overuse injuries are treated non- Rehabilitation of musculoskeletal injury is most operatively. Treatment involves settling the effective when conducted in a multidisciplinary body’s inflammatory response in order to allow environment. Depending on the nature and healing to occur, while investigating the likely severity of the injury and the anticipated time cause of repetitive localized microtrauma, which away from competition, the rehabilitation team usually involves altering the skater’s boot, tech- may include a sports medicine physician, phys- nique, training programme, muscle strength, iotherapist (manual therapist), physiologist, flexibility or biomechanics. This applies to the sports psychologist and nutritionist. The degree majority of knee and lower leg injuries exclud- of involvement of various members of the team ing the specific boot-related injuries discussed with the athlete, coach and parent depends below. figure skating 527

skate. These are rarely painful but at times Boot-related injuries require doughnut-shaped padding. stress fractures Large bursae can develop over the bony prominences of the foot and ankle due to exces- All stress fractures require review of the skater’s sive pressure of the boot against these areas. nutritional, training and menstrual history. These bursae occur over the malleolli, calcaneal Stress fractures of the fibula are caused by pres- tuberosity, navicular bone and anterior tibial sure from the hard rim of the boot and can be pre- tendon (Fig. 35.10). In most cases malleollar vented by padding the proximal portion of the bursae do not interfere with training but are boot with orthopaedic felt or lamb’s-wool, ensur- more of a nuisance in getting the boot to fit. Once ing correct placement of the skate blade, and the skate is on, the skater adjusts the laces repeat- improving strength and flexibility of the lower edly as fluid is extruded from the bursae due to extremity. Navicular stress fractures should bear increasing pressure from the tightened boot. no weight during the healing period. Rarely, However, the fluid tends to reaccumulate once surgery is required for ununited or displaced the skate is removed. Although the bursae can be fractures. Biomechanical stresses must be identi- aspirated and injected with corticosteroid in an fied and relieved. Metatarsal stress fractures attempt to prevent reaccumulation, this is not are caused by the repetitive localized trauma of particularly successful. The skater can also pad landing from jumps. The skate itself provides no shock absorption and in addition limits ankle dorsiflexion, which would normally attenuate the impact force. In this situation, skaters must eliminate all moves that aggravate their symp- toms both on and off the ice. Most skaters can continue stroking and compulsory figures but may require increased support for walking activities off the ice. To prevent recurrence of metatarsal stress fractures, a shock-absorbing insole is placed in the skate and any abnormal weight distribution across the foot corrected by use of an orthotic. (a) painful bumps

Painful accessory navicular bones are very common. These accessory navicular bones can cause a medial mid-foot prominence that can be exacerbated by overpronation. Correction of overpronation is helpful, although the boot- maker should also punch out the appropriate part of the boot in order to avoid pressure on these areas. Similar pressure areas occur over the base of the fifth metatarsal. Calluses and corns over the dorsal aspect of the toes are very (b) common. The dorsal portions of the digits rub Fig. 35.10 (a) Cyst development on the anterior tibial against the toe box of the boot while trying to tendon with (b) corresponding ultrasound confirming grip the insole to achieve better control of the fluid collection. (Photo courtesy of Dr R.G. Danowski.) 528 sport-specific injuries: prevention and treatment

the area in order to prevent further pressure prior decrease the pressure and limit forceful plantar to correction of the boot. Treatment involves flexion. This should alleviate the problem. It altering the boot either by punching out the should be noted that skating boots have an ele- appropriate spots to avoid pressure over these vated heel, which tends to maintain the ankle in bony prominences or by decreasing the padding slight plantar flexion. This leads to relatively over the pressure area and increasing the shortened Achilles tendons and predisposes padding around the prominence. Some skaters skaters to Achilles tendonitis. Skaters should have the bursa excised, although care must be stretch their Achilles tendon both before wearing taken not to replace a non-painful bursa with an their boots and when they have their boots on. irritating and painful scar that continues to be a Occasionally, the boot padding in this area also pressure area inside the boot. causes irritation to the tendon as the ankle is Haglund’s deformity of the calcaneal tuberos- moved through plantar flexion and dorsiflexion. ity is caused by the heel slipping within the boot In this case, the padding should be compressed during knee and ankle flexion because of exces- or removed in order to alleviate the pressure sive movement of a narrow heel in a wide heel adjacent to both sides of the tendon. cup. This is treated by improving the fit of the boot by adding padding over the medial and ankle injury lateral aspects of the Achilles tendon and by increasing the flexibility of the boot to allow Ankle injuries constitute a large proportion of more ankle dorsiflexion. The back stay can also figure skating injuries. Retraining of propriocep- be punched out to relieve pressure over the cal- tion is a critical element in the off-ice training caneal prominence. Alternatively, the skater can programme, and should include walking on replace the skate with a make that has an appro- even and uneven surfaces and running in priately narrow heel counter. straight lines and zigzag patterns. Balance and proprioception can be enhanced by hopping and tenosynovitis jumping or by the use of a trampoline or balance board (Fig. 35.11a). Varying the free leg and arm Tenosynovitis of the anterior ankle is caused by position on the balance board can enhance the pressure of boot laces and tongue crease on balance. Resistance exercises are important in the the dorsum of the ankle during ankle flexion. restoration of ankle strength (Fig. 35.11b,c) and This can be relieved by adding padding, such as are important in the prevention of recurrent orthopaedic felt or sheepskin, to the tongue of injury. The skater may begin stroking as soon as the skate. Smith (1990) suggests using Plastazote the foot can fit into the skating boot but should or other malleable plastic insert between the avoid double or triple jumps, especially those leather of the boot and the padding of the tongue. that land on an outside edge, until normal per- The plastic insert is heated and placed between oneal strength and proprioception have been the leather and padding of the tongue and the restored. Normal strength and proprioception skate is then laced up loosely. This allows can be judged to have been restored when the grooves to form in the hardening plastic that skater can maintain balance on the injured limb form a firmer area over the tendon and distribute alone during continuous independent move- the forces over a wider area, alleviating the pres- ment of one or more of the unaffected sure of the laces and leather over the tendon. extremities. Achilles tendonitis may result from pressure of the proximal rim of the boot when performing General aspects of injury management toe jumps repeatedly. In this case, toe jumps should be limited until symptoms subside. The All muscle groups that provide support and upper rim of the boot should be padded to balance are important for figure skating. All figure skating 529

(a) (b)

Fig. 35.11 (a) Balance board exercises to increase pro- prioception and strengthening of the ankle. (b, c) Two ankle strengthening exercises using resistant elastic bands. (Photos courtesy of Dr Kelly Flannigan.) (c) 530 sport-specific injuries: prevention and treatment

skating disciplines require adequate strength of the muscle groups stabilizing the ankle, knee and hip joints, as well as those muscle groups respon- sible for maintenance of body posture, especially arm position. If an injury has limited on-ice train- ing, effective injury management must provide for maintenance of all these components during the rehabilitation period. One particularly effective off-ice conditioning activity that can be incorporated into a rehabil- itation programme is the slide board, which offers sport-specific cardiovascular fitness and strengthening of the lower extremity without impact forces. Provost-Craig and Pies (1997) reported that heart rate response to 70–80 slides per minute did not differ from the mean heart rate response during the 4-min programme on the ice. Correct use of the slide board increases back stabilization, promotes good body align- ment and balance, and simulates skating move- ment patterns. In addition to its usefulness in rehabilitation, it is an effective non-impact, off- ice conditioning device for preseason training programmes. Depending on the injury, other Fig. 35.12 Harness support used as a training or reha- appropriate activities, such as swimming, bilitation device. cycling, rowing and treadmill, could be used to maintain cardiovascular fitness and ideal body weight during the rehabilitation phase. A harness device (Fig. 35.12) can be used to very important for balance on the ice and limit weight-bearing during practice sessions for jumping. Neuromuscular stability of the for skaters recovering from injury. This device lumbar–pelvic region requires both the neuro- decreases the impact load by 10–30% during logical control to attain the proper lumbar–pelvic landing from jumps and prevents skaters from position via proprioception and the muscular falling as they gradually recover their training control to maintain this position. This trunk sta- programme (Gross, 1997). It allows skaters to bility is maintained by the coordinated action of return to training without the fear of falling and the back extensor, abdominal flexor and gluteus reinjury, thus improving confidence and helping muscle groups. Weakness of the gluteus medius to overcome any psychological barriers. Skaters and poor trunk stability allows unwanted lateral with upper extremity injuries, including hand movement of the pelvis. Conversely, strengthen- and wrist fractures, can continue skating as long ing of these muscle groups and increasing their as immobilization is sufficient to prevent symp- endurance increases core trunk stability. This in toms during practice. The skater may need to turn increases the skater’s ability to absorb mul- decrease lifts if involved in pairs or dance. If tiaxial loading through the trunk of the body, involved in precision skating, the athlete will rather than through the vertebral joints and the need an adequate grip required for precision lower extremity. In addition to the obvious role elements. in enhancement of performance, core trunk sta- Trunk stability in relationship to the pelvis is bility and balance are therefore also an integral figure skating 531

(a)

Fig. 35.13 Examples of two spine stabilization exercises where a level pelvis is maintained in order to increase core stability. (Photos courtesy of Dr Kelly Flannigan.) (b)

part of injury prevention. Specific spine stabiliza- musculoligamentous strains. However, because tion exercises (Fig. 35.13) are used to improve of skating’s emphasis on lumbar lordosis and trunk strength and core stability selectively. holding the free leg extended at all times, skaters Weakness of the hip and trunk stabilizers can are at increased risk of spondylolysis. If skaters present as knee pain because of inability to lack flexibility in the hip joint, they attempt to control the pelvis on landing. This causes more achieve further leg extension through the lum- rotation, overcorrection and consequently more bosacral area, thus increasing strain and the pos- shock absorption at the knee. sibility of injury to the structures of the low back. Groin strains involving hip flexors and ad- It is also important that the skater has full physio- ductors are not uncommon in figure skaters, logical movements at the uncovertebral joints although fortunately they respond to flexibility of the lumbar spine, as stresses that result and strengthening exercises. Low back pain from inadequate joint ranges will present as is a common complaint and usually involves overuse injuries. Tight lumbodorsal fascia is also 532 sport-specific injuries: prevention and treatment

a cause of back pain in figure skaters. Stretching With the increased popularity of figure of the lumbodorsal fascia is important in main- skating, there are more skaters seeking advice taining muscle balance and proper lumbar from their physicians with respect to the more mobility (Fig. 35.14). Spine stabilization exercises common problems encountered. Physicians who are used in rehabilitation of back injury and for understand the basics of the sport will be able to prevention of recurrent injury. provide more effective injury prevention and management services to this group of recre- ational and competitive athletes.

Recommendations for future research Because of the increased demands in the training of competitive figure skaters and in recognition of the lack of research delineating the effects of high-impact, repetitive loading on the growth and development patterns of young athletes, the ISU has recently reviewed and raised the age limits for competing at international and Olympic events. Further prospective and longi- tudinal studies are necessary in order properly to advise skaters and coaches on the content of figure skating training programmes. In this highly technical world, the skating boot (the (a) source of most injuries in figure skating) has not changed significantly in the last century. A hinged plastic boot is currently undergoing eval- uation, although much further study will be required to develop a skate that can match the abilities of the athletes who wear them. In the last few years, several international meetings specific to figure skating have been held in America and Europe. These events have provided skaters, coaches, therapists, scientists and physicians the opportunity to expand their knowledge and to plan future research for the benefit of all figure skaters and those who help them reach their goals.

Acknowledgements I would like to thank the following who assisted in creating this chapter: Penny Dain, Interna- tional Skating Union Media Relations, Sue Pavli- cic and Kim Ward for their time and energy (b) devoted to the clinical photographs; Audiovisual Fig. 35.14 Two different methods to stretch the Services of the Capital Health Region of Victoria, lumbodorsal fascia. (Photos courtesy of Dr Kelly BC for the reproduction of slides and pho- Flannigan.) tographs; and Dr Kelly Flannigan for his profes- figure skating 533

sional photography, valued insight and com- exercise-induced asthma. Physician and Sportsmedi- puter mastery. cine 17, 125–130. McMaster, W., Liddle, S. & Walsh, J. (1979) Condition- ing program for competitive figure skating. American References Journal of Sports Medicine 7, 43–47. Moskvina, T. (1997) Preventing injuries with off ice Aleshinsky, S., Podolsky, A., McQueen, C., Smith, A. & training. In ISU International Congress on Medicine Van Handel, P. (1988) Strength and conditioning and Science in Figure Skating, p. 20. International program for figure skating. National Strength and Skating Union, Lausanne, Switzerland. Conditioning Association Journal 10, 26–30. Niinimaa, V., Woch, Z. & Shephard, R. (1979) Intensity Authorsen, S., Wingendorf, M. & Weyer, R. (1997) Boot of physical effort during a free figure skating related injuries as seen at the Olympic Training program. In Science in Skiing, Skating and Hockey, pp. Center, Dortmund, Germany. In ISU International 74–81. Academic Publishers, Edmonton, Canada. Congress on Medicine and Science in Figure Skating, Pierson, W.E. (1988) Exercise induced bronchospasm in p. 15. International Skating Union, Lausanne, children and adolescents. Pediatric Clinics of North Switzerland. America 35, 1031–1040. Brock, R. & Striowski, C. (1986) Injuries in elite figure Podhajsky, H. (1997) Foot alignment and the skating skaters. Physician and Sportsmedicine 14, 111–115. boot fit. In ISU International Congress on Medicine and Brown, E. & McKeag, D. (1987) Training, experience, Science in Figure Skating. International Skating Union, and medical history of pairs skaters. Physician and Lausanne, Switzerland. Sportsmedicine 15, 100–114. Provost-Craig, M.A. (1997) Off ice training of the Danowski, R.G. (1997) The foot instability syndrome specific parameters. In ISU International Congress of the ice skater. In ISU International Congress on Med- on Medicine and Science in Figure Skating, p. 27. Inter- icine and Science in Figure Skating, p. 9. International national Skating Union, Lausanne, Switzerland. Skating Union, Lausanne, Switzerland. Provost-Craig, M.A. & Pies, N. (1997) Heart rate Davis, M.W. & Litman, T. (1979) Figure skater’s foot. response of the long program and guides for Minnesota Medicine 62, 647–648. improvement. In ISU International Congress on Medi- Ferstle, J. (1979) Figure skating: in search of the winning cine and Science in Figure Skating, p. 26. International edge. Physician and Sportsmedicine 7, 129–136. Skating Union, Lausanne, Switzerland. Garrick, J. (1982) Figure skating injuries. Medicine and Provost-Craig, M.A., Whaler-Beck, P., Arbour, K., Science in Sports and Exercise 14, 141. Sestili, D., Chabalko, J. & Ekinci, D. (1996) The inci- Gledhill, N. (1997) Physiological changes in figure dence of exercise induced bronchospasm in competi- skaters over the years. In ISU International Congress tive figure skaters. In First Congress on the Sports on Medicine and Science in Figure Skating, p. 12. Inter- Medicine and Sports Science of Skating, p. 20. US Figure national Skating Union, Lausanne, Switzerland. Skating Association, San Jose, California. Gross, J. (1997) Automatic harness. In ISU International Richards, J. & Henley, M.S. (1996) Effects of ankle Congress on Medicine and Science in Figure Skating, mobility on landing forces in skating. In First Con- p. 14. International Skating Union, Lausanne, gress on the Sports Medicine and Sports Science of Switzerland. Skating. US Figure Skating Association, San Jose, Kjaer, M. & Larsson, B. (1992) Physiological profile and California. incidence of injuries among elite figure skaters. Ross, W.D., Brown, S.R., Faulkner, R.A., Vajda, A. & Journal of Sports Sciences 10, 29–36. Savage, M.V. (1976) Monitoring growth in young Lockwood, K. (1996) Kinetic and kinematic characteris- skaters. Canadian Journal of Applied Science 1, 163–167. tics of impact upon landing single, double, and triple Schroeckenstein, D.C. & Busse, W. (1988) Exercise and revolution jumps in figure skating. In First Congress asthma: not incompatible. Journal of Respiratory on the Sports Medicine and Sports Science of Skating, Disease 9, 29–45. pp. 5–7. US Figure Skating Association, San Jose, Slemenda, C.W. & Johnston, C.C. (1993) High intensity California. activities in young women: site specific bone mass Lockwood, K. (1997) The effects of repetitive impact load- effects among female figure skaters. Bone and Mineral type training on skeletal health and integrity in competi- 20, 125–132. tive figure skaters. PhD thesis, Faculty of Physical Smith, A. (1990) Foot and ankle injuries in figure Education and Recreation, Edmonton, Alberta. skaters. Physician and Sportsmedicine 18, 73–86. Lowry, C.B. & Leveau, B.F. (1982) A retrospective study Smith, A. (1996) Reduction of injuries among elite of gymnastics injuries to competitors and non- figure skaters: a 4-year longitudinal study. In First competitors in private clubs. American Journal of Congress on the Sports Medicine and Sports Science of Sports Medicine 10, 237–239. Skating, p. 18. US Figure Skating Association, San McCarthy, P. (1989) Wheezing or breezing through Jose, California. 534 sport-specific injuries: prevention and treatment

Smith, A. & Ludington, R. (1989) Injuries in elite pair competitive skaters. In First Congress on the Sports skaters and ice dancers. American Journal of Sports Medicine and Sports Science of Skating, p. 17. US Figure Medicine 17, 482–488. Skating Association, San Jose, California. Smith, A. & Micheli, L. (1982) Injuries in compet- Zauner, C., Maksud, M. & Melichna, J. (1989) Physio- itive figure skaters. Physician and Sportsmedicine 10, logical considerations in training young athletes. 36–47. Sports Medicine 8, 15–31. Smith, A., Stroud, L. & McQueen, C. (1991) Flexibility Ziegler, P. (1996) The nutritional status of teenage and anterior knee pain in adolescent elite figure female competitive ice skaters. In First Congress on the skaters. Journal of Pediatric Orthopedics 11, 77–82. Sports Medicine and Sports Science of Skating, p. 9. US Yu, L. (1996) Injuries of national and international Figure Skating Association, San Jose, California. Chapter 36

Cycling

LISA LAMOREAUX

Introduction Bike fit: the foundation for prevention of overuse injury The sport of cycling takes many forms: road, track, mountain and BMX to name a few. Women Cycling is a concentric form of exercise and is are quite active in the sport of cycling. In 1995 therefore less likely to cause muscle strain type and 1996, the number of women competing injuries. However, due to the repetitive nature of in the National Off Road Biking Association cycling any mechanical malalignment that pro- (NORBA) National Series rose by 60% and duces undue strain on a tendon or a joint can 75% respectively. These statistics also reveal that eventually lead to injury. Overuse injuries gener- the median age of the female NORBA rider is 32. ally are attributable to one of three factors: This is an interesting statistic and may, in part, poor fit of rider and bike, training error or reflect the fact that many women enter the sport increased stress. These three factors are relevant as a method of rehabilitation from injuries in not only when evaluating a cyclist with an other sports. Cycling offers a wide range of overuse injury but also for the athlete using aerobic and anaerobic exercise without the high cycling for rehabilitation or entering the sport for price of repetitive impact. the first time. Cycling injuries fall into two broad categories: What is proper bike fit and how does this traumatic and overuse. An understanding of the apply to the female cyclist? Traditional bike fit mechanics of cycling aids in the prevention and has been based upon the proportions of the treatment of both types of injuries. This chapter average male, thus leaving most women and attempts to compile the current scientific litera- many men struggling with back, shoulder or ture on the biomechanics of cycling and places knee pain. Most traditional fit systems are based it alongside the experience gained by the on standover clearance or inseam length (Burke, author as both an orthopaedic surgeon and 1994). However, women tend to be proportion- professional cyclist. Though professional cycling ately longer in the legs than the torso compared is still a male-dominated sport, women are with a male of the same height. Additionally, receiving increasing support and interest. An most women have shorter arms than a male of understanding of the specific cycling problems comparable height. What constitutes proper fit is of women will aid in keeping them active in their influenced not only by body configuration but sport. also by riding style, flexibility and goals. Proper fit can mean upright and comfortable for a recre- ational rider with neck pain, while it can mean the most aerodynamic and metabolically effi- cient position for an élite time triallist. Proper fit 535 536 sport-specific injuries: prevention and treatment

is as dependent upon riding style and goals as it forward leg when the crank is parallel to the floor is upon body size. (Fig. 36.2). This will not be optimal for many riders, but provides a good starting point. For example, a rider with proportionately greater The frame femoral length will find that her centre of gravity Frame geometry fits into several general cate- is placed too far back with this positioning. When gories: road racing, touring, mountain and BMX. pedalling, it is best if the cyclist supports most of The traditional ‘double diamond’ frame configu- her weight through her legs, which are generally ration is still the most prevalent but many mono- pushing down on the pedals. Some weight coque designs and alternative geometries are should be supported on the saddle and some on becoming more common (Fig. 36.1). the hands; however, the hands are least tolerant Frame size is best determined by the cyclist’s of load-bearing. total height and riding style. The reach and Good fit is not only important for achieving height of the cyclist determines the position of comfort but is also a key element in the maxi- the top of the head tube and the handle bar and mization of transfer of power from the body to therefore frame size. This is because, unlike the the cycle drive train (Gonzalez & Hull, 1989). The saddle, there is not very much useful adjustment transfer of power depends primarily upon five in the handlebar and stem. There is one factor variables: seat-tube angle, seat height, crank common in comfortable fit and that is centre of length, longitudinal foot position on the pedal gravity. For most riders, having the centre of and pedal cadence. gravity just in front of the bottom bracket spindle The seat-tube angle (STA) determines the results in a comfortable fit. Again this is not a position of the seat and thus the hip axis relative fixed rule. For an élite time triallist in an aero to the crank axis. There are varying opinions as position, the centre of gravity will be pushed to the ‘optimal’ STA. Traditionally, competitive further forward. For the ‘average’ rider with road cyclists ride with STAs of 72–76°, while ‘average’ body proportions, a comfortable seat triathletes ride with steeper STAs, sometimes position will be achieved using the knee-over- as much as 80–90°. The STA tends to decrease spindle rule. This is accomplished by positioning with increasing frame size as it mostly reflects the seat so that a plumb-line dropped from the the length of the femur. This allows the taller tibial tuberosity bisects the pedal spindle of the cyclist with a longer femur to shift her position

Fig. 36.1 Although the traditional double-diamond frame configuration is still most prevalent, alternative geometries are becoming more common. cycling 537

Fig. 36.2 Saddle fore–aft positioning: with the cranks parallel to the floor the ‘average’ rider will find that a good starting position is with the tibial tuberosity over the pedal spindle.

rearward, maintaining the body’s centre of 100% of trochanteric height or 106–109% of sym- gravity. STA may also be altered effectively by physis pubis height. These studies, when cor- sliding the seat forward or backwards. Different rected for the different methods of measuring leg riding styles and events are reflected by different length, correlated well. Leg length should be geometries. This is seen in mountain and touring measured with the subject wearing cycling bikes, which have shallower STAs (more laid footwear, the feet spread 30cm, body erect and back) to aid in seated climbing. The effect of back flush with the wall. Saddle height is mea- varying STA on cardiorespiratory responses sured from the pedal, at its most distal position during steady-state cycling has been studied by from the seat, to the top of the seat at a point Heil et al. (1995). Trend analysis suggested that directly through the pedal axis. A simpler, less cardiorespiratory responses minimize around scientific method of adjusting seat height is to sit STAs in the range of 83–90°. This study reflects comfortably on the bike with heels on the pedals conditions similar to time trialling and thus may and pedal backwards. The leg should come to not reflect other forms of cycling. The observed full extension with the foot flat. Now clip in and responses may be largely due to increased pedal. At the bottom of the stroke the knee hip angle, as mean hip angle increases with should have a slight flexion angle; recommenda- increased STA thus affecting muscle forces. tions range from 15 to 30° (Fig. 36.3). Observing Although the cardiorespiratory responses were the rider from behind, the hips should not be small, it was calculated that the 2.5% reduction in rocking back and forth to gain extension as this · VO2 between an STA of 83° and an STA of 69° indicates that the seat is too high. A second indi- would result in a difference of 54s over a 40-km cator of excessive seat height is ‘ankling’, exces- time trial. sive ankle flexion in an attempt to reach the Optimal seat height has been evaluated with bottom of the pedal stroke. Additionally, a seat respect to oxygen consumption and lower that is too low results in excessive patellofemoral limb kinematics (Asmussen, 1953; Shennum & loading, as the knee experiences increased deVries, 1976; Nordeen-Snyder, 1977). Oxygen flexion with each revolution. consumption is minimized at approximately With limb length discrepancy, it is easiest to fit 538 sport-specific injuries: prevention and treatment

Fig. 36.3 Seat height: at the bottom of the pedal stroke the knee should have a slight flexion angle.

the bike to the longer leg. The shorter leg should length of 6.3:1 (Inbar et al., 1983). General guide- be evaluated to determine if the discrepancy is lines are that shorter cyclists use crank arm primarily tibial or femoral. If it is tibial, adding a lengths of 165–166.5mm, with 160mm being a lift or shim of slightly less than the total discrep- consideration for those under 1.5m tall. Cyclists ancy between the cleat and shoe solves the 1.6–1.8m tall use a crank arm length of 175mm; problem. If it is femoral, a lift of approximately in mountain biking 177.5mm should be half the discrepancy should be combined with considered. moving the shorter leg back slightly on the pedal. The pedal provides the platform through Limb length discrepancy may also be adressed which the cyclist transfers energy to the bike. A by using a shorter crank for the shorter leg. variety of pedal styles are currently available. Crank length is another important variable in The traditional platform pedal is still commonly the transfer of power from the body to the bike used for recreational and children’s bikes, BMX, (Hull & Gonzalez, 1988). Optimum crank arm slalom and stationary bikes. This allows the rider length depends on several factors, particularly to use any type of shoe. Toe-clips and cleated riding style, whether sprinting, touring, time tri- cycling shoes have been found to improve alling or hill climbing. For every style there is an cycling efficiency (Davis & Hull, 1981). When optimum crank arm length, for example a longer cleating the shoe to the pedal, proper placement crank arm increases the leverage and decreases becomes an important issue. Several studies the revolutions and is good for pushing big have evaluated cycling parameters in relation to gears. In general the minimum cost function changes in foot position (Ericson et al., 1985, 1988; occurs at longer crank arm lengths and lower Ericson & Nisell, 1986; Gonzalez & Hull, 1989; pedalling rates in tall people compared with Mandroukas, 1990). Longitudinal position of the short people (Faria, 1992). It is not uncommon to foot on the pedal plays an important role in knee see a short woman using a long crank arm that and ankle kinematics, as well as in perceived will result in excess hip and knee flexion at the exertion and transfer of power to the pedal. top of the pedal stroke. Mechanical power output Ericson et al. defined the anterior foot position as tends to be greatest with a ratio of leg length the second metatarsal head in contact with the (trochanter to floor in centimetres) to crank centre of the pedal (Ericson et al., 1985, 1988; cycling 539

Ericson & Nisell, 1986, 1987). This position was support foot structures has a significant effect on shown to result in a 5° increase in ankle joint the energy cost of cycling. Anderson and Sockler dorsiflexion, increased ankle load moment (1990) found no benefit from orthotics in the and increased mean force efficiency ratio with energy cost of submaximal cycling. However, increased soleus electromyographic activity. The Hice et al. (1988) found reduced oxygen con- posterior position (foot moved distally 10cm sumption and heart rate when orthoses were from the anterior position so that the midfoot is used to place the rear foot at its neutral calcaneal in contact with the centre of the pedal) increased stance position. hip joint motion by 7°, knee joint motion by 3° Although technically not an aspect of bike ‘fit’, and increased stress on the anterior cruciate liga- cadence is one of the elements significant in the ment. Mandroukas (1990) analysed foot place- transfer of power from the cyclist to the bike. ment and seat height and also found that the Cadence is also one of the most frequently impli- anterior foot position with the seat height allow- cated culprits in cycling overuse injuries. The ing near full knee extension was more effective optimal cadence for gross work efficiency is and perceived as easier. 60–91r.p.m. for moderate to high workloads The position of the foot on the pedal is also (Seabury et al., 1977; Faria et al., 1982; Boning et influenced by anatomical alignment. Many al., 1984). Coast et al. (1986) demonstrated a trend women tend to have slight valgus knee align- for the most economical cadence to rise from 50 ment or increased external tibial torsion. With to 78r.p.m. as power output increased from 100 · this type of alignment, if the foot is locked to the to 800W, or approximately 80% VO2max. Both pedal in a straight-ahead position tendon strain force at the pedal and muscle stress are mini- will probably result. This is well demonstrated in mized at cadences between 90 and 100r.p.m. This a study by Ruby and Hull (1993) that evaluated suggests that a pedalling rate of 90–110r.p.m. the response of intersegmental knee loads to foot may minimize peripheral muscle fatigue, even pedal platform degrees of freedom. With a plat- though this rate may result in higher oxygen form that allowed rotation, there was signifi- uptake (Patterson & Moreno, 1990; Widrick et al., cant reduction in axial and varus/valgus knee 1991). Even when climbing, a high cadence is moments. For the average cyclist this means more economical than a low cadence (although using a clipless pedal with a few degrees of float standing to climb has other advantages, such as to allow this rotational degree of freedom. There recruiting other muscle patterns and relieving are cases of extreme alignment anomalies that fatigue, or enhancing power production) (Swain may not be so easily adapted to the standard & Wilcox, 1992). bicycle. Excessive varus or valgus alignments For most cyclists bike fit is a very haphazard can produce increased stress on the medial or process. Most riders, whether entering the sport lateral knee. Spacers can be used to widen stance for the first time, being prepared for a team width and improve alignment from hip to knee. or even riding a bike in a health club, depend Lifts or cants can often be used to aid the valgus on peers and friends to make these important knee, placing these between the pedal and the adjustments. It is unlikely that even most élite shoe. The structure of the foot also influences athletes have analysed these studies, and low-level load transmission to the knee. Extreme most cyclists probably set up their bikes by trial inversion of the forefoot relative to the transverse and error. Women quite commonly enter plane causes significantly greater average poste- the sport for the first time riding a second-hand rior knee forces and extensive knee moments bike from a boyfriend or spouse. By aiding the (Ruby et al., 1992). This suggests that corrective understanding of good fit, not only can the orthotics may play a role in preventing overuse rider’s enjoyment be improved but additionally injury. However, there is some debate as to a significant impact can be made in prevention of whether using inserts to optimize alignment and injury. 540 sport-specific injuries: prevention and treatment

Traumatic injuries women were injured twice as frequently as men (Brogger et al., 1990). There is very little in the literature that differenti- Estimates of overall accidental injury rates ates cycling injury patterns by gender. Pfeifer vary (Thompson et al., 1990a). Estimates of a (1994) used a self-administered questionnaire to 2–3% incidence of injury in competitive cri- evaluate injury in NORBA Pro/Elite racers. terium, road, and track and circuit races have Although the numbers were small (47 males and been reported (Kiburz et al., 1986; Mclennan et al., 14 females), this is one of the few studies that 1988), while Kronisch et al. (1996) reported an investigated gender-specific injury differences. overall injury rate of 0.4% at a mountain bike Of the female cyclists who responded, bruises national series event in 1994 that encompassed and wounds accounted for 68% of injuries, 4027 individual starts in five events. For the strains and tendinitis 21% and fractures 4.4%. entire 1995 NORBA national series season, the This was not much different from the male distri- rate of injuries for all entries was 0.1% (National bution of injury. When analysed by region, the Off Road Biking Association, 1996). In BMX knee was most commonly injured in males, racing, an injury rate of 6.3% was reported at the accounting for more than half of reported 1983 BMX European Championship (Brogger injuries. In female riders lower extremity injury et al., 1990). was also quite high (39%); however, the low back Although traumatic injuries are an inherent accounted for the greatest number of injuries. It risk of cycling, the severity and incidence can be would be interesting to evaluate this discrepancy greatly influenced. Head injuries account for further. Is it secondary to training error, repre- most fatal accidents in cyclists and helmets can senting possibly poor upper body and trunk have a significant effect on lessening the severity strength or flexibility, or is it the result of difficul- of injury (Sacks et al., 1991; Spaite et al., 1991; Ash- ties with bike fit? Mountain biking also repre- baugh et al., 1995; Noakes, 1995). Many helmet sents a ‘young’ sport and there are few data manufacturers have designed helmets specifi- regarding specific injuries. cally for women, taking into account head size Road cycling has been popular for quite some and shape and even hair. Newer helmet designs time, so it would seem more likely that a data- have also focused on improving weight, ventila- base on injuries would be available. However, tion and aerodynamics, leaving very few excuses there is very little information with respect to for not wearing them. Helmets not only influence gender-specific injury. Wilber et al. (1995) evalu- the severity of head injury, but also have a ated 294 male and 224 female recreational significant effect on decreasing facial injury cyclists selected at random. Significant differ- (Thompson et al., 1990b). In downhill mountain ences were noted between male and female train- bike racing helmets now even offer full-face pro- ing characteristics. Overall, 85% reported one or tection (Fig. 36.4). All cycling governing bodies more overuse injury with 36% requiring medical in the USA require helmet use at sanctioned treatment. The odds of female cyclists develop- events. ing neck and shoulder overuse injury were 1.5–2 Road rash is probably the most common times greater than their male counterparts. cycling injury (Coyle et al., 1991; Mellion, 1991; This brings up the recurring issue of bike fit. Tra- Chan et al.,1993; Pfeifer, 1994). Although protec- ditional methods of bike fit would leave many tive clothing can be of some aid, the frictional women in a stretched-out position, contributing abrasion that results in road rash occurs even to neck and shoulder problems. In the paediatric beneath clothing. The padded armour of the population, several studies have observed downhill mountain bike racer offers significant higher traumatic injury rates in boys than girls protection to direct contact, but is impractical in (Gerbesich et al., 1994; Noakes, 1995), while in a most other events where heat dissipation and survey evaluating BMX racers it was noted that aerodynamics are an issue.The care of road rash cycling 541

block for 6 months to a year to protect the affected area. Upper extremity trauma is a significant issue in cycling. Tucci and Barone (1988) evaluated urban cycling injuries and reported that 41.9% of subjects had injuries to the upper extremity; this was nearly twice that of the lower extremity. If there is time, a common reaction is to try to break the fall with an outstretched hand, commonly resulting in fracture of the wrist or forearm. Fre- quently, however, the rider is still gripping the bars or is thrown over the bars to land on the point of the shoulder. This results in shoulder girdle injury, such as fracture of the clavicle and injury to the acromioclavicular joint (Davis et al., 1980). Clavicle fractures and acromioclavicular joint injuries are most commonly treated conser- vatively. For the competitive rider a stationary trainer may be tolerated within a few days of injury. Return to the road or dirt will be as toler- Fig. 36.4 Padded body wear and full-face helmets add ated, frequently by 3 weeks. Fracture union extra protection for the downhill mountain bike racer. requires approximately 6 weeks. Return to riding must be based on clinical findings and risk of non-union. Fractures at highest risk for non- union are those involving the distal end with the is directed first at preventing infection and coracoclavicular ligaments detached from the second at maximizing cosmesis. The first priority proximal fragment. This allows the proximal is complete cleansing and removal of any foreign fragment to retract upwards and into the trapez- body, which can result in infection or ius while the distal fragment drops downwards. tattooing. Non-viable skin is also débrided. Competitive cyclists may opt for surgical stabi- Scrubbing should be thorough and can be aided lization to speed their return to competition. This by the use of chlorhexidine or an iodophor scrub. must be approached with caution, as the stresses The use of viscous lignocaine or a slush of ice and induced by cycling may cause the orthopaedic lignocaine may make it easier for the rider to tol- hardware to fail with potential for migration erate. Allergic sensitivity, although very rare, (potentially into the chest). may occur in association with the preservatives Injury may occur at any level of the upper (methylparaben) used in multidose vials of lig- extremity. Injury to the hand may result in abra- nocaine. Using lignocaine from a crash cart or for sion, contusion or fracture. One injury of interest intravenous use avoids this problem. Lignocaine has become more common since the advent of toxicity is probably more common than allergic twist-shifters, particularly in mountain biking. sensitivity and manifests as seizure; doses of lig- As with skiing, the ‘grip’, or position of the hand nocaine should be limited to 5mg·kg–1 to avoid at impact, may predispose the thumb to an this. Daily care should include keeping the abduction force, resulting in tear of the ulnar col- newly forming dermis clean and lubricated, lateral ligament of the thumb. With twist-shifters whether by antibiotic ointment or hydrocolloid the grip is around the shifter with the thumb dressing (Mellion et al., 1988; Hermans, 1991). under the bar and a fall such as an ‘endo’ (rider Pigmentation may be decreased by using sun- launched over the bars, either from locking up 542 sport-specific injuries: prevention and treatment

the front brake or the bike coming to a dead stop as the front tyre hits an obstacle) can easily result in tear of the ulnar collateral ligament. Pre- vention is readily addressed by consciously remembering to keep the thumb over the top of the bar. Treatment depends upon the degree of disruption of the ligament. In my experience with mountain bike riders, a fairly circumferen- tial dislocation with volar plate injury frequently occurs; this requires surgical repair. Return to riding can be quite rapid. The surgical repair or sprain can be protected with a hand–thumb spica cast or heat-moulded plastic spica splint, custom moulded to the cyclist’s grips.

Overuse injuries Fig. 36.5 Most neck and back pain in cyclists is caused Overuse injuries account for the majority of by load-bearing through the arms and shoulders and by hyperextension of the neck. injuries in cycling and most commonly result from training errors, poor position or excessive stress, which need to be specifically evaluated and addressed. injury/complaint was 1.5 times that of the males; shoulder overuse injury/complaint was 2.12 times more frequent in the females than the Neck and back pain males. In evaluating the female cyclist with Neck and back pain are extremely common prob- neck, shoulder or back pain, bike fit should be lems with cyclists, particularly women (Weiss, reviewed. Many women are matched to a bike 1985; Pfeifer, 1994). Most neck and back pain in with too long a top tube, the fit being based on road cyclists is caused by load-bearing through their leg length. There is some room for modifica- the arms and shoulders and hyperextension of tion by using a shorter stem, although this will be the neck, particularly in the horizontal and limited and also alters the handling characteris- dropped riding position (Fig. 36.5). The more tics of the bike. In mountain biking, a bike that is upright position assumed for mountain biking too small can also be a culprit. This may result in and BMX produces less positional strain. How- the rider being in an excessively dropped posi- ever, the trade-off is increased impact in off-road tion and bearing increased load through the arms conditions and jumps. Trigger points about the and shoulders. Changing the stem to one with neck and shoulder girdle occur most commonly increased rise may be sufficient to resolve in the levator scapula, trapezius, rhomboid and this. Stems for mountain bikes are commonly sternocleidomastoid muscles (trigger points are marketed with 0, 10 and 20° rise; 15 and 30° rise irritable foci arising in muscle or fascia due to are also available or a custom stem can be trauma). Overuse, repetitive motion and strained designed. or abnormal postures can all contribute to the Riding technique is also an important element. trigger point pain–spasm–pain cycle. A rigid riding position transmits force directly to Wilbur et al. (1995) used a mailed question- the neck and shoulder girdle, while a stiff inflexi- naire to survey randomly 294 male and 224 ble back increases low back strain. Changing female recreational cyclists. The odds of the position frequently, absorbing shock through a female cyclists developing neck overuse flexed elbow position, stretching and standing cycling 543

are all important in preventing or resolving the ent to mountain biking than road cycling. These pain. Strength and flexibility exercises are an are poorly documented in the literature. Moun- important element of the medical management tain bike riding is associated with greatly of these problems. Additionally, women should increased repetitive impact and vibratory not ignore upper body strengthening and condi- trauma, which are borne by the hands. Beginners tioning. All too frequently the emphasis of the in particular may grip the bars or brakes with competitive female cyclist is so focused on devel- undue ferocity during long or technical descents, oping leg power and endurance that upper body resulting in tenosynovitis. Triggering of the conditioning is ignored. Good upper body and flexor tendons tends to be more common in the trunk strength and flexibility are an important little and ring fingers, suggesting that this is pri- factor in bike handling and are very necessary to marily associated with increased braking strain. add power to sprinting and hill climbing. This deserves further evaluation, particularly as it appears to be more common in female cyclists. It may be due to smaller hand size and compo- Hand and wrist nent mismatch or may simply be secondary to Ulnar neuropathy is an extremely common overgripping. Getting the rider to relax her grip problem in cyclists at all levels (Noth et al., 1980; is an important element in addressing the Burke, 1981; Hankey & Gubbay, 1988). This is the problem. This should be coupled with stretching, result of compression of the ulnar nerve at or anti-inflammatory drugs and padded gloves. In adjacent to Guyon’s canal or from traction mountain biking a front shock absorber does on the nerve secondary to wrist hyperextension much to resolve the vibration and trauma trans- (Eckman et al., 1975; Wilmarth & Nelson, 1988). mitted to the hands, different shocks having dif- The ulnar nerve in Guyon’s canal is more superfi- fering characteristics. Triggering that does not cial than the median nerve in the carpal tunnel, resolve with conservative management may making it potentially more prone to external benefit from steroid injection into the A1 pulley compression. The ulnar nerve as it enters the of the flexor sheath or surgical release of the A1 hand contains both sensory and motor fibres, pulley (Green, 1993). and in cyclist’s palsy both the superficial sensory Tendinitis may also occur from repetitive and deep motor branch are involved (Munnings, gripping and shifting, resulting in either de 1991). The symptoms of ulnar neuropathy in the Quervain’s tenosynovitis or crossover syndrome cyclist may be mild, with intermittent paraesthe- (Green, 1993). De Quervain’s tenosynovitis sias relieved by positional change, or severe, involves the extensors and abductors of the with significant neuropraxia lasting for several thumb in the first extensor compartment of the months after all pressure is relieved. wrist and may result from a long hilly ride Ulnar neuropathy is markedly influence by requiring frequent shifting, particularly early in bike fit. Compression and traction are both the season. Intersection syndrome is more often induced by increased weight-bearing through the result of twist-shifting, particularly if the the hands, especially with the wrists in a hyper- shifters are slippery or muddy. Stretching the extended position. The reach and drop to the involved tendons, along with anti-inflamma- bars should be evaluated, reach being shortened tory medication or injection, may be sufficient and drop being raised as necessary. Less than to resolve this. The competitive cyclist may one-third of the rider’s weight should be borne require a moulded orthoplast splint in order on the bars (Gardner, 1975). Padded cycling to allow continued racing and training. The gloves and handlebar padding are also tension in the shifters may also be altered to important. decrease the resistance; this may be an important Tenosynovitis and tendinitis about the hand factor in a woman with small hands or poor hand and wrist are problems that may be more inher- strength. 544 sport-specific injuries: prevention and treatment

increased rocking in the saddle in order to gain Saddle problems extension at the bottom of the pedal stroke, thus Although buttock and saddle problems are well increasing chafe. Additionally, a saddle that is documented in the cycling literature, most of this too far forward or backward does not support is empirical evidence rather than scientific the weight of the rider as it is meant to. Tilt is a research. Women’s issues are particularly poorly matter of personal preference; neutral to slightly addressed. Recently, saddles designed specifi- downward tilt is most commonly recommended cally for women have become more widely to decrease perineal and labial pressure. marketed. Whereas previously women’s saddles were essentially something wide, bulky and Knee heavily padded, they are now available in light- weight aero designs. These designs commonly Cycling kinematics reveals that the knee flexes have a slightly wider seat to accommodate the and internally rotates from bottom dead centre to increased distance between the ischial tuberosi- just past top dead centre, and then extends and ties while still tapering to a narrow nose. Fre- externally rotates until bottom dead centre. quently, cutouts are incorporated to decrease During gait, when the knee flexes and internally perineal and labial pressure. As to what factors rotates there is associated subtalar joint prona- are associated with seat symptoms there is very tion; when the knee extends and externally little in the medical literature. Weiss (1985) evalu- rotates there is subtalar joint supination. ated the relationship between seat symptoms However, in cycling the foot is fixed, preventing and seat height, seat tilt, handlebar height, rela- this compensatory subtalar joint motion and tive height of handlebars and seat, and seat con- referring it proximally, primarily to the knee struction in a group of recreational cyclists on a (Ericsson & Nisell, 1987; Ericson et al., 1988). week-long bike tour. The only significant asso- Although there is no impact in steady-state ciation was that riders who used a padded cycling, it is highly repetitious and thus any seat were more likely to experience buttock malalignment of the rider or cycle will be accen- problems. tuated over time. The knee was the second most Chafing of the skin of the medial thigh and commonly reported site of overuse injury/com- groin can be a painful problem. This is thought to plaint in recreational cyclists (Wilber et al., 1995). be more common in women, although again this It is easy to see how mechanically the knee is at is based on speculation (Weiss, 1994). The saddle risk for overuse injury in the cyclist; however, may very well be the culprit here, as a wider nose cycling is also one of the most widely prescribed with increased padding will result in increased forms of rehabilitation for the injured knee. chafe. An important element in preventing saddle sores, whether on the thigh, groin or but- patellofemoral pain tocks, is keeping the skin clean and dry. Padded cycling shorts with an absorbent lining help in Patellofemoral pain is not uncommon in cyclists wicking moisture away, as well as adding and can generally be traced to errors in training padding without increasing friction. It is very technique or bike fit. Patellofemoral disorders important that these shorts are cleaned and dried and valgus knee problems are quite common in between each ride. Additionally, after a strenu- women so this is an important issue (Zelisko ous race or training ride it is helpful to change et al., 1982; Ireland & Wall, 1990; National Col- into dry clean shorts as soon as possible, decreas- legiate Athletic Association, 1991). Training ing the risk of furunculitis. errors to look for are too many miles too fast, Saddle position may play a role in saddle sores addition of hill or interval work, pushing too big and chafe. A seat that is too high results in a gear (riding at a relatively low cadence with cycling 545

high pedal resistance) or standing to climb. iliotibial band syndrome Training errors must also be sought outside the cycling routine, such as extension weight train- ITB syndrome presents as sharp pain along the ing. Errors of bike fit include positioning the seat lateral aspect of the knee. The ITB is a thickening too low or too far forward; this increases knee of the fascia lata that commences at the level of flexion angle and increases strain. Pedal align- the greater trochanter, where three-quarters of ment and float are also important. A cleat that is the gluteus maximus and tensor fasciae latae are set toe-out increases valgus strain, while a pedal inserted into it. It passes down the posterolateral with no float locks the foot in and increases knee aspect of the thigh, crossing the lateral epi- strain (Ruby & Hull, 1993). condyle of the femur. With knee flexion the ITB Treatment must be aimed at altering the train- passes anterior to the lateral epicondyle and with ing or fitting error. This takes patience, particu- extension posterior to the lateral epicondyle larly in the competitive cyclist who is worried (Last, 1984). Thus with cycling the ITB can about losing fitness. Maintaining a high cadence become inflamed with repetitive friction across and avoiding hills, along with appropriate the lateral epicondyle. The pain of ITB syndrome adjustments to the bike, are the first steps. can begin quite suddenly, possibly during a ride, Stretching should be aimed at not only the making it very difficult for the rider to complete. quadriceps patellofemoral mechanism but also Evaluation should look for point tenderness at the iliotibial band (ITB) and hamstrings, as tight- the lateral epicondyle, along with pain with com- ness in these structures has been shown to be a pression of the ITB as the knee is flexed and significant factor in patellofemoral pain (Zappala extended. Tightness of the ITB is evaluated with et al., 1992). Ice massage is useful for patellar ten- Ober’s test (Magee, 1987). Increased pronation, dinitis and a short course of anti-inflammatory internal tibial rotation or varus alignment medication may be beneficial. Generally patellar increase tension in the ITB, as does limb length bracing or taping is poorly tolerated in cycling, discrepancy and a foot too far forward on the although a simple patellar strap may be benefi- pedal. It is important to check that the cleat posi- cial in patellar tendinitis. Cyclists with marked tion is not internally rotated and that saddle hyperpronation may benefit from orthotics, use height is not too high. Excessive hill work is a of a medial heel wedge or use of a medial washer common training error in the cyclist with ITB on the pedal. Cleat alignment should be checked. syndrome. Treatment is aimed at stretching Patellofemoral problems are best managed with (Ober’s stretch and lateral hip drop stretch), rehabilitation and very rarely require surgical training modifications and decreasing inflamma- intervention (Fulkerson, 1994). tion with ice and modalities. In extremely recalci- trant cases that fail to respond to prolonged quadriceps tendinitis conservative management, surgical intervention has been shown to have effective results (Noble, A less common but similar problem about the 1980). This is accomplished by resecting a knee is quadriceps tendinitis. This may occur at portion of the distal posterior fibres of the ITB the superior pole of the patella and be con- over the lateral femoral epicondyle (Martins fused with chondromalacia; more commonly in et al., 1989; Holmes et al., 1993). cyclists, it may present laterally and be confused with ITB syndrome. Inciting factors for qua- medial knee pain driceps tendinitis are the same as those for patellofemoral problems and thus diagnosis and Medial knee pain may be the result of several dif- treatment follow the same process. Ultrasound ferent problems. In mountain bikers, climbing, may be a useful adjunctive modality. particularly steep, loose or prolonged climbs, or 546 sport-specific injuries: prevention and treatment

grinding through loose sand may result in pes associated with long-distance rides. Fortun- anserinus bursitis or semimembranosus tendini- ately this is usually a self-limiting problem. tis/bursitis. The pes anserinus is the tendinous Paraesthesias most commonly arise secondary to insertion of the sartorius, gracilis and semitendi- pressure from straps, whether on shoes or clips nosus muscles on the anteromedial aspect of the (the cages some cyclists use for securing the foot proximal tibia. A bursa lies between the aponeu- to the pedal). Using clipless pedals relieves this rosis of these tendons and the medial collateral source of pressure and also allows a small ligament, about 5cm below the anteromedial amount of float (rotation about the cleat) that joint line. Pes anserinus bursitis and tendinitis allows the cyclist to alter position occasionally of the pes tendons are caused by overuse friction and relieve fatigue. Cleat position can be the or direct contusion (O’Donoghue, 1987). Semi- source of irritation and needs to be evaluated membranosus tendinitis presents as persistent both for rotational and fore–aft positioning. aching pain located on the posterior medial Cycling shoes are designed for rigidity in order aspect of the knee, just below the joint line (Ray to improve transfer of pressure to the pedal. A & Clancy, 1988). Semimembranosus tendinitis good cycling shoe is essentially the most com- occurs in the endurance athlete as a result of fortable shoe for that particular rider’s foot, gen- repetitive loading or overloading. Both of these erating no pressure points or sites of friction. injuries must be differentiated from the joint line There are no cycling shoes designed specifically pain of a meniscal tear; bursal swelling may help for women. in this differentiation (Henningan et al., 1994). A Achilles tendinitis, although far less common history of the sensation of locking or catching than in impact sports, may cause significant dis- must not be assumed to be meniscal, as semi- ability in the cyclist. This most commonly results membranosus tendinitis with an enlarged bursa from problems of bike fit or technique. A seat that may cause the sensation of catching, particularly is too low or a foot that is placed too far behind when the cyclist stands to climb. Both conditions the pedal spindle may produce ankling (exces- significantly inhibit hamstring power. Again, sive flexion extension at the ankle). Leg length both these tendon injuries are due to overuse discrepancies should also be sought, as many and inflammation, rather than the eccentric cyclists adapt by ankling on the short side. muscle–tendon junction injury that occurs in Ankling may also be simply an error of technique runners (Garrett, 1990). Treatment must first be and can be sought by watching the athlete ride. aimed at altering training. Hill work should be Treatment is aimed at correcting bike fit and tech- avoided and hamstring weight training dis- nique. The fit can even be modified temporarily continued. Stretching and modalities to fight by placing the foot a few millimetres forward inflammation are beneficial. The bursa may be of the pedal axis in order to decrease motion. aspirated and injected with a small amount of Conservative measures aimed at stretching, cortisone. If the bursal inflammation becomes decreasing inflammation and then strengthening chronic, surgical resection may be indicated (Ray aids return to sport. & Clancy, 1988). Rehabilitation Foot and ankle In rehabilitating the knee after injury or surgery, In cycling the foot functions mainly as a rigid the bicycle can be a very useful tool. This also platform through which force is applied to the seems to be a frequent entry point into the sport pedal (O’Brien, 1991). Foot and ankle problems of cycling for women. Many women have signifi- in cycling tend to be less debilitating than in cant disorders of the patellofemoral joint and impact sports. Foot paraesthesias are one of cycling for rehabilitation is commonly recom- the more common problems, particularly when mended (Hungerford & Lennox, 1983; Zappala et cycling 547

al., 1992). Cycling is a closed-chain exercise and Ashbaugh, S.J., Macknin, M.L. & VanderBrug M.S. allows neuromuscular development without sig- (1995) The Ohio bicycle injury study. Clinical Pedi- atrics 34, 256–260. nificant patellofemoral joint reaction forces. As a Asmussen, E. (1953) Positive and negative muscular closed-chain exercise, cycling is also commonly work. Acta Physiologica Scandinavica 28, 364–382. used for rehabilitation after anterior cruciate lig- Boning, D., Gonen, Y. & Massen, N. (1984) Relationship ament reconstruction. After injury or surgery the between work load, pedal frequency, and physical bicycle or ergometer can be used to work on fitness. International Journal of Sports Medicine 5, 92–97. range of motion and strength, as well as car- Brogger, J.T., Hvass, I. & Bugge, S. (1990) Injuries at the diovascular fitness. Cycling can frequently be BMX cycling European championship, 1989. British started before full weight-bearing. Approxi- Journal of Sports Medicine 24, 269–270. mately 100° of flexion is needed before a com- Burke, E.R. (1981) Ulnar neuropathy in bicyclists. plete crank cycle can be performed. Physician and Sportsmedicine 9, 53–56. Burke, E.R. (1994) Proper fit of the bicycle. Clinics in The electromyographic activity of various Sports Medicine 13, 1–14. muscles during cycling has been evaluated by Chan, K.M., Yuen, Y., Li, C.K., Chien, P. & Tsang, G. Mcleod and Blackburn (1980). Activity in the (1993) Sports causing most injuries in Hong Kong. quadriceps and gastrocnemius was well docu- British Journal of Sports Medicine 27, 263–267. mented, although, interestingly, under normal Coast, J.R., Cos, R.H. & Welch, H.G. (1986) Optimal pedalling rate in prolonged bouts of cycle ergometry. conditions the hamstrings were relatively inac- Medicine and Science in Sports and Exercise 18, 225–230. tive. With instruction, hamstring activity could Coyle, E.F., Fletner, M.E., Kautz, S.A. et al. (1991) Physi- be enhanced. In trained cyclists electromyo- ological and biomechanical factors associated with graphic recordings show significant hamstring elite endurance cycling performance. Medicine and activity during the crank stroke from 90 to 270° Science in Sports and Exercise 23, 93–107. Davis, M.W., Litman, T., Crenshaw, R.W. & Mueller, (Faria, 1992). Thus with training, cycling can be J.K. (1980) Bicycling injuries. Physician and Sports- used to build strength and endurance in multiple medicine 8, 88–96. muscle groups. Davis, R. & Hull, M. (1981) Measurement of pedal loading in bicycling. II. Analysis and results. Journal of Biomechanics 14, 857–872. Conclusion Eckman, P.B., Perlstein, G. & Altrocchi, P.H. (1975) Ulnar neuropathy in bicycle riders. Archives of Neu- Although cycling, particularly in professional rology 32, 130–131. circles, is still a male-dominated sport, women Ericson, M.O. & Nisell, R. (1986) Tibiofemoral joint are participating in increasing numbers. There is forces during ergometer cycling. American Journal of very little in the way of gender-specific informa- Sports Medicine 14, 285–290. Ericson, M.O. & Nisell, R. (1987) Patellofemoral joint tion regarding women in cycling. It seems sensi- forces during ergometer cycling. Physical Therapy 67, ble to suggest that traumatic injuries in cycling 1365–1371. will not be greatly influenced by gender. On the Ericson, M.O., Ekholm, J., Svensson, O. & Nisell, R. other hand, overuse injuries have great potential (1985) The forces of ankle joint structures during to be influenced by gender. Women may have ergometer cycling. Foot and Ankle 6, 135–142. Ericson, M.O., Nisell, R. & Nemeth, G. (1988) Joint more frequent problems with bike fit due to motions of the lower limb during ergometer cycling. gender-influenced guidelines. Another issue Journal of Orthopedic Sports Physical Therapy 9, may be differences in training techniques. This is 273–279. an area wide open for further investigation. Faria, I.E. (1992) Energy expenditure, aerodynamics and medical problems in cycling, an update. Sports Medicine 13, 43–63. References Faria, I.E., Sjogaard, G. & Bonde-Petersen, F. (1982) Oxygen cost during different pedalling speeds for Anderson, J.C. & Sockler, J.M. (1990) Effects of orthoses constant power outputs. Journal of Sports Medicine on selected physiologic parameters in cycling. and Physical Fitness 22, 295–299. Journal of the American Podiatric Medical Association 80, Fulkerson, J.P. (1994) Patellofemoral pain disorder: 161–166. 548 sport-specific injuries: prevention and treatment

evaluation and management. Journal of the American Kronisch, R.L., Chow, T.K., Simon, L.M. & Wong, P.F. Academy of Orthopedic Surgery 2, 124–132. (1996) Acute injuries in off road bicycle racing. Gardner, K.M. (1975) More on bicycle neuropathies. American Journal of Sports Medicine 24, 88–93. New England Journal of Medicine 292, 1245. Last, R.J. (1984) Anatomy, Regional and Applied, 7th edn. Garrett, W.E. (1990) Muscle strain injuries: clinical and Churchill Livingstone, London. basic aspects. Medicine and Science in Sports and Exer- Mclennan, J.G., Mclennan, J.C. & Ungersma, J. (1988) cise 22, 436–442. Accident prevention in competitive cycling. Ameri- Gerbesich, S.G., Parker, D. & Dudzik, M. (1994) can Journal of Sports Medicine 16, 266–268. Bicycle–motor vehicle collisions. Epidemiology of Mcleod, W.D. & Blackburn, T.A. (1980) Biomechanics of related injury incidence and consequences. Minne- knee rehabilitation with cycling. American Journal of sota Medicine 77, 27–31. Sports Medicine 8, 175–180. Gonzalez, H. & Hull, M.L. (1989) Multivariate Magee, D.J. (1987) Orthopedic Physical Assessment. W.B. optimization of cycling biomechanics. Journal of Bio- Saunders, Philadelphia. mechanics 22, 1151–1161. Mandroukas, K. (1990) Some effects of knee angle and Green, D.P. (1993) In D.P. Green (ed.) Operative Hand foot placement in bicycle ergometer. Journal of Sports Surgery, 3rd edn, pp. 1988–1998. Churchill Living- Medicine and Physical Fitness 30, 155–160. stone, New York. Martins, M., Librecht, P. & Burssens, A. (1989) A surgi- Hankey, G.J. & Gubbay, S.S. (1988) Compressive cal treatment of the iliotibial band friction syndrome. mononeuropathy of the deep palmar branch of the American Journal of Sports Medicine 17, 651–654. ulnar nerve in cyclists. Journal of Neurology, Neuro- Mellion, M.B. (1991) Common cycling injuries. Sports surgery and Psychiatry 51, 1588–1590. Medicine 11, 52–70. Heil, D.P.W., Ilcox, A.R. & Quinn, C.M. (1995) Car- Mellion, M.B., Fandel, C.M. & Wagner, W.F. (1988) diorespiratory responses to seat-tube angle variation Hydrocolloid dressings in the treatment of turf during steady-state cycling. Medicine and Science in burns and other athletic abrasions. Athletic Training Sports and Exercise 27, 730–735. 23, 341–346. Henningan, S.P., Schneck, C.D., Mesgarzadeh, M. Munnings, F. (1991) Cyclist’s palsy. Physician and & Clancy, M. (1994) The semimenbranosus–tibial Sportsmedicine 19, 113–119. collateral ligament bursa. Journal of Bone and Joint National Collegiate Athletic Association (1991) NCAA Surgery 76A, 1322–1327. Injury Surveillance System. NCAA, Overland Park, Hermans, M.H.E. (1991) Hydrocolloid dressing versus Kansas. tulle gauze in the treatment of abrasions in cyclists. National Off Road Biking Association (1996) Jeep Series International Journal of Sports Medicine 12, 581–584. Information. NORBA, Colorado Springs. Hice, G.A., Kendrick, A. & Weber, K. (1988) The effect of Noakes, T.D. (1995) Fatal cycling injuries. Sports Medi- foot orthoses on oxygen consumption while cycling. cine 20, 348–362. Journal of the American Podiatric Medical Association 75, Noble, C.A. (1980) Iliotibial band friction in runners. 513–521. American Journal of Sports Medicine 8, 232–234. Holmes, J.C., Pruitt, A.L. & Whalen, N.J. (1993) Iliotib- Nordeen- Snyder, K.S. (1977) The effect of bicycle seat ial band syndrome in cyclists. American Journal of height variation upon oxygen consumption and Sports Medicine 21, 419–424. lower limb kinematics. Medicine and Science in Sports Hull, M.L. & Gonzalez, H. (1988) Bivariate optimiza- 9, 113–117. tion of pedalling rate and crank arm length in Noth, J., Dietz, V. & Mauritz, K.H. (1980) Cyclist’s cycling. Journal of Biomechanics 21, 839–849. palsy: neurological and EMG study in 4 cases with Hungerford, D.S. & Lennox, D.W. (1983) Rehabilitation distal ulnar lesions. Journal of the Neurological Sciences of the knee in disorders of the patellofemoral joint: 47, 111–116. relevant biomechanics. Orthopedic Clinics of North O’Brien, T. (1991) Lower extremity cycling biome- America 14, 397–402. chanics: a review and theoretical discussion. Journal Inbar, O., Dotan, R., Trousil, T. & Dvir, Z. (1983) The of the American Podiatric Medical Association 81, effect of bicycle crank-length variation upon power 585–592. performance. Ergonomics 26, 1139–1146. O’Donoghue, D.H. (1987) Injuries of the knee. In D.H. Ireland, M.L. & Wall, C. (1990) Epidemiology and com- O’Donoghue (ed.) Treatment of Injuries to Athletes, 4th parison of knee injuries in elite male and female edn, pp. 470–471. W.B. Saunders, Philadelphia. United States basketball athletes. Medicine and Patterson, R.P. & Moreno, M.I. (1990) Bicycle pedalling Science in Sports and Exercise 22, 582. forces as a function of pedalling rate and power Kiburz, D., Jacobs, R. & Reckling, F. (1986) Bicycling output. Medicine and Science in Sports and Exercise 22, accidents and injuries among adult cyclists. American 512–516. Journal of Sports Medicine 14, 416–419. Pfeifer, R.P. (1994) Off road bicycle racing injuries: the cycling 549

NORBA pro/elite category. Clinics in Sports Medicine Incidence of bicycle related injuries in a defined 13, 207–218. population. American Journal of Public Health 80, Ray, J.M. & Clancy, W.G. (1988) Semimembranosus ten- 1388–1390. dinitis: an overlooked cause of medial knee pain. Thompson, D.C., Thompson, R.S., Rivara, F.P. & Wolf, American Journal of Sports Medicine 16, 347–351. M.E. (1990b) A case control study of the effectiveness Ruby, P. & Hull, M.L. (1993) Response of intersegmen- of bicycle safety helmets in preventing facial injury. tal knee loads to foot/pedal platform degrees of American Journal of Public Health 80, 1471–1474. freedom in cycling. Journal of Biomechanics 26, Tucci, J.J. & Barone, J.E. (1988) A study of urban bicy- 1327–1340. cling acccidents. American Journal of Sports Medicine Ruby, P., Hull, M.L., Kirby, K. & Jenkins, D.W. (1992) 16, 181–184. The effect of lower-limb anatomy on knee loads Weiss, B.D. (1985) Nontraumatic injuries in amateur during seated cycling. Journal of Biomechanics 25, long distance bicyclists. American Journal of Sports 1195–1207. Medicine 13, 187–191. Sacks, J.J., Homgren, P., Smith, S.M. & Sosin, D.M. Weiss, B.D. (1994) Clinical syndromes associated (1991) Bicycle-associated head injuries and deaths with bicycle seats. Clinicics in Sports Medicine 13, in the United States from 1984 to 1988: how many 175–186. are preventable? Journal of the American Medical Asso- Widrick, J.J., Freedson, P.S. & Hamill, J. (1991) Effect of ciation 266, 3016–3018. internal work on the calculation of optimal pedalling Seabury, J.J., Adams, W.C. & Ramey, M.R. (1977) Influ- rate. Medicine and Science in Sports and Exercise 24, ence of pedalling rate and power output on the 376–382. energy expenditure during bicycle ergometry. Wilber, C.A., Holland, G.J., Madison, R.E. & Loy, S.F. Ergonomics 20, 491–498. (1995) An epidemiological analysis of overuse Shennum, P.L. & deVries, H.A. (1976) The effect of injuries among recreational cyclists. International saddle height on oxygen consumption during Journal of Sports Medicine 16, 201–206. bicycle ergometer work. Medicine and Science in Wilmarth, M.A. & Nelson, S.G. (1988) Distal sensory Sports 8, 119–121. latencies of the ulnar nerve in long distance bicy- Spaite, D.W., Murphy, M., Criss, E.A., Valenzuela, T.D. clists. Journal of Orthopedic Sports Physical Therapy 9, & Meslin, H.W. (1991) A prospective analysis of 370–374. injury severity among helmeted and nonhelmeted Zappala, F.G., Taffel, C.B. & Scuderi, G.R. (1992) Reha- bicyclists involved in collisions with motor vehicles. bilitation of patellofemoral joint disorders. Orthope- Journal of Trauma 31, 1510–1516. dic Clinics of North America 23, 555–566. Swain, D.P. & Wilcox, J.P. (1992) Effect of cadence on Zelisko, J.A., Noble, H.B. & Porter, M.A. (1982) A com- economy of uphill cycling. Medicine and Science in parison of men’s and women’s professional basket- Sports and Exercise 24, 1123–1127. ball injuries. American Journal of Sports Medicine 10, Thompson, D.C., Thompson, R.S. & Rivara, F.P. (1990a) 297–299. Chapter 37

Tennis

CAROL L. OTIS

Introduction Tennis was an Olympic sport in the first revival of the modern games in Athens in 1896 and Tennis is one of the most popular and widely continued in the Olympics until 1924. Tennis played of all Olympic sports. An estimated returned as a demonstration sport in the 1968 40–50 million children and adults worldwide Olympics in Mexico City and in Los Angeles in play tennis each year on more than 1 million 1984, and has been a full Olympic sport since the tennis courts (B. Patterson, personal communica- 1988 Olympics in Seoul. tion, 1997). They play on different types of court Women first played Olympic tennis in the 1900 surface and at different levels of competition, Paris Olympics, where Charlotte Cooper of Great from the beginner hitting against a wall to pro- Britain defeated Helene Prevost of France in the fessionals competing before thousands of specta- final. Women played mixed doubles in 1900, 1906 tors for hundreds of thousands of dollars. In the and 1912. Women’s doubles were not played at USA, the Tennis Industry Association estimates the Olympics until 1920 in Antwerp. In the 1924 that 19.4 million people played tennis in 1996, Paris Olympics, 28 countries sent a total of 113 comprising 60% men and 40% women (Tennis tennis players, 82 men and 31 women (Collins & Industry Association, 1997). Approximately 1 Hollander, 1994). million players are aged over 50. Called ‘the Women have represented their countries sport for a lifetime’ by the United States Tennis in international tennis competitions. Hazel Association, tennis can be played and enjoyed by Hotchkiss Wightman, an American tennis people aged 6 to 96. champion, founded the Wightman Cup, a competition modelled on the men’s Davis History Cup. The first Wightman Cup competition was contested between American and British The game of tennis as we recognize it today was teams in 1923. It continued between these ‘invented’ in 1874 when an Englishman, Major two countries until 1989. In 1963, the Interna- Walter Clopton Wingfield, patented a set of tional Tennis Federation (ITF) approved an equipment and instructions for the game called international competition among women lawn tennis (Collins & Hollander, 1994). Lawn playing in teams representing their countries. tennis was first played on hourglass-shaped Modelled on the Davis Cup competition and croquet lawns. Grass was the first court surface called the Federation Cup (Fed Cup), the first and the most traditional one. James Dwight competition was played in London in 1963. brought tennis to the USA in 1876 and the It was won by the American team of Billie rectangular court outline was codified in 1882 Jean Moffitt, Darlene Hard and Carole Caldwell. (Yeomans, 1987; Collins & Hollander, 1994). Today the Fed Cup is played yearly by teams 550 tennis 551

of professional and amateur women represent- requires both anaerobic bursts of speed and ing their countries. intervals of submaximal effort during rallies. Tennis was traditionally an amateur sport but Women’s matches can last as long as 2–3 hours in 1968 the era of ‘open tennis’ and payment to with 90s between change-overs every two players began. In 1971, 12 women’s tournaments games. The physical demands of the sport were designated as ‘open’ to both amateurs and involve both the aerobic and anaerobic cardiores- professionals, with prize money going to the piratory systems and the entire kinetic chain of players who declared themselves as profession- the musculoskeletal system. Mastery of the game als (Collins & Hollander, 1994). The women’s requires a progression from learning stroke tech- professional tour was formed in 1970 by eight nique to achieving ball control and placement players, who included Billie Jean King, Rosie with consistency, depth and power. These skills Casals, Peaches Bartkowicz and Nancy Richey. are then used with court sense, concentration Dubbed the ‘Houston Eight’, they played for and mental toughness (Fig. 37.1). Movement on US$7500 in prize money at a tournament in the court is forward, back, diagonal and lateral. Houston, Texas (Collins & Hollander, 1994). In 1971, 14 tournaments sponsored by Virginia Training for the sport Slims were held, with total prize money of US$309000. That year, Billie Jean King won Professional and amateur tennis is played the US$117000, becoming the first woman athlete to entire year. Successful training involves a prepa- break the milestone of US$100000 a year in win- ration phase, followed by precompetition, com- nings. petition and transition (active rest) phases. Since tennis can be played all year, periodization of training cycles with a build-up to the competitive Physiological demands of the sport phase and a period of recovery and rest are Tennis has been called ‘a game of continual emer- important in minimizing burnout, overtraining gencies’ (Groppel & Roetert, 1992), featuring and injuries (Groppel & Roetert, 1992; Gould et long rallies interspersed with short bursts of al., 1996). Training should emphasize: (i) muscu- activity. Playing the game takes all of an individ- lar strength and endurance; (ii) cardiovascular ual’s skill, agility, strength, speed, coordination, training for both aerobic and anaerobic condi- endurance, flexibility and mental toughness. It tioning; and (iii) flexibility, i.e. full range of

Fig. 37.1 Mary Joe Fernandez (USA) in a doubles match, Atlanta 1996. (© Allsport / S. Dunn.) 552 sport-specific injuries: prevention and treatment

motion of the upper and lower extremities and trunk (Kibler et al., 1988; Chandler, 1995). Sport- specific strengthening for tennis emphasizes abdominal, low back, shoulder, trunk, wrist, scapular and forearm muscles (Groppel & Roetert, 1992).

Node Equipment

Racquet

The most significant changes in tennis equip- ment are the modifications in racquet design. The original racquets were made of laminated wood. Racquets have been made from aluminium, steel, graphite, ceramic, magnesium, titanium, com- posites, fibreglass and boron. The head size and shape have also varied. A larger head allows greater surface area for ball contact. In 1981, the ITF proclaimed formal rules regarding racquet size for competition play (Collins & Hollander, 1994). The frame of the racquet cannot exceed 81.28cm in length from the bottom of the handle Fig. 37.2 Oscillations of a tennis racquet with different to the top of the head. The width of the racquet ball impact locations. The location where the ball pro- head cannot exceed 31.75cm. The string surface duces the least vibration is called the node. (From Roetert et al., 1995 with permission.) must not be greater than 39.37cm in length and 29.21cm in width. Racquet weight varies from 280 to 448g with 14g for the strings (Maylack, 1988; Collins & Hollander, 1994). Racquets of ness of the racquet frame. The preferred racquet 280g are the modern design. These racquets are type for injury protection is a mid-size racquet of powerful and highly manoeuvrable because of graphite composition, which is lightweight and the lighter weight. Lightweight racquets can also has medium flexibility (Nirschl, 1995). Injuries cause less arm strain compared with heavier can often be traced to the use of a new racquet, racquets. improper grip size, an increase in racquet string Racquet type, string tension and location of tension or poor stroke technique. It is important ball impact on the string surface are some of the to choose the correct racquet grip size for the determinants of racquet frame vibration. The individual player. The common method to deter- location on the strings where ball impact causes mine size is to measure the ring finger along the the least vibration is the node (Brody, 1979; radial border from the proximal palmar crease to Roetert et al., 1995) (Fig. 37.2).Balls that impact the tip of the ring finger (Nirschl, 1988) (Fig. outside the node cause more sting and racquet 37.3). frame vibration. Vibration may be a factor in The racquet can be strung with a wide variety causing injury. Several factors influence the of string types. Traditionally strings were made transmission of vibration and force to the wrist of cow gut, but their expense and limited dura- and forearm: the distance of the impact from the bility have led to a market in synthetic strings. racquet node, the speed of the ball and racquet Good-quality synthetic strings, in thinner gauges velocity, the tightness of the strings and the stiff- for more responsive play and thicker gauges for tennis 553

15 and ITF rules, Collins & Hollander, 1994). Ball 14 speed at impact is 80–225km·h–1 (Maylack, 1988). 13 Worn balls require more stroke energy and 12 bounce lower and may be a factor in injury pro- 11 duction. This is the reason the professional 10 players use new balls every seven to nine games. 9 8 7 Courts 6 5 The original court surface was grass but there are 4 many other surfaces available now. Each type of 3 court surface predisposes to different types of 2 injuries (Lehman, 1988). Grass is fast and balls

1 have an irregular low bounce, favouring quick players with a serve-and-volley game. Players bend to reach balls, resulting in low back, gluteal and piriformis injuries. Agility training helps a player prepare for grass court play. Clay and indoor carpet courts are the most cushioned and are easier on the joints. Balls bounce higher on clay surfaces, giving the player more time to reach the ball and favouring backcourt players and long rallies. The longer rallies can lead to Fig. 37.3 Measurement of hand size to determine more thigh and forearm strains from overuse. proper grip handle size. A good technique is to Stretching routines are helpful. The newest measure the ring finger along the radial border from surface, Rebound Ace, is very fast and has a very the proximal palmar crease to the ring finger tip. (From Nirschl, 1988 with permission.) hard surface with a low amount of cushioning. Low back problems, sprains and ankle injuries are common. Dynamic trunk stabilization, practice play, are used by most players. They strength training and ankle taping can help should be strung at the racquet manufacturer’s players prevent injuries on this surface. Hard recommended range of tension. A high string courts that heat up result in a tacky surface that tension gives more control but increases the causes the foot to stick and results in more foot torque and vibration. When returning to play friction (blisters) and deceleration trauma. Hard after a lay-off for an upper extremity injury, surfaces transmit more force to the entire kinetic the player should have the racquet strung at chain and can be a factor in overload injuries and 1.35–2.25kg less pressure for the first few weeks. heel bruises. More protective and well-fitted cushioned shoes, foot powder and socks are important for hard-court players. Balls

Tennis balls have not undergone much modifica- Injuries tion, except for the change from white to yellow to aid visibility. Balls are made of hollow rubber ‘Tennis is a complex neurophysiological sport, spheres with felt covering. ITF rules specify involving the actions of running, catching, the amount of deformation and bound when hitting, and throwing in many body segments’ dropped 254cm. For play at altitudes above (Nirschl, 1995). Since tennis involves the entire 1219m, non-pressurized balls can be used (ATP body, many different injuries are seen in the 554 sport-specific injuries: prevention and treatment

sport, particularly those due to overuse or shoulder contributes 13% of total energy and overload. 21% of force (Kibler, 1995). The muscular activity of the shoulder is most effective in stabilizing the shoulder rather than generating a great deal of Types of injuries force. The shoulder therefore acts like a funnel to Injuries result from a combination of factors, transfer, direct and concentrate the energy from including imbalances in underlying muscle the legs and trunk into the upper extremity. If the strength, prior injuries, flexibility or inflexibility, shoulder is well balanced, the transfer of energy age, racquet, technique, surface and condition- is efficient. If there are imbalances in the shoul- ing. The biomechanical analysis of tennis is in its der, lowered efficiency and performance and infancy, although it is known that for effective clinical symptoms of injury may result. movement the body must be linked in the kinetic chain. Motions and forces of all body parts must Anatomical adaptations work together in order best to generate power and force. The kinetic chain in tennis starts with There are several adaptations found in tennis the ground reaction forces of the feet and legs, players caused by the demands of the sport on which are funnelled through the trunk and into the dominant side of the body to generate mus- the shoulder, elbow and hand, eventually reach- cular force at high speed. The characteristic ing the racquet for ball contact (Fig. 37.4). posture of élite and senior tennis players is a Researchers have determined the contribution drooping or depression of the dominant shoul- of each link in the kinetic chain to total energy der, with increased muscular girth of the domi- and force development by using the formulas for nant arm (Priest & Nagel, 1976). The depressed 1 2 kinetic energy (KE= /2mv ) and force (F=ma). shoulder may be due to stretching of the poste- Calculations on élite tennis players found that rior shoulder capsule and the shoulder-elevating 51% of total kinetic energy and 54% of total force muscles because of either repetitive overhead are developed in the leg–hip–trunk link. The motions or the increased weight of the dominant arm (Ellenbecker, 1995). Depression of the shoulder may produce or exacerbate rotator cuff impingement, tendinitis or thoracic outlet syn- Force dromes. Grip strength is greater in the dominant Wrist hand. Other differences in strength between the dominant and non-dominant arms of skilled Elbow tennis players are greater isokinetic strength of the dominant arm for internal rotation, extension Shoulder and flexion of the shoulder as well as for exten- sion and flexion of the wrist and pronation of the forearm (Ellenbecker, 1992). All these strengths Trunk and back are specific for actions relevant to tennis skills. Of particular interest are the consequences of increased strength of the dominant arm on pos- tural alignment and range of motion. In both Legs male and female tennis players, limitation of internal shoulder rotation by as much as 10° has been found in the dominant shoulder (Chinn Time et al., 1974; Kibler et al., 1988; Chandler et al., Fig. 37.4 The normal kinetic chain of a tennis serve. 1990; Ellenbecker, 1992, 1995) (Table 37.1). For (From Kibler, 1995 with permission.) standardization, shoulder range of motion is tennis 555

Table 37.1 Range of motion (in degrees) of internal and external shoulder rotation in 147 élite junior tennis players aged 11–15. (From Ellenbecker, 1995 with permission)

Dominant arm Non-dominant arm

Motion Mean SD Mean SD

External rotation Boys 94.6 26.0 95.9 21.3 Girls 104.9 10.0 103.5 10.1 Internal rotation Boys 54.5 23.6 65.4 16.8 Girls 53.6 11.2 62.7 9.8

Data generated with 90° of glenohumeral joint abduction with scapular stabilization.

Fig. 37.5 Measurement of the internal rotation of the glenohumeral joint, with stabilization of the scapulothoracic joint being accomplished with anterior support from the examiner’s hand; 90° of abduction was used during measurement. (Adapted from Ellenbecker, 1995.) assessed in the supine patient with the shoulder instability of the shoulder and is a contributing at 90° of abduction and the scapulothoracic joint factor for shoulder rotator cuff instabilities and stabilized by the examiner placing a hand over tendinitis. the anterior glenohumeral joint (Fig. 37.5). The decrease in internal rotation is attributed to pos- Specific injuries terior capsular tightness and is associated with increases in external rotation that may indicate Young players anterior and inferior capsular laxity. The changes in shoulder range of motion may be due to the Epidemiological studies in young athletes show repetitive demands of the tennis serve and the that injuries are sport specific and occur in overhead shot. The decrement in internal rota- different body structures compared with injured tion may predispose to anterior subluxation and adults (Cahill & Pearl, 1993). While bones are still 556 sport-specific injuries: prevention and treatment

growing during puberty, injuries occur around result of overload injuries is pain and dysfunc- the growth plate at the end of the long bones. tion, with reduction in strength, flexibility, joint Such injuries are well documented in young range of motion and function. Chandler et al. players in sports such as baseball, for example (1990) showed that junior tennis players had less Little Leaguer’s elbow. Pubertal tennis players flexibility in the shoulder, low back and ham- are also at risk for these problems (Kibler et al., string musculotendinous units compared with 1988). other junior athletes. These patterns of inflexibil- The other types of injury seen in adolescents ity in young tennis players result in abnormal are due to overload, cumulative injuries that mechanics during tennis strokes that can lead to result from overuse plus improper training and further injury, overload and imbalances. underlying anatomical malalignment. In a study of élite junior tennis players, 63% of all injuries Lateral epicondylitis were due to overload, 25% were strains and 12% were fractures (Kibler et al., 1988) (Table 37.2).The This painful, often chronic problem was recog- nized before tennis was popular. Although it is now called ‘tennis elbow’, previously it was named ‘housemaid’s elbow’ after one of sev- Table 37.2 Incidence of injury. (From Kibler et al., 1988 eral occupations with which it was connected. with permission) Lateral elbow pain is most common in recre- E´lite juniors (%) Recreational (%) ational players over the age of 3 years and accounts for as much as 50% of their chronic Overload 63 62 injuries (Nirschl, 1995). Medial epicondylitis is Sprains 25 22 less frequent, accounting for 10% of chronic Fractures 12 14 injuries. Lateral epicondylitis is associated with Other 2 the backhand stroke and medial epicondylitis

Lateral epicondyle

Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorum communis

Olecranon Extensor carpi ulnaris

Fig. 37.6 The lateral epicondyle serves as a site of attachment for the forearm and wrist muscles. In patients with lateral epicondylitis (tennis elbow), faulty backhand technique places a strain on the extensor carpi radialis brevis, the extensor digitorum communis, the extensor carpi radialis longus and the extensor carpi ulnaris muscles. Result- ing high forces on the extensor supinator origin may cause inflammation and pain. The ulnar nerve travels under the medial epicondyle and is covered by a retinaculum. It can be injured easily. In some patients, the nerve is poorly fixed and actually subluxes or dislocates out of its normal position within the groove. (From Shaffer & O’Mara, 1997 with permission.) tennis 557

with the forehand, serve or overhead. The cause nal rotators (Field & Alcheck, 1995; Nirschl, 1995; of lateral epicondylitis is postulated to be micro- Roetert et al., 1995). trauma to the tendon insertions of the wrist Proper stroke technique, with motion coupling extensors at their common origin on the lateral rotation of the trunk with shoulder and arm humeral epicondyle (Fig. 37.6). acceleration during the stroke, is important Repetitive microtrauma may be caused by in order to decrease overload to the forearm concentric muscle overload, overuse of forearm muscles. Unskilled players, who do not use the muscles and/or transmission of vibrations from entire body in stroke production, lead with their the racquet frame to the forearm muscles and elbow and use a one-handed backhand stroke, tendons (Roetert et al., 1995). Microtrauma at the are at most risk. These faults create more forearm origins of the extensors can lead to microtears torque, muscle overload and strain and, if the that heal through fibrosis and granulation tissue. ball is hit off-centre, more vibration. A two- The result is a mucinoid degeneration of the handed technique on the backhand reduces these tendons at their origin. Under pathological forces. The position of the ball at contact should inspection there is non-inflammatory, oedema- be in front of the player, giving effective energy tous, grey tissue with loss of the normal resilient transfer to the ball from the racquet speed gener- parallel fibres. The normal tendon fibres are ated by trunk rotation (Roetert et al., 1995; Sobel disrupted by fibroblastic invasion and vas- et al., 1995) (Fig. 37.7). cular overgrowth, referred to as angiofibroblastic The clinical symptoms of lateral epicondylitis hyperplasia (Nirschl, 1995). This condition has are morning stiffness and day-long aching pain been called a tendinosis instead of a tendinitis at the lateral elbow. Night pain or neck or shoul- because it is more of a degenerative process than der pain may reflect referred pain or an underly- a true inflammation. ing pathological process such as infection or Risk factors for the development of lateral tumour (Shaffer & O’Mara, 1997). Symptoms of epicondylitis include overuse, poor stroke locking, snapping or catching may be due to technique, improper equipment, age over 35, loose bodies or articular cartilage tears in the inadequate muscular and cardiovascular condi- elbow joint. On physical examination, pain is tioning, and postural defects such as thoracic reproduced by palpation distal and anterior to kyphosis and tight shoulder adductors and inter- the lateral epicondyle and with resisted wrist

(a) (b) (c)

Fig. 37.7 Stages of the backhand stroke. (a) Racquet preparation is followed by the acceleration stage (b); (c) the stroke is completed with follow-through. (From Field & Altchek, 1995 with permission.) 558 sport-specific injuries: prevention and treatment

extension. Pain may also be elicited by resisted extension of the middle finger when the elbow is extended. A complete evaluation to determine the specific cause of the injury is needed. Differ- ential diagnosis includes arthritis or osteochon- dritis dissecans of the radial capitellar joint, loose bodies, bursitis and radial nerve compression (radial tunnel syndrome). X-rays of the elbow, computed tomography for loose bodies and nerve conduction studies are used in the evalua- tion (Field & Alcheck, 1995; Shaffer & O’Mara, (a) 1997). Management includes rest, local application of ice for 10–20min two or three times a day and 1–3 weeks of oral anti-inflammatory medication to decrease the pain and any associated inflamma- tion. The forearm extensor muscles should be protected so that activities of daily living are pain-free. Sufferers can lift bags and briefcases with a palm-up motion. A counterforce brace applied below the elbow will constrain extensor muscles and thereby reduce muscle contractile (b) tension (Nirschl, 1988) (Fig. 37.8). The brace is Fig. 37.8 (a) Lateral counterforce elbow brace. Coun- used daily until symptoms produced by resisted terforce bracing is used to decrease pain and control wrist extension are lessened. Steroid injections abusive force overloads. Adequate design includes are used infrequently, as this injury is not felt to multiple tension straps and wide bracing for full be an inflammatory process. If used, there should patient control. Curved contours allow accurate fit to not be more than three injections in one year key areas in the conically shaped extremities. (b) Medial counterforce elbow brace. Medial protection (Field & Alcheck, 1995; Shaffer & O’Mara, 1997). adds extra support for the common flexor origin. (From Only 1–5% of cases of lateral epicondylitis are Nirschl, 1993 with permission.) resistant to conservative measures and require surgical intervention. Acupuncture has been used for centuries to treat this common overuse syndrome. Specific acupuncture sites are used for pain relief and three or more treatments may lization by a trained manual physical therapist be needed. When done by an experienced can be part of therapy. Therapists may use licenced practitioner using sterilized needles, modalities such as ultrasound, iontophoresis acupuncture can be well tolerated and con- and phonophoresis with or without topical sidered part of conservative treatment (Baldry, anti-inflammatory medications. Some clinicians 1993). advocate cross-fibre tissue massage to aid in Early in the course of management the patient healing; others feel that this aggressive massage should be referred to a physical therapist for worsens the pain and causes a synovitis (Sobel gentle passive, then active, range of motion et al., 1995). exercises in symptom-free range of motion. A When the athlete is pain-free, therapy is not common deficit is lack of mobility of the radio- completed. It is important to include strengthen- ulnar joint, especially in supination. This deficit ing exercises and a coordinated rehabilitative should be addressed and corrected. Joint mobi- exercise programme to build strength and tennis 559

endurance of the forearm muscles in all motions. Age eligibility in women’s The athlete must also review equipment and, if professional tennis necessary, learn proper stroke technique with the therapist or a coach (Ellenbecker, 1995). The ther- A new era for tennis began in the late 1970s when apist works to achieve reduction of tissue over- it became a sport played not only for enjoyment load and total arm rehabilitation, not only for the but also for financial gain. In 1972, Title IX legis- wrist and elbow but also for the shoulder and lation in the USA mandated equal access and scapular muscles. facilities for sport for boys and girls in federally funded programmes. With increased opportuni- ties came increased participation by girls and Prevention of tennis elbow injuries women in all sports, an improved image of ath- Reducing the known risk factors for elbow letic girls, and greater access to coaching, facili- injuries can reduce the probability of these ties and rehabilitation. In the world of tennis, this injuries. Emphasis on correct stroke technique new era of sport provided more opportunities for is essential in reducing risk of this and other not only participation but also the possibility overuse injuries. Proper stroke technique of a college scholarship, turning professional or requires coordination between trunk rotation making a living as a coach. The professional and movement of the entire arm and contact with world of sport provided the chance of prize the ball as the angular momentum of the body money, endorsements and fees for exhibition begins to move forward in a coordinated manner. play. As the stakes in tennis increased, so did the When these motions are properly coupled, the pressures. force of trunk rotation is transferred through the A new era of tennis training began to emerge, arm to the racquet. If uncoupled, the forces of with young girls starting early in life because of hitting the ball are not coordinated, resulting in the unproven notion that the earlier the training, excessive isolated arm motions and overload of the more likely the chance for success. Girls as the arm and shoulder muscles and soft tissues young as 8 or 10 years and their families (Field & Alcheck, 1995) A two-handed backhand uprooted their lives and moved to tennis acade- technique is protective. A forehand stroke hit late mies to train year round, while girls as young as with wrist snap also increases the risk of lateral 13 and 14 turned professional. Between the elbow injury (Roetert et al., 1995; Sobel et al., ages of 10 and 18, girls pass through two critical 1995). developmental phases, puberty and adolescence. The racquet should have correct grip size. Training for, and competing in, professional String tension can be lowered by 1.35–2.25kg tennis can interrupt and add stress to these and new balls should be used in order to mini- developmental phases. It is not uncommon for mize the added stroke energy required for hitting girls to spend up to 6 hours a day training and older, deader balls (Field & Alcheck, 1995). playing. This can lead to high levels of physical, Devices on the strings to reduce vibration have financial and psychological demands on the girls not been shown to be of any benefit. Mid-sized and their families, and can disrupt normal racquets with medium flexibility ratings are rec- patterns of schooling, socialization, pubertal ommended (Nirschl, 1988; Ellenbecker, 1995). A psychosocial development, and family life. It counterforce brace applied distal to the elbow is important to remember that for every player joint can help decrease elbow angular accelera- who ‘makes it’ on the tour, there are dozens if not tion and muscle activity (Nirschl, 1988). If the hundreds of others who do not achieve success. player has postural distortions such as kyphosis, In the late 1980s and early 1990s some of these these should be evaluated and addressed as part younger players had visible problems that of the therapy in correcting underlying risk received widespread publicity. Some young pro- factors. fessionals left the game before the age of 20 due 560 sport-specific injuries: prevention and treatment

to repetitive injuries and burnout. The media age of players was 22.8 years with a range of reported allegations of parental abuse and drug 16–37 years. There were only two players in the abuse among some of the youngest players. Indi- top 225 under the age of 16 (Otis et al., 1999). The viduals in tennis administration, coaching and average age of the top 20 international players sports science raised the alarm regarding the has been remarkably stable since 1980, ranging adverse effects of intensive early training on the from a low of 21.7 years (1990) to 24.45 years mental and physical health of young athletes (1981). Analysis of the top-ranked American (Cahill & Pearl, 1993; Gould et al., 1996; Skolnick, women from 1980 to 1992 found that the average 1996). age ranged from 22.2 to 23.3 years (Galenson, The first governing body to respond to these 1995). The belief that success comes at an early concerns and to change the rules was the age is derived from the prominence of a few Women’s Tennis Council. The Council is the gov- ‘phenoms’, players who achieve high rankings erning body of international professional tennis while young. Precocious talents have been and is composed of player representatives, identified and developed in many fields, from tournament representatives and leaders from the music to science to sport and entertainment. ITF and the WTA Tour (Women’s Tennis Asso- However, these individuals are the rare excep- ciation, the governing body of the professional tion. Contrary to the prevailing notion that to be tour). The WTA Tour sets the regulations for play successful in professional tennis one must and age of participation on the professional achieve success early, statistical analysis showed women’s tour. In 1992, girls could begin limited that success at an early age was rare: only 11 professional play at age 13 and play unrestricted women under the age of 17 have ever been at age 16. Spurred by the requests of the players, ranked in the top 20 (1981–93). Early success may in particular Pam Shriver, the president of the make a media star, but the price may be high. Players’ Advisory Board, the Women’s Tennis Analysis showed that the younger a girl started Council and the ITF formed an independent vol- playing professional tennis, the shorter her untary commission of seven experts in sports career. Of girls who turned professional before science and sports medicine to review the age eli- the age of 15, 19% left the tour before the age of 20 gibility rule in women’s professional tennis. The (n=26) compared with only 3% of girls who Age Eligibility Commission was charged with turned professional between the ages of 15 and not only reviewing the rule but also identifying 17 (n=262) (Otis et al., 1999) (Fig. 37.9). factors that would contribute to career longevity and enhance well-being and health on the women’s professional tour. 25 The Commission established a base of evi- 19% dence and information from diverse sources and 20 held a consensus conference in 1994 to review the 15 evidence and make recommendations. They reviewed the scientific literature and solicited 10 and received written and oral testimony from 5 3% everyone in the tennis community: agents, Number of players (%) sponsors, coaches, parents, spouses, athletes, 0 tournament directors, athletic trainers, media, Group 1 Group 2 physicians and manufacturers. They also obtained a detailed statistical analysis of the Fig. 37.9 Percentage of players leaving the WTA Tour before the age of 20 years. Group 1, players starting career longevity of the top 225 players on the aged 13–14 (n = 26); Group 2, players starting aged WTA Tour from 1981 to 1993 (Otis, 1994; Otis et 15–17 years (n = 262). (From Otis et al., 1999 with al., 1999). This review showed that the average permission.) tennis 561

Direct, coded oral and written testimony from In order to reduce the risks and pressures, the 91 different members of the tennis community Commission recommended not only changing was obtained by the Age Eligibility Commission the age of participation but also trying to amelio- about the appropriateness of the age rule in pro- rate the known stressors. The Commission also fessional tennis, the proper ‘dose’ of tennis for recommended that there should be no unre- young players, and the risks and stressors of pro- stricted play on the professional tour until age 18 fessional tennis. Of the respondents, 97% felt that (Table 37.3). Play is gradually phased in at age 14, the 1993 age eligibility rules were not appropri- with only five tournaments on the satellite ITF ate, while 88% felt that a ‘phased-in’ approach to circuit and no play on the WTA Tour above the playing professional tennis was appropriate, Tier III level until age 16. The Commission also with the majority favouring no unrestricted recognized the dangers associated with young play until 18 years of age. The stressors des- players becoming ‘revenue producers’, partici- cribed included the competitiveness of the tour, pating in unlimited exhibition matches staged by injuries, financial issues, pressure from agents, promoters and agents and receiving wild-card families and media, loneliness and isolation, entries into tournaments. Therefore, players travel and night matches. The players who gave aged between 14 and 17 are permitted to play in a testimony ranked the pressures from the media limited number of exhibition matches (Otis, and parents and families as their greatest stres- 1994; Worcester & Otis, 1995). These rules allow sors, followed by travel, competition, loneliness the gifted adolescent player to adjust to partici- and pressures from agents. pation in professional tennis and become Review of the literature and testimony from exposed gradually to the physical and psycho- sports scientists and physicians identified the logical demands of the professional tennis world. risks of early participation, including acute and To lessen the stressors, other rules were recom- chronic musculoskeletal imbalances and injuries, mended and adopted in a multifaceted pro- impaired social and educational development, gramme (Women’s Tennis Association, 1997). disruption of normal menstrual cyclicity, and The athlete is required to undergo annual acute and chronic psychological problems such detailed medical and musculoskeletal examina- as depression, anxiety, drug abuse, low self- tions and to meet the educational requirements esteem and burnout (Kibler et al., 1988; Otis, of her country of origin. Her coaches and agent 1994; Gould et al., 1996; Skolnick, 1996). These are required to register with the tour and to sign a problems are difficult to quantify as there is no code of conduct. Night matches are forbidden for literature about professional women players. players under age 18. To monitor these rules, the Moreover, these problems are often hidden, vary WTA Tour made some changes in its structure. A greatly among individuals and may not appear Player Development Program was created to until years after a woman finishes her career. track younger players and to monitor their wild-

Table 37.3 New age-eligibility rules 1995

WTA Tour ITF Tour Grand Slam Non-Tour Events under Age Total events events events events events prior rule

13 0 0 0 0 0 3 ITF 14 5 0 4 0 1 12 + championships 15 9 4 (tier III/IV) 8 0 1 17 + championships 16 14 10 + championships All 3 Unrestricted 17 18 13 + championships All 4 Unrestricted

ITF, International Tennis Federation; WTA, Women’s Tennis Association. 562 sport-specific injuries: prevention and treatment

card entries, educational requirements and Chinn, C.J., Priest, J.D. & Kent, B.E. (1974) Upper physical examination. In addition, the WTA Tour extremity range of motion, grip strength, and girth in highly skilled tennis players. Physical Therapy 54, adopted the Commission’s recommendation for 474–482. mandatory educational and orientation courses Collins, B. & Hollander, Z. (eds) (1994) Bud Collins’ for young players to learn about the tour and Modern Encyclopedia of Tennis, 2nd edn. Visible Ink about injury prevention, nutrition, periodization Press, Detroit. of training and coping with the media. A girl’s Ellenbecker, T.S. (1992) Shoulder internal and external rotation strength and range of motion of highly parents or guardian also are required to attend skilled junior tennis players. Isokinetics and Exercise courses. A mentor programme was adopted, Science 2, 1–8. where older or retired players are connected Ellenbecker, T.S. (1995) Rehabilitation of shoulder and to younger players as a source of advice and elbow injuries in tennis players. Clinics in Sports Med- support. The Commission also recommended icine 14, 87–108. Field, L.D. & Alcheck, D.W. (1995) Elbow injuries. increased safeguards for players on the road by Clinics in Sports Medicine 14, 59–78. recommending the presence of athletic trainers Galenson, D.W. (1995) Does youth rule? Trends in the at all levels of tournament play on the ITF satel- ages of American women tennis players, 1960–1992. lite circuit and additional trainers for the WTA Journal of Sport History 22, 46–59. Tour, with greater access to medical, psychologi- Gould, D., Tuffey, S., Udry, E. & Loehr, J. (1996) Burnout in competitive junior tennis players. Sport Psycholo- cal and career counselling services (Otis, 1994; gist 10, 322–340. Howard, 1995; Worcester & Otis, 1995; Otis et al., Groppel, J.L. & Roetert, E.P. (1992) Applied physiology 1999). of tennis. Sports Medicine 14, 260–268. The investigation of the problems and the Howard, R.R. (1995) Rule changes in women’s tennis adoption of these rules in 1994 was a trailblazing target medical issues. Physician and Sportsmedicine 23, 25–26. move by the Women’s Tennis Council and the Kibler, W.B. (1995) Biomechanical analysis of the shoul- chief executive officer of the WTA Tour, Anne der during tennis activities. Clinics in Sports Medicine Person Worcester, and the director of the ITF 14, 79–86. women’s division, Debbie Jevans. The problems Kibler, W.B., McQueen, C. & Uhl, T. (1988) Fitness eval- identified and their solutions are not unique to uation and fitness findings in competitive junior 7 tennis. Tennis has led the way and set the stan- tennis players. Clinics in Sports Medicine , 403–417. Lehman, R.D. (1988) Surface and equipment variables dard for sports governing bodies to recognize in tennis injuries. Clinics in Sports Medicine 7, and implement changes that will improve 229–232. the health, well-being and long-term success of Maylack, F.H. (1988) Epidemiology of tennis, squash players. It is hoped that the rest of the world will and racquetball injuries. Clinics in Sports Medicine 7, listen and follow suit. 233–243. Nirschl, R.P. (1988) Prevention and treatment of elbow and shoulder injuries in the tennis player. Clinics in References Sports Medicine 7, 289–308. Nirschl, R.P. (1993) Muscle and tendon trauma: tennis Baldry, P.E. (1993) Acupuncture, Trigger Points and Mus- elbow. In B.F. Morrey (ed.) The Elbow and Its Disorders, culoskeletal Pain. Churchill Livingstone, London. 2nd edn, pp. 63–85. W.B. Saunders, Philadelphia. Brody, H. (1979) Physics of the tennis racquet. American Nirschl, R.P. (1995) Tennis injuries. In E. Hershman & J. Journal of Physics 6, 482–487. Nicholas (eds) The Upper Extremity in Sports Medicine, Cahill, B.R. & Pearl, A.S. (eds) (1993) Intensive Participa- 2nd edn, pp. 789–803. Mosby, Philadelphia. tion in Children’s Sports. Human Kinetics Publishers, Otis, C.L. (1994) A review of the age eligibility commis- Champaign, Illinois. sion report. USTA Sport Science Newsletter Fall, 1–3. Chandler, T.J. (1995) Exercise training for tennis. Clinics Otis, C.L., Roetert, E.P., Loehr, J. et al. (1999) Age eligi- in Sports Medicine 14, 33–46. bility in women’s professional tennis. (Draft in Chandler, T.J., Kibler, W.B. & Uhl, T.L. (1990) Flexibility submission.) comparisons of junior elite tennis players to other Priest, J.D. & Nagel, D.A. (1976) Tennis shoulder. athletes. American Journal of Sports Medicine 18, American Journal of Sports Medicine 4, 28–42. 134–136. Roetert, E.P., Brody, H., Dillman, C.J., Groppel, J.L. & tennis 563

Schulties, J.M. (1995) The biomechanics of tennis Tennis Industry Association (1997) Participation Report. elbow: an integrated approach. Clinics in Sports Medi- Tennis Industry Association, 200 Castlewood Drive, cine 14, 47–57. N. Palm Beach, Florida 33408, USA. Shaffer, B. & O’Mara, J. (1997) Common elbow prob- Women’s Tennis Association (1997) The Official Corel lems. Journal of Musculoskeletal Medicine 14, 61–75. WTA Tour Rules. COREL WTA Tour Corporate Head- Skolnick, A.A. (1996) Health pros want new rules quarters, 1299 East Main Street, Fourth Floor, Stam- for girl athletes. Journal of the American Medical Associ- ford, Connecticut 06902-3546, USA. ation 275, 22–24. Worcester, A.P. & Otis, C.L. (1995) Explaining the Sobel, J., Pettrone, F.A. & Nirschl, R.P. (1995) Preven- wisdom of the ages. Tennis March, 24. tion and rehabilitation of racquet sport injuries. In E. Yeomans, P.H. (1987) Southern California Tennis Champi- Hershma & J. Nicholas (eds) The Upper Extremity in ons Centennial. Southern California Committee for Sports Medicine, 2nd edn, pp. 805–822. Mosby, the Olympic Games. Philadelphia. Chapter 38

Basketball

SUSAN W. RYAN

Introduction sional basketball for both men and women involves considerable physical exertion, which Women’s basketball has enjoyed a tremendous puts the athlete at greater risk for injuries. rise in popularity. In the USA, participation in Injuries are often defined as a traumatic or girls’ youth basketball has outnumbered all other chronic problem that requires diagnosis and sports for the first time, while in the last decade treatment from either the team physician or the attendance at women’s college basketball trainer. The time lost as a result of the injury has tripled. In fact, in the 1996 National Coll- further distinguishes the severity or complexity egiate Athletic Association (NCAA) Basket- of the problem. In 1982, the NCAA Injury Sur- ball Championships, the women’s final drew veillance System was created in order to gather more spectators than the men’s final and had data on collegiate athletic injuries. This has the highest television rating in the history of proved to be a current and reliable source of data women’s basketball. Women also have an oppor- that involves an enormous sampling pool. tunity to compete in professional leagues in the Trends can be identified that may prevent future USA and Europe (Fig. 38.1). injuries by modification of training regimens or A great deal of interest has been sparked in the equipment standards. field of sports medicine because of the increased During the 1991–92 NCAA women’s basket- participation in women’s basketball. As has often ball season, acute injuries accounted for 77% been the case in other sports, the female athlete’s of musculoskeletal complaints presenting to the psychological and physiological responses to attending medical staff. Nearly 60% of injuries participation in sport has been extrapolated from are noted to occur during practice (National Col- studies on male athletes. Books such as this serve legiate Athletic Association Injury Surveillance to identify the particular risks to women in their System, 1991–1992). It has often been noted that sports and hopefully will encourage the scholars despite the increased intensity of competition of science and sports medicine to carry out more time is spent in practice, which exposes an further research on the impact of female athlete to increased probability of injury. Accord- athleticism. ing to this same NCAA data, injuries due to contact with another athlete (36%) and those due Injury rates to non-contact (28%) do not differ greatly. The two most likely areas of the body to be injured Basketball injuries in men and women are gener- are the ankle and the knee, accounting for 45% of ally similar in their severity and frequency. There all basketball injuries in women. The guard posi- are a few exceptions, which are highlighted in tion in basketball is also noted to be at greater this chapter. In general, collegiate and profes- risk of injury than either the forward or centre 564 basketball 565

progressing through the calcaneofibular liga- ment to the posterior talofibular ligament. An immediate physical examination is valu- able in assessing swelling, tenderness and ability to bear weight. Stress testing of the ligaments can provide some information about their integrity. These tests are most valuable if carried out prior to the development of significant swelling and guarding. A positive anterior drawer test, per- formed with the foot in a neutral position and pulled forward against a secured tibia, reveals disruption of the anterior talofibular ligament. The talar tilt or inversion test assesses the stabil- ity of the lateral calcaneofibular ligament. Pain usually prevents active strength testing of the ankle at the time of injury. Guidelines for determining the need for radi- ographic testing exist. It is generally agreed that most ankle sprains do not require radiographic examination; however, if the physical examina- tion reveals bony tenderness over the distal 6cm of the tibia, fibula or the tarsals or metatarsals, radiographs are warranted. Radiographs are also necessary if pain with weight-bearing Fig. 38.1 A player for the Colorado Xplosion team persists despite an otherwise negative physical brings the ball downcourt in a game with the Seattle examination. Reign team. (Photo courtesy of Brian Lewis.) Standard protocols for the treatment of muscu- loskeletal injuries should be followed. Ice and early range of motion are critical components. position. A guard also is more likely to suffer Proprioceptive training is another key element in from lower extremity injuries, while the forward the treatment of ankle sprains and is crucial to and centre positions receive more upper extrem- prevention. Numerous studies have been carried ity and facial trauma injuries. out on various preventative programmes. Ankle taping is effective in restricting motion initially, although its value decreases rapidly with activ- Lower extremity injuries ity. Many standardized motion-controlled braces are more effective than taping and more econom- Ankle ical; they also reduce the rate of ankle injuries by The ankle is the joint most commonly injured in 50% (Ashton-Miller, 1996). High-top shoes and basketball as well as in many other sports. The strengthening of the peroneals have also been most common mechanism for ankle sprain is added to many basketball programmes with inversion on a plantar flexed foot (Ray et al., good success. 1991). This occurs with cutting manoeuvres, as Ankle sprains are so common that many are well as when an athlete lands on another player’s treated with little regard to some serious compli- foot. Depending upon the severity of the injury, cations that may develop or are overlooked the lateral ligaments are stretched or torn, begin- initially. The examination should include palpa- ning with the anterior talofibular ligament and tion of the peroneal ligaments as they course be- 566 sport-specific injuries: prevention and treatment

hind the lateral malleolus. The peroneal brevis rior tibial tendon of the medial ankle. It is often attaches to the base of the fifth metatarsal and missed initially but fortunately is not a signifi- occasionally to the cuboid as well. Tenderness cant cause of chronic dysfunction in the athlete. over the bony attachments warrants radiographs Large fragments that are symptomatic may need in order to rule out an avulsion fracture of the to be surgically excised. proximal end of the fifth metatarsal. Tearing or Os trigonum injuries are sustained in basket- stretching of the retinaculum can also cause sub- ball when a player steps on the foot of another, luxation of the peroneals as a late complication of causing a forceful plantar flexion of the foot. The ankle sprains. os trigonum is an accessory bone of the lateral High ankle sprains involve the syndesmosis tubercle of the talus and is found in about 10% of or interosseous membrane between the tibia the population. An acute fracture can cause pos- and fibula. Initial testing to determine this injury terior lateral ankle pain as well as pain with ankle includes direct palpation over the tissue, as well motion. The flexor hallucis longus tendon travels as dorsiflexing and externally rotating the foot to through this area. Hyperextension of the great stress this structure. Compression at the proxi- toe can reproduce this pain as the tendon is mal ends of the tibia and fibula can also elicit dragged across the fracture site. Treatment is dif- symptoms distally. Treatment with rigid, pneu- ficult as protection from weight-bearing for 4–6 matic compressive braces can aid significantly in weeks is often necessary. Occasionally, surgical returning the athlete to an active rehabilitation attention must be given to this problem. programme. These injuries can be quite problem- Calcaneal beak fractures occur through a atic in the recovery phase and can delay the similar mechanism to os trigonum fractures return to play by several weeks. Because of the except that the anterior structures of the foot are tremendous forces involved with this injury, under extreme tension. The bifurcate ligament tenderness along the proximal fibula should connects the anterior process of the calcaneus to be evaluated radiographically to rule out a the cuboid and navicular bones. Most commonly, Maisonneuve’s fracture. patients present with pain anterior to the lateral Late complications of ankle sprains include malleolus. Despite a good prognosis in the long capsular scarring, anterior impingement and term, convalescence is tediously slow for the occult talar dome injuries, including osteochon- athlete eager to return to play. Most often, a non- dritis dissecans and chondral defects. Late insta- weight-bearing cast is required for 4–6 weeks. bility of the ankle can be identified by stress Acute rupture of the Achilles tendon is usually radiographs but is still best treated by non-opera- seen in the older, recreational athlete unaccus- tive exercises that accentuate muscle strengthen- tomed to the explosive demands of a sport such ing and proprioception. as basketball. However, tendinopathies of this area are extremely common. Pain is fairly well localized to the distal tendon and, depending Foot upon the degree of fibrous degeneration and Injuries to the foot can present with symptoms inflammation of the peritendinous structures similar to those of an ankle sprain. In the acute and the tendon itself, palpation reveals a certain setting, it is important to consider injuries to the bogginess to the tissue. Recommended treat- hindfoot and midfoot in the assessment. ment includes an aggressive regimen to prevent Navicular fractures of the foot can be quite a further deterioration of the condition. This problem for an athlete. Avulsion fractures alone includes heel wedges and curtailing activities, account for more than 50% of injuries to this along with the usual approaches to reducing bone. The mechanism for these injuries is acute pain and inflammation. Ogilvie-Harris and eversion of the foot, which places tension on the Gilbart (1995) have found that ultrasound offers fibres of both the deltoid ligament and the poste- little advantage to ice and exercise for this and basketball 567

other tendinous injuries. However, many others ing of the plantar fascia and the Achilles tendon. still contend that ultrasound serves as a useful The first step in the morning can be excruciating adjunct to other therapeutic approaches. Even as these tissues are abruptly stretched. Splinting more controversial is the use of steroids in this in a neutral 90° of dorsiflexion or even an addi- area. While many feel comfortable with phono- tional 5 or 10° allows the inflamed tissue to heal phoresis as the delivery method, injections of in a functional position. Stretching and ice con- corticosteroid remain potentially risky. tinue to play an important role in the recovery. Insertional Achilles tendinitis is often seen In the forefoot, sesamoiditis is common. Acute as a distinct entity. It has been associated with fractures occur but can be difficult to distinguish Haglund’s disease or ‘pump bumps’. This is from bipartite sesamoids. A roughened, irregular where the bony prominence of the posterosupe- margin on plain films can help with this distinc- rior calcaneus can impinge upon the tendinous tion but bone scans are sometimes necessary. insertion, which causes a collection of debris and Steroid injections, rest and occasionally surgical fibrosis that may occasionally need surgical excisions may be necessary to improve the débridement. Inflammation of the retrocalcaneal symptomatology. bursa, located in this same area, can mimic this Hallux rigidus is a degenerative arthritic problem. response to repetitive trauma at the metatarsal Posterior tibial tendinitis can be caused by an joint of the great toe. It is a progressive problem acute injury or repetitive forces, causing pain that begins with extreme positions of dorsiflex- along the medial aspect of the midfoot and radi- ion at the joint, as is seen in basketball with ating along the length of the muscle more proxi- sudden starting and jumping. A synovitis occurs mally. Patients often present with pain with heel that later leads to dorsal lipping across the joint. raises and weakness with inversion of the foot. Pain and limitation of motion bring the athlete in Often seen with this condition is collapse of the for examination. Initial treatment is to provide a longitudinal arch, which then leads to abduction more rigid sole to decrease motion. Surgical of the forefoot and associated genu varum. treatment is often necessary at some point in the Viewing the foot from behind while stand- future. ing reveals the ‘too many toes sign’, which indicates progressive perisubluxation of the Lower leg talus. Complete disruption of this ligament is rare in younger athletes and most respond well Problems of the lower leg are seen in basket- to symptomatic treatment and the use of heel ball because of the unforgiving court surface cups or orthotics that limit heel valgus and and repetitive running and jumping (Fig. 38.2). support the longitudinal arch. Medial tibial stress syndrome is the term that has Heel pain from plantar fasciitis is another replaced ‘shin splints’, which was originally pro- common problem seen in basketball players. posed by Drez (Mubarak et al., 1982). It is thought Both a flat foot and a cavus foot predispose the to represent a condition of chronic overload of athlete to this problem but differ in their mecha- the posterior tibial tendon but can also include nisms. The cavus foot is subject to repetitive periostitis, fascial shearing of the muscle and stretching at its attachment to the calcaneal stress fractures of the tibia. The pain initially is tuberosity. In the flat foot, however, pronation felt with exertion but progresses to pain at rest. and valgus changes in the heel cause instability Some describe it as a sharp, lancinating pain, during the gait that strains the plantar fascia. Vis- while others perceive it as a dull ache. Diagnosis coelastic heel cushions help significantly and is often aided by radiological studies. Plain films night splints have recently become a popular and may show hypertrophy and periosteal thicken- effective treatment option. During sleep, the foot ing of the posterior cortex of the tibia secondary falls into an equinus position, allowing shorten- to remodelling due to repetitive stresses (Michael 568 sport-specific injuries: prevention and treatment

repetitive actions of basketball. Diagnosis of a stress fracture should alert the physician to the possible presence of the female athlete triad (see Part 6).

Knee

Injuries to the knee are second only to the ankle in frequency but account for more serious prob- lems (Sonzogni & Gross, 1993). Acute injuries commonly include ligamentous tears, meniscal contusions and tears, and patellar dislocations. In basketball, the most common mechanism of acute injury is rapid deceleration with a valgus and external rotatory force (Sonzogni & Gross, 1993). The diagnosis of anterior cruciate ligament (ACL) tears is relatively straightforward. The athlete often notes an audible pop and may expe- rience an acute effusion. On-site examination offers an invaluable chance to obtain a positive Lachman test, which is the most sensitive test for an ACL tear. There is considerable discussion in the medical community about the higher inci- Fig. 38.2 Repetitive jumping can lead to lower leg dence of ACL disruption in female athletes. This injuries. (Photo courtesy of Brian Lewis.) is particularly true in women’s basketball, where ACL injuries occur at three times the rate in men’s basketball (Arendt & Dick, 1995). Current & Holder, 1985). These authors also noted that consensus is that the cause is probably multifac- subperiosteal lucency and scalloping can be torial and includes some anatomical considera- seen on the tibia. Numerous studies have docu- tions, such as a smaller femoral condylar notch mented that the characteristic findings of triple- and a greater Q-angle. Others point to physiolog- phase radionuclide bone imaging distinguishes ical reasons, such as a relative imbalance of the medial tibial stress syndrome from a true stress hamstring complex to the quadriceps muscles fracture (Rupani et al., 1985). The syndrome and a weaker vastus medialis muscle. Proprio- shows increased activity along the posterior ception, which develops in early childhood play, border of about one-third of the tibia on delayed is undoubtedly an important factor. Oestrogen images. The radionuclide angiogram and blood receptors and the effect of circulating oestradiol pool images, phase 1 and 2, are always normal. is an area of recent discussion and contro- A stress fracture, on the other hand, shows a versy. Studies are continuing to investigate why focal, intense reaction with a typical fusiform women might be more at risk for ACL injuries appearance. and hopefully these will provide insight into In either injury, evaluation of the biomechanics ways that these injuries can be prevented. Treat- of the foot, ankle and knee is important. Close ment of an ACL tear includes early control of examination of the conditioning programme is pain, swelling and initiation of range of motion. necessary in order to correct factors that lead to This is followed by a rehabilitation programme muscle fatigue and failure due to the rhythmic that precedes the surgical repair. After surgery, basketball 569

an aggressive rehabilitation protocol should be with rest can help. Counterforce bracing of the designed by the team physicians and training patellar tendon may allow the athlete to continue staff. to play. Steroid injections should be avoided in Meniscal tears can occur with rotatory or com- this area because of the tremendous forces acting pressive forces in a hyperflexed knee. A small on this tendon (Kennedy & Willis, 1991). Rarely tear can be elusive but suggestive findings is surgical débridement necessary except in the include joint line tenderness and a positive most recalcitrant cases. McMurray’s or Apley’s grind test. With a large Patellofemoral pain plagues many female ath- tear, it is common to have an effusion as well as letes and basketball players appear even more limitation of joint motion. Plain films offer little susceptible to this problem. Many factors play a aid in this diagnosis and although magnetic role in the maltracking of the patella, including resonance imaging (MRI) is a valuable tool it femoral anteversion, increased genu valgus or is relatively expensive. Treatment is surgical varus deformities and excessive Q-angles. In the for large tears but small tears are followed lower leg, increased tibial torsion and pronation symptomatically. or supination of the foot can contribute to this Patellar dislocations are usually obvious to the condition. Physical examination can sometimes observer. The patella is found laterally and the reveal crepitation of the patella, facet pain or reti- athlete resists movement of the knee. Most nacular tenderness. Observation of patella alta or reduce spontaneously but, like subluxations of a lateral tilt is important. Standard radiographs the patella, require careful physical examination. contribute little to the diagnosis (Merchant et al., There is usually an effusion and tenderness 1974). Newer techniques such as kinematic along the medial retinaculum. The patellar facets MRI offer some insight into this abnormality may be tender and there is usually apprehension but come at a prohibitive price (Shellock et al., with lateral movement of the patella. Protected 1989). Treatment is directed at strengthening the range of motion while stabilizing the patella quadriceps within a pain-free arc. This is often allows the tissues to heal in a functional manner. carried out with the knee in extension from zero These injuries have a high rate of recurrence to 30° (Huberti & Hayes, 1984) in order to so rehabilitation is designed to strengthen the minimize the contact forces across the patello- quadriceps. Adjuncts such as McConnell taping femoral surfaces. Functional ‘closed-chain’ exer- and patellofemoral sleeves can help prevent cises are preferred along with McConnell taping patellar subluxation. (McConnell, 1986) until proper strength and Basketball exposes the joint to tremendous function are restored. Selective training of the repetitive microtrauma. ‘Jumper’s knee’, a vastus medialis obliquus using biofeedback is common ailment, is an example of an overuse another useful tool in the rehabilitation process injury to the knee. It includes a tendinitis any- (Wise et al., 1984). where along the quadriceps extensor mecha- nism, although many consider it limited to the Back injuries bone–tendon junction at the tibial tuberosity (Molnar & Fox, 1993). It is easy to see that the Serious back injuries are uncommon in rapid, eccentric forces of jumping and sprinting basketball players ( Jackson & Mannarino, 1984). associated with basketball are the cause of this During the 1991–92 basketball season, back com- condition. Highly specific training schedules plaints accounted for less than 7% of the muscu- using eccentric loads must be incorporated into loskeletal injuries noted that year by the NCAA the preseason as well as the rehabilitation condi- Injury Surveillance System. Some genetic predis- tioning programme. It is critical to intervene posing factors, such as spondylolysis, spon- early in order to prevent a chronic inflammatory dylolisthesis, spinal stenosis, scoliosis and leg condition. Aggressive use of modalities along length discrepancies, can contribute to back dys- 570 sport-specific injuries: prevention and treatment

function. However, the most common factor ments, a thorough examination must be carried is mechanical overload leading to structural out to reveal any avulsion that may interfere with fatigue (Jackson & Mannarino, 1984). When there future functioning of the extremity. Radiographs is a breakdown in form and mechanics due should be obtained to complete this examination to fatigue, injuries can occur. The majority of in cases where there is any suggestion of a back problems respond to the usual anti- fracture. inflammatory regimens. They can be prevented The proximal interphalangeal joint is the most from recurring by following a well-balanced commonly injured part of the hand (Wilson & strength and flexibility programme that includes McGinty, 1993). Injuries include collateral liga- pelvic and core stabilization. ment tears, volar plate disruptions and dorsal Defects in the pars interarticularis can cause capsule injuries involving the central extensor spondylolysis or spondylolisthesis. The pain slip. The evaluation of all these injuries includes may be unilateral and accentuated by hyperex- active range of motion, localized tenderness and tension and twisting. It is uncommon to see any deformity, along with plain films. Stress testing is neurological defects on examination (Jackson & carried out last to determine the degree of joint Mannarino, 1984). Radiographs usually clinch instability. All this information then determines the diagnosis but bone scans can help distinguish the treatment plan. Most of these injuries allow a relatively acute stress fracture from a chronic or for splinting and return to play. congenital defect. Low-grade spondylolisthesis Common complications of volar plate injuries with less than 50% slippage, as well as spondy- include the development of persistent flexion lolysis, usually respond to restriction of activity contractures called ‘boutonnière’ and ‘swan- and physiotherapy within a few months. Formal neck’ deformities (Wilson & Liechty, 1986). These lumbosacral bracing is selectively indicated and can be prevented by proper treatment initially should be considered on an individual basis. Pro- but may require correction by surgery later. They gression of symptoms or slippage warrants a sur- should be splinted in 30° of flexion for 2–3 gical opinion. weeks followed by ‘buddy-taping’ to the adja- cent finger. Mallet finger can result from a blow to the Upper extremity injuries distal tip with a sudden flexion force. It results in Basketball is a fast-paced sport that requires a closed avulsion of the terminal extensor tendon skilful hands. It predisposes the hand and fingers from the distal phalanx. Splinting the distal joint to acute trauma. Hand injuries that appear alone in full extension for 4–6weeks may prevent inconsequential initially may have devastating the extension lag that is characteristic of this long-term consequences. It is imperative that the injury. Similarly, avulsion of the flexor digitorum medical staff have familiarity with the anatomy profundus occurs on the opposing side of the and subtle nuances of hand injuries. phalanx and is frequently overlooked. Examin- ation reveals a lack of active flexion at this joint. This injury is equally responsive to appropriate Fingers splinting in flexion, unless the tendon had Injuries to the fingers include distal tuft fractures, retracted significantly. interphalangeal fractures, shaft fractures and metacarpal–phalangeal fractures. The integrity Hand and congruence of the articular surface must be maintained in order to minimize the potential Injuries to the hand are usually the result of falls. disabilities of phalangeal fractures. Because of Localization of pain and deformity guide the the extensive ligamentous and tendinous attach- examiner to order appropriate radiographs and basketball 571

treatment. Scaphoid fractures are the most noto- mucosal haematomas. This latter problem can rious of hand injuries to escape detection and cause necrosis of the surrounding tissue if have the most serious consequences (Culver & not evacuated. Protective masks are available, Anderson, 1992). The goal of treatment is to although most players opt to return to play establish anatomical alignment and prevent non- without them. Cosmetic repair can be carried out union. The prognosis is dependent upon the within a few weeks or at the completion of the degree of disruption to the vascular supply, season or the player’s career. which enters dorsally (Taleisnik, 1985). All patients with tenderness over this bone should Eyes be treated with a thumb spica cast until radi- ographs are negative at 2 weeks. The supporting An elbow to the eye poses a serious threat to ligaments of the scapholunate are also subject to both the globe of the eye and the surrounding disruption. Clenched fist radiographs along with bony orbit. Orbital fractures require a high standard views of the wrist usually demonstrate degree of suspicion because there is rarely this altered relationship (Wilson & McGinty, crepitance or a palpable depression of the ridge. 1993). Pinning is usually required to maintain the More commonly, there is significant pain and a stability of these bones. complete eye examination rules out entrap- ment of the muscles to the eye. Frequently, com- puted tomography is necessary to appreciate Facial trauma these fractures. Involvement of a subspecialist is Of the sports that do not use protective gear, few appropriate. pose such a risk of facial trauma as basketball. Direct injuries to the eyeball are common. Injuries to the head and face account for almost Most are the result of finger pokes that result in 10% of the injuries seen in a typical basketball minor corneal abrasions and blepharospasm. season (National Collegiate Athletic Association Observation of pupil size, reactivity and Injury Surveillance System, 1991–1992). There is extraocular movement, along with a fundoscopic increasing physical contact at the collegiate and examination, are necessary. The use of a topical professional level of competition and serious anaesthetic, such as 0.5% tetracaine hydrochlo- injuries can occur. ride solution, can relieve the pain and allow examination. Fluorescein staining demonstrates any corneal abrasions or foreign bodies. These Nose can be cared for with irrigation, removal of the Broken noses are relatively common in sports. offending irritant, instillation of antibiotic drops, An inadvertent elbow can not only fracture but cycloplegics and possibly an eye patch. It has also displace the nasal bones and cartilage. Epis- been common automatically to patch the eye but taxis is a common result and initial attention because of the rapid epithelialization of the must be given to controlling the bleeding, which cornea and the beneficial effects of tears, it may is aided by the use of intranasal tampons, direct not be necessary in all cases. pressure and ice. Topical vasoconstrictors in the An acute hyphaema or haematoma collection form of a nasal spray can be used with great within the anterior chamber is a serious but for- effectiveness. If initial attempts fail, a more tunately rare occurrence. With the athlete in a serious posterior bleed is possible that may seated position, blood will pool in the inferior require instrumentation and nasal packing. aspect of the chamber allowing visualization Examination must include evaluation of airway without specialized equipment. The athlete then obstruction due to displacement of the bones or needs to be transported in an upright position for cartilage as well as of the development of more extensive evaluation and observation. 572 sport-specific injuries: prevention and treatment

practical nor feasible for all athletes so reliance Teeth on a diligent history and physical examination is Dental trauma is seen on occasion and referral to necessary. a dentist is usually necessary. Initial manage- ment of the injury can determine the potential The adolescent athlete success of reparative work. Any loose teeth should be left in place and dislodged teeth In addition to the injuries that plague all basket- should be replaced or at least left in the mouth ball players, the adolescent player suffers some until seen by the dentist. unique injuries. As in adults, the rate of injuries is slightly greater for girls than boys (Chandy & Grana, 1985). During adolescence, not only Medical issues are there changes in emotional and psycho- Bleeding from any source needs to be taken logical development, there are also rapid seriously. Universal precautions mandate the use changes in body composition, muscular strength of protective gloves and eyewear. Prompt and conditioning. Young ‘roundball’ enthusiasts removal of the athlete with active bleeding may play in the driveway for hours. Younger minimizes the risk of exposure to other players. players may not have adequate coaching and Regulations require the removal of blood-soaked conditioning programmes to prevent some uniforms, although transmission of an infec- injuries. tion from this source has never been docu- As in the adult, the ankle is the most vulnera- mented. Control of the bleeding, whether ble joint followed by the knee (Micheli, 1986). via direct pressure or suture placement, is appro- Upper extremity injuries are quite infrequent. priate and dictated by the injury. Return to play is When evaluating adolescents for musculoskele- possible. tal injuries, special consideration must be given to the potential for growth plate injuries. Physeal injuries can mimic sprains so suspicion must be Sudden cardiac death maintained in any adolescent with pain over a The greatest medical threat in basketball is growth plate. Virtually all adolescent injuries sudden cardiac death. Although this is relatively that are serious enough for the child to miss play rare, it has gained increased attention because warrant radiography (Nicholas & Herschman, of some televised and publicized episodes, 1986). including the death of Hank Gathers in March Pain at the heel can include Achilles tendinitis, 1990. The cause of sudden death in athletes retrocalcaneal bursitis, calcaneal apophysitis or under the age of 35 is usually hypertrophic Sever’s disease, and stress fractures of the calca- cardiomyopathy. This accounts for about half neus. The symptoms may overlap and when the cases, the remaining being due to congenital radiographs are obtained may show fragmenta- anomalies of the coronary artery, ruptured tion and sclerosis, which is normal. Parental reas- aorta due to cystic medial necrosis associated surance is usually indicated as these injuries with Marfan’s syndrome, myocarditis and idio- respond nicely to rest, stretching, heel pads and pathic left ventricular hypertrophy (Maron et al., regular ice. 1986). Stress fractures are a particular concern Identifying athletes at risk is essential. The with adolescent athletes. They are vulnerable preparticipation examination is an opportunity because of the combination of training errors, to identify some of these athletes. Attention to a improper mechanics, equipment, training sur- family history of sudden death, as well as any faces and a rapidly changing body. The diagnosis history of collapse in the athlete, warrants and treatment are similar to the protocols used in further investigation. Echocardiography is not an adult. basketball 573

participation has led to an increasing awareness ACL tears of injuries in women’s basketball. Further inves- ACL tears in the young present a unique man- tigation into injury trends, prevention and treat- agement problem. Since the injury is sustained at ment is promising. an early age, there is more time for development of meniscal tears and arthritic damage to the References knee (Fetto & Marshall, 1980). These authors have also noted that within 5 years of ACL Arendt, E. & Dick, R. (1995) Knee injury patterns tears, 70% of these young athletes subsequently among men and women in collegiate basketball develop a meniscal tear. Drilling across the and soccer. NCAA data and review of literature. American Journal of Sports Medicine 23, 694–701. growth plate to reconstruct the ACL poses a chal- Ashton-Miller, J.A. (1996) What best protects the lenge to the orthopaedic surgeon. Some consider inverted weight-bearing ankle against further inver- a rehabilitation programme necessary, while sion? Evertor muscle strength compares favorably others deem it appropriate to perform the repair. with shoe height, athletic tape and three orthoses. This matter remains controversial and is best American Journal of Sports Medicine 24, 800–809. Bowers, K.D. Jr (1981) Patellar tendon avulsion as a managed on an individual basis. complication of Osgood–Schlatter’s disease. Ameri- can Journal of Sports Medicine 9, 356–359. Chandy, T.A. & Grana, W.A. (1985) Secondary school Anterior knee pain athletic injuries in boys and girls. A three year com- The differential diagnosis of ‘jumper’s knee’ in a parison. Physician and Sportsmedicine 13, 106–108. Culver, J.E. & Anderson, T.E. (1992) Fractures of the younger athlete must include two apophyseal hand and wrist in the athlete. Clinics in Sports Medi- injuries, Osgood–Schlatter disease and Sinding– cine 11, 101–128. Larsen syndrome. Both involve traction of the Fetto, J.F. & Marshall, J.L. (1980) The natural history patellar tendon on either the tibial tubercle or the and diagnosis of anterior cruciate ligament insuffi- inferior pole of the patella. Rapid growth and ciency. Clinical Orthopaedics 147, 29–38. Huberti, H. & Hayes, W. (1984) Patellofemoral contact relatively inflexible quadriceps contribute to this pressures. Journal of Bone and Joint Surgery 66A, problem. There is minimal risk of rupture of 715–721. either the tendon or its bony attachment (Bowers, Jackson, D.W. & Mannarino, F. (1984) Lumbar spine in 1981). This is well managed by ice, relative rest athletes. In W.N. Scott, B. Nisonson & J.A. Nicholas and stretching. (eds) Principles of Sports Medicine, pp. 130–147. Williams and Williams, Baltimore. Patellofemoral dysfunction is very problem- Kennedy, J.C. & Willis, R.B. (1976) The effects of local atic in adolescent girls. All the anatomical vari- steroid injections on tendons: a biochemical and ants previously noted are beginning to play a microscopic correlative study. American Journal of greater role. With the increasing demands of Sports Medicine 4, 11–21. sport participation, coupled with these physio- McConnell, J. (1986) The management of chondromala- cia patellae: a long term solution. Australian Journal of logical changes, it is common to see anterior knee Physiotherapy 33, 215–222. pain in young girls. Treatment is directed at bal- Maron, B.J., Epstein, S.E. & Roberts, W.C. (1986) Causes ancing strength and flexibility of the quadriceps of sudden death in competitive athletes. Journal of the mechanism in an attempt to ameliorate some of American College of Cardiology 7, 204–214. the causative factors. Merchant, A.C., Mercer, R.L., Jacobsen, R.H. & Cool, C.R. (1974) Roentgenographic analysis of patello- femoral congruence. Journal of Bone and Joint Surgery Conclusion 56A, 1391–1396. Michael, R.H. & Holder, L.E. (1985) The soleus syn- Basketball is increasing in popularity among drome. A cause of medial tibial stress. American women in the USA and greater opportunities Journal of Sports Medicine 13, 87–94. Micheli, L.J. (1986) Pediatric and adolescent sports exist for women to play this sport at both the col- injuries: recent trends. Exercise and Sport Sciences legiate and professional levels. This increasing Reviews 14, 359–373. 574 sport-specific injuries: prevention and treatment

Molnar, T.J. & Fox, J.M. (1993) Overuse injuries of the Rupani, H., Holder, L.E., Espinola, D.A. & Engin, S.I. knee in basketball. Clinics in Sports Medicine 12, (1985) Three-phase radionuclide bone imaging in 349–362. sports medicine. Radiology 156, 187–196. Mooney, V. & Robertson, J. (1976) The facet syndrome. Shellock, F.G., Mink, J.H. & Deutsch, A. (1989) Kine- Clinical Orthopaedics 115, 149–156. matic magnetic resonance imaging for evaluation of Mubarak, S.J., Gould, R.N., Lee, Y.F., Schmidt, D.A. & patellar tracking. Physician and Sportsmedicine 17, Hargens, A.R. (1982) The medial tibial stress syn- 99–106. drome. A cause of shin splints. American Journal of Sonzogni, J.J. & Gross, M.L. (1993) Assessment and Sports Medicine 10, 201–205. treatment of basketball injuries. Clinics in Sports National Collegiate Athletic Association Injury Surveil- Medicine 12, 221–237. lance System (1991–1992) Women’s Basketball. NCAA, Taleisnik, J. (1985) The Wrist. Churchill Livingstone, Overland Park, Kansas. New York. Nicholas, J.A. & Herschman, E.B. (1986) The Lower Wilson, R.L. & Liechty, B.W. (1986) Complications Extremity and Spine in Sports Medicine. Mosby, St following small joint injuries. Hand Clinics 2, 329– Louis. 348. Ogilvie-Harris, D.J. & Gilbart, M. (1995) Treatment Wilson, R.L. & McGinty, L.D. (1993) Common hand and modalities for soft tissue injuries of the ankle: a wrist injuries in basketball players. Clinics in Sports critical review. Clinical Journal of Sport Medicine 5, Medicine 12, 265–291. 175–186. Wise, H.H., Feibert, I.A. & Kates, J.L. (1984) EMG Ray, J.M., McCoomb, W. & Sternes, R.A. (1991) Basket- biofeedback as treatment for patellofemoral pain ball and volleyball. In B. Reider (ed.) Sports Medicine: syndrome. Journal of Orthopedic Sports Physical The School-aged Athlete, pp. 84–126. W.B. Saunders, Therapy 6, 95–114. Philadelphia. Chapter 39

Soccer

MARGOT PUTUKIAN

Introduction strengthening and conditioning, injury patterns and injury prevention is sparse. The sport Soccer is the world’s game: it is by far the most involves many specific activities that are very popular sport worldwide, with an estimated 200 different from other team sports, such as use of million participants internationally and 42 the head, chest, thigh and feet. In fact, it is one of million in the USA (Barkley, 1997). Most of the the rare sports where use of the upper extremities world knows it as ‘football’ but in the USA it has is limited. Information that pertains specifically been called ‘soccer’ to differentiate it from rugby to the female athlete is even more difficult to find. as well as other types of football, including This chapter presents the sport-specific medical American and Canadian football. The World problems and, as far as possible, relates them Cup draws the biggest global television audience specifically to the female soccer player. for a sporting event. In the USA, although the overall growth of participation in soccer has been Physiology remarkable, the increased involvement of girls and women is even more impressive. Women Soccer is a sport whose physical demands account for 22% of soccer players worldwide and require a mixture of endurance running as well close to 40% of soccer players in the USA (Brewer as discontinuous sprinting. In addition, due to & Davis, 1994). Soccer is a physically challenging the complex nature of the skills and tactics team sport that emphasizes intermittent high- involved, there is also an emphasis on quick intensity activity as well as endurance perfor- turns, pivots, jumps in the air, and both forward mance in combination with sport-specific skills. and backward running. All surfaces of the body Soccer is safely enjoyed by all age groups and can be used, with the exception of the arms and body types. Understanding the sport-specific hands, although these are used during throw-ins medical issues of this tremendous sport is useful as well as by the goalkeeper. The legs are used in taking care of soccer players and allowing most frequently, and many different surfaces of them to enjoy participation safely. the thigh and foot may be employed to control There are many challenges facing the sports the ball and maintain possession by passing it to medicine team taking care of female soccer ath- teammates. Most of the sport-specific activities letes and this chapter attempts to present some of that occur involve balancing on one leg while these issues as well as the sport itself, which in controlling or kicking the ball with the other. The many ways is poorly understood from a sports most effective players make use of both feet medicine perspective. Despite the extensive equally. history of soccer, information about the physiol- The demands of the women’s game are similar ogy and biomechanics of the game, nutrition, to those of the men’s game. In a study by B. 575 576 sport-specific injuries: prevention and treatment

Ekblom and P. Aginger (unpublished observa- foot as well as use of the head and potentially all tions) of élite Swedish players, women covered a surfaces of the body except the upper extremities similar total distance (8471m) compared with is unique. The variety of kicking styles along their male counterparts and sprinted an average with the surfaces presented by the foot, thigh and of 14.9±5.6m over 100 times per game. Blood chest to control the ball and pass it to teammates lactate measurements made at half-time and are complex skills that require continuous prac- after a game were 5.1±2.1 and 4.6±2.1mmol·l–1 tice to master. The majority of these techniques respectively. These measurements are slightly require placing one’s full weight on one leg while lower than those reported by Ekblom (1986) for controlling or striking the ball with the other. male players (range 8.0–12.0mmol·l–1). Average Understanding the biomechanics of basic soccer heart rates during three full-sided women’s techniques can help the healthcare provider games were roughly 175±11beats·min–1, 89–91% understand injury mechanisms as well as indi- of the mean peak heart rate (Ekblom, 1994). vidualize treatment programmes. · VO2max, or aerobic capacity, has been reported The inside of the foot is commonly used for to be between 47.1 and 57.6ml·kg–1·min–1 short passing and redirecting the ball with accu- (Rhodes & Mosher, 1992; Jensen & Larsson, racy. It provides a large surface that minimizes 1993), with the latter value improving from error but limits the velocity with which the ball 53.3ml·kg–1·min–1 during a 15-month training can be struck. The foot and hip are externally programme. Colquhoun and Chad (1992) rotated roughly 90° and the knee is slightly assessed anaerobic power in élite Australian flexed as the ball is struck (Fig. 39.1). The foot is soccer players and found that peak anaerobic maximally dorsiflexed to ‘lock’ the ankle, which power averaged 47.8±11.2W. These athletes creates a rigid surface and increases accuracy. were able to maintain 62.1% of peak power This skill can be associated with specific injury. If output at the end of the test. an athlete has a prominent tarsal navicular bone, ball contact in this area can create pain due to trauma. If the ball makes contact towards the Flexibility and strength toes, instead of properly at the space between the There are data to suggest that inflexibility of the medial malleolus and the tarsal navicular bone, it lower leg musculature is common in soccer can create an external rotation force at the foot players and that a programme of flexibility and and place a stretch on the medial structures, most prophylactic ankle taping can lead to a decrease notably the posterior tibialis tendon. In addition, in injuries over a season (Ekstrand & Gillquist, because of the external rotation that occurs at the 1982). While inflexibility may increase the risk of hip, there can be overuse of the adductor, sarto- lumbar spine problems as well as muscle rius and gracilis musculature. injuries, it may be protective for anterior cruciate The inside of the foot is also used for block ligament (ACL) injuries. In a prospective study tackles, when a player attempts to take the ball of female collegiate athletes, Knapik et al. (1991) away from an opponent with the ball on the demonstrated that flexibility and imbalances of ground. Often, both players strike the ball at the >15% in lower extremity strength were associ- same time, both using the inside of the foot. ated with a 2.6-fold increase in injury rate. These Proper technique is essential in order to avoid data emphasize the importance of proper flexi- injury. If performed properly, the player’s weight bility as well as strengthening as part of the con- is balanced over the tackling leg and the ball, pro- ditioning programme for soccer players. viding strength and support to the tackling leg. However, if the player extends the leg so that the body is leaning back, the weight of the leg is all Biomechanics that is behind the tackle and often the player not Soccer has many specific skills that make it dif- only loses the ball but also sustains an injury. ferent from most other sports. The reliance on the Poor tackling technique puts the medial aspect of soccer 577

(a) (b) (c)

Fig. 39.1 (a–c) Technique for controlling the ball with the inside of the foot, illustrating the position of the foot and knee. (Courtesy of Steven Manuel.)

the knee at risk for valgus stress, which can result degree of error in striking the ball accurately in injuries to the medial collateral ligament and is consequently larger. The foot is maximally pes anserinus. plantar flexed and again ‘locked’, an action that The outside of the foot can be used for short attempts to decrease the motion that occurs at the passing, a natural motion associated with ankle and provides an increase in the force trans- running, as well as for striking the ball to mitted. During the approach and ball-strike produce a curve or ‘bend’ to its flight that can phases of the instep kick, a varus torque of deceive a goalkeeper or defender. The foot is >200N·m and an extension torque of 280N·m is plantar flexed and inverted, with the ball striking generated on the proximal tibia; during the the junction between the lateral aspect of the follow-through phase, an extension torque of tibiotarsal junction and the cuboid (Fig. 39.2). A 230N·m is produced on the proximal tibia varying amount of spin is applied depending on (Gainor et al., 1978). Although a total of 2000N·m how the foot strikes the ball. When the foot is in can be generated during a kick, only 15% of this this position, it may be at risk for forceful inver- is transferred to the ball, the remainder being sion plantar flexion injuries, midfoot and fore- absorbed by eccentric contraction of the ham- foot ligament sprains and peroneal tendon string muscles (Gainor et al., 1978). Understand- problems. If the foot is ‘locked’ and ball contact ing the tremendous forces generated in kicking occurs correctly, injuries are less likely to occur. If explains the predominance of lower extremity the ball is struck incorrectly, the anterior tibialis injuries in soccer. and peroneal muscle groups can be stressed, and If the ball is on the ground, most players injuries to the metatarsal or tarsal bones can often approach it from an angle in order to result. In the young athlete, these mechanisms prevent the toe from striking the ground. If can lead to apophysitis or avulsion fractures at the ball is in the air, it is easier to strike the the base of the fifth metatarsal. ball straight on, although it is more difficult The instep kick is used for power, although to control. Injury mechanisms associated with there is less surface area for contact and the the instep kick are usually related to the ankle 578 sport-specific injuries: prevention and treatment

(a) (b) (c)

Fig. 39.2 (a–c) Technique for controlling the ball with the outside of the foot, illustrating the position of the foot and knee. (Courtesy of Steven Manuel.)

position of extreme plantar flexion. Injuries to the controlling the ball in soccer are similar to catch- tarsal navicular bone, other tarsal bones or ing a ball. If the surface is held out rigidly, the ball metatarsals can occur. Muscle overuse injuries will bounce away as opposed to being controlled. generally involve the anterior tibialis muscula- The specific skill of ball control in soccer is one of ture, although posterior impingement can also the most difficult tasks to learn and master. occur. This may be more likely in those athletes Any surface of the body except the arms can be with os trigonum or in individuals with posterior used to control the ball and pass it to teammates. tibialis tendonitis. This includes the chest, which is a difficult skill to All these surfaces used to strike the ball can teach the female athlete. Many are uncomfort- also be used to take the ball out of the air and able when first learning the ‘chest trap’, and inex- ‘control’ it. When the ball is in the air it must be perienced coaches may be reluctant to teach this controlled and prepared for whatever the player skill to their female players. The ball can be com- wants to do next. This often entails complex skill fortably controlled if it is taken on the sternum, and preparation by the player prior to receiving with relaxation of the upper torso as the ball the ball. A player often decides what to do with strikes. If the athlete is afraid to use this part of the ball before it arrives and then uses the first her body, she effectively excludes a large surface touch to prepare it for the next move. In control- area with which she can control the ball. The ling the ball, significant velocity may need to be chest can be used to direct the ball downwards absorbed, and these skills are difficult to perform towards the feet, forwards or to the side. Players well. The contact surface must be presented should be taught this skill early so that they early, and good balance and proprioception are realize it can be performed easily and safely. essential. Once initial contact occurs, the surface Probably the most difficult skill in soccer is is generally withdrawn such that the energy on heading. This complex activity is unique to the the ball is absorbed and its incoming direction game and one where proper technique is very and velocity controlled. The biomechanics of important. The ball is struck with the middle of soccer 579

the forehead where the skull is thickest. The are severe. Nutritional deficiencies, although action of heading has been compared to a cata- uncommon in individuals consuming a well- pult, where both the upper and lower parts of the balanced diet, are important to consider in ath- trunk are extended prior to striking the ball. The letes, especially if they complain of fatigue or head is brought back with the low back arched poor exercise tolerance. Iron deficiency is the and the chin tucked down by the chest. The eyes most common nutritional deficiency seen in the are open and the ball is struck with the head female athlete and can directly affect perfor- brought forward through the ball. Just before mance (see Chapter 21). contact the trunk flexors, hip flexors and knee Fluid ingestion during exercise serves two extensors contract strongly, creating the major major purposes: to provide an energy source to forces in heading. In skilled players, the muscles supplement the body’s limited stores and to of the neck become rigid at impact (Burslem & supply water and electrolytes to replace those Lees, 1987), which reduces the angular accelera- lost through sweating. Decisions regarding the tion of the head and decreases the risk of injury to optimal fluid intake depend on the intensity and the head and neck (Tysvaer, 1992). duration of exercise, the ambient temperature Technique is important, and improper execu- and humidity, and the individual characteristics tion may be related to headaches or other neuro- of the athlete (see Chapter 4). As there is tremen- logical symptoms. Players are taught not to strike dous individual variability in sweating rates, the ball on the top of the head or over the temple weight loss can be used to predict the amount of and also to keep their eyes open and strike sweat loss (1kg weight loss is equivalent to 1litre through the ball. They are also told to strike the sweat). It has been reported that during a 90-min ball instead of letting the ball strike them. Proper match, female soccer players had a fluid intake of technique can minimize injury and this is espe- 1.4 litres and a drop in body mass of 0.9kg, sug- cially important for the young soccer player. For gesting an overall decrease of 2.3kg. Studies younger players learning proper technique, the have demonstrated that exercise performance is use of a smaller, lighter ball is useful in avoiding impaired when as little as 2% of body weight is injury. In addition, some players are afraid to lost; when dehydration reaches 5%, work capac- head the ball and using a lighter ball to overcome ity can decrease by roughly 30% (Saltin & Costill, this apprehension is helpful for the beginner. 1988). Sortland et al. (1982) reported degenerative The most serious side-effect of dehydration changes in 40-year-old soccer players equivalent resulting from a failure to replace fluids during to those seen in 50–60-year-old non-players that exercise is impaired dissipation of heat, which were felt to be secondary to repetitive heading. can lead to heat exhaustion and heat illness (see Although there has been concern regarding head Chapter 4). The effects of heat stress on a youth injury as a result of chronic repetitive heading, soccer tournament in Minnesota were well illus- little substantive evidence for this exists. This trated by Elias et al. (1991). Modifications made topic is discussed in greater detail later in the as the tournament progressed, such as shortened chapter. playing periods, more water breaks and more player substitutions, decreased the number of heat-related illnesses. The wet-bulb globe tem- Fluid and nutrition perature (WBGT) index can be used to measure Because soccer is played for 90min, it is very the relative risk of heat injury. This measurement important to optimize fluid and nutrition so integrates absolute temperature, humidity and that energy stores and fluid balance can be solar radiant energy into a formula. If the WBGT maintained. This becomes even more important is >27.8°C (82°F), unnecessary activity should be if the athlete is playing numerous games over a curtailed. General recommendations for fluid short span of time or if the ambient conditions replacement and exercise have recently been 580 sport-specific injuries: prevention and treatment

updated by the American College of Sports Table 39.1 Soccer injuries per 1000 player hours in Medicine (1996). boys and girls The benefits of carbohydrate and fluid inges- Reference Girls Boys tion on performance in soccer have been exam- ined by several researchers and have been Ergstrom et al. (1991)* 12 5 reviewed recently (Kirkendall, 1993). Leatt and Nilsson & Roaas (1978) 32 14 Jacobs (1989) investigated the effect of glucose Maehlum et al. (1986) 17.6 8.9 polymer ingestion before and during a soccer Schmidt-Olsen et al. (1991) 17.6 7.4 Sullivan et al. (1980)* 1.1 0.5 match on muscle glycogen utilization. They per- formed a biopsy of the vastus lateralis muscle *Studies using time lost from practice/play as before and after the game and gave 10 players 0.5 definition of injury. litre of 7% glucose polymer solution 10min before the match and at half-time and compared the results with players given a placebo. They found an injury incidence of 7.4 and 17.6 per 1000 found that the change in muscle glycogen was player years for boys and girls respectively. Their significantly less in the experimental group com- definition included time-loss injuries as well as pared with the placebo group (111 vs. 181± those requiring ‘special bandaging or medical 24mmol·kg–1, P<0.001). This correlates to a attention’ in order for the player to continue to muscle glycogen concentration 31% higher in participate. In most of the studies that have those subjects given glucose polymer. Ekblom assessed both girls and boys, girls have almost (1986) showed that soccer players with the twice the injury rate (Table 39.1). lowest glycogen reserves at half-time had a There is good documentation of injuries slower average speed and covered less ground through the National Collegiate Athletic Asso- than other team members during the second half ciation (NCAA) Injury Surveillance System (ISS) of the game. in collegiate soccer in the USA. The ISS reports injuries from several NCAAinstitutions and uses a definition of injury as one that requires medical Injury statistics attention and results in time lost from practice or Overall, the incidence of injury in outdoor soccer play. The injury data collected by the ISS are rates is favourable, with one-fifth the number of expressed as the number of injuries per athlete injuries of American football (Pardon, 1977; exposure. In NCAA ISS data from 1986 to 1996, Pritchett, 1981). The injury data for indoor soccer the injury rates in women per 1000athlete expo- are less well known. sures were 17.8 and 6.0 for games and practices The injury rate for outdoor soccer is well respectively. This compares with the rates in men established, although the results have varied of 20.8 and 4.9 for games and practices respec- somewhat. In the Norway Cup (an outdoor tour- tively during the same time span. During this nament) in 1975 and 1977, the injury rates for period, the injuries seen in women’s soccer were boys and girls were 23.0 and 44.0 per 1000 player predominantly mild, with 72.9% resulting in hours respectively (Nilsson & Roaas, 1978). In time loss of less than 7days (vs. 74.9% in men). the same tournament in 1984, the injury rates for The ankle, upper leg and knee are the parts boys and girls were 8.9 and 17.6 per 1000 player injured most frequently. In the 1995–96 season, hours respectively (Maehlum et al., 1986). In ISS data reveal that the injury rates during games these studies, the definition of injury used was in men’s and women’s soccer are 20.2 and 17.3 any medical problem for which attention was per 1000 athlete exposures respectively. Simi- sought and thus included mild abrasions and larly, in 1995–96 the injury rates during practice blisters. Schmidt-Olsen et al. (1991) examined in men’s and women’s soccer are 4.8 and 5.8 per injuries in youth players over a 1-year span and 1000 athlete exposures respectively. These rates soccer 581

Table 39.2 Injury rates per 1000 athlete exposures in week and 1 month; severe injuries (18.4%) were practice and games. (Adapted from Dick, 1996) defined as more than 1 month of time lost. As the injuries increased in severity, they were more Sport Practice Games likely to have a non-contact mechanism. Amajor- American football 4.1 36.1 ity of the injuries occurred in the lower extrem- Wrestling 7.2 30.6 ities (71.4%). Women’s gymnastics 8.1 21.4 The upper leg, ankle and knee account for the Spring football 9.4 20.8 three main body parts injured for both men and Men’s soccer 4.8 20.2 Women’s soccer 5.8 17.3 women in the NCAA ISS data. Between 1986 and Ice hockey 2.3 16.9 1996, these three body parts comprised 49–58% Men’s gymnastics 4.7 15.7 of the men’s total injuries and 50–61% of the Men’s lacrosse 3.8 15.7 women’s total injuries. Therefore, it appears that Men’s basketball 4.6 10.1 indoor and outdoor soccer result in a similar Women’s basketball 4.4 9.4 Field hockey 4.2 9.4 pattern of injuries in both their location and Women’s lacrosse 3.5 7.2 severity. Because the indoor game is often played Baseball 2.2 6.2 on an artificial surface, there may be more abra- Women’s volleyball 4.6 5.2 sions and more injuries that relate specifically to Women’s softball 3.3 4.9 the surface than the game itself.

Specific musculoskeletal injuries for games and practice compare favourably with In the following sections, emphasis is placed on football, wrestling and women’s gymnastics and those injuries that occur most commonly in are slightly greater than the injury rates of other soccer. Some of these injuries are discussed in NCAA sports (Table 39.2). detail in Chapter 15 and therefore in these sec- Two recent studies have evaluated indoor tions more attention is given to specific rehabili- soccer injuries, assessing the rate of injury and tation or training issues than in discussing how including data for women as well as men. Lin- these injuries occur. denfeld et al. (1994) examined the injury rate over 7weeks of indoor league play and found injury Head rates of 5.04 and 5.03 per 100 player hours for men and women respectively. They defined In the NCAAdata for 1996–97, the injury rates for injury as any injury in which a player left the concussion in men’s and women’s soccer were game or requested medical attention, as well as 0.44 and 0.46 per 1000 athlete exposures respec- any injury that required stoppage of play. In a tively, accounting for 4.7% and 4.4% of the total study assessing injuries during a 3-day indoor injuries seen. Soccer is a sport where the head can tournament, Putukian et al. (1996) found that the be used to contact the ball and pass it to team- rates of injury were 5.79 and 4.74 per 100 player mates, clear it from the defensive area or strike it hours in men and women respectively. In this at goal (Fig. 39.3). Generally, the acute head study, the definition of injury was time lost from injuries seen in soccer occur from impact of the play. The difference between the incidence of head with another player, the ground or the goal- injury in men and women was not significant, posts. These mild injuries are often termed con- and there was no difference in the knee injuries cussions and are generally the head injuries that seen. In this study, 65.8% of the injuries seen were are reported. mild, where time lost from play or practice was The assessment of head injuries should always less than 1 week. Moderate injuries (15.8%) were include the possibility of cervical spine injury. defined as those where time lost was between 1 The most important and often most difficult part 582 sport-specific injuries: prevention and treatment

tomography (CT) should be obtained to assess for skull fracture or other focal bleeding after radiographs have precluded cervical spine abnormality. Neuropsychological testing may provide more sensitive assessment of cognitive function and may demonstrate deficits in function when other tests, such as magnetic resonance imaging (MRI), CT and electroen- cephalography, are ‘normal’ (Putukian et al., 1996). Head-injured athletes should be watched closely for complications such as postconcussive syndrome, seizures or repetitive trauma. Although there are several systems in the liter- ature that define classification and return to play, the one recommended by Kelly and Rosenburg (1997) is the one most often used (Table 39.3). No matter which classification system is utilized, it is more important that the physician and athletic trainer agree to embrace the same system and be consistent. It may also be more useful to use descriptive terms, e.g. loss of consciousness, retrograde and/or post-traumatic amnesia, in describing these injuries. There has been concern that cumulative encephalopathy, similar to the ‘punch-drunk’ Fig. 39.3 Liping Wang heading the ball in the 1996 syndrome in boxing (Jordan & Zimmerman, Olympics. (© Allsport / David Cannon.) 1990), can occur over time due to repetitive minor head impacts with the ball. One study of Norwegian professional soccer players found of assessing a head injury is detection. Many central cerebral atrophy on CT and that these head injuries occur without being obvious. A changes were more likely to be present if a player concussion is defined as an immediate and tran- was a ‘typical header’ (likely to head the ball) sient impairment of neurological function that (Sortland & Tysvaer, 1989). In another study, elec- occurs as a result of mechanical forces. The troencephalographic changes were seen in soccer athlete may be disoriented, may or may not lose players with acute or protracted complaints consciousness and may have impairment in secondary to heading, some of these changes memory both prior to the injury and after the persisting months or years (Tysvaer et al., event. They may complain of headache, nausea, 1989). These studies have been criticized because visual changes, dizziness or difficulty with of methodological problems, including lack of concentration. good control groups and lack of screening for If an athlete is unconscious it is essential that other problems such as alcohol use. A more care is taken to protect the cervical spine and that recent well-controlled study of national players more significant focal brain injuries such as sub- in the USA using MRI assessment found no sta- dural or epidural haematomas be considered. tistical differences between soccer players and These athletes should be transported to a hospi- track athletes (Jordan et al., 1996). This is an area tal for further testing and close observation. If where much more work is needed, especially as there is loss of consciousness, computerized it relates to the female athlete. soccer 583

Table 39.3 Guidelines for the management of concussion in sport. (From Kelly & Rosenburg, 1997)

Grade I: Transient confusion, no LOC, concussion symptoms or mental status abnormalities on exam resolve in <15 min Remove from contest Examine immediately and at 5-min intervals for development of mental status abnormalities or post-concussive symptoms at rest and with exertion May return if abnormalities/symptoms clear within 15 min Second grade I concussion in same contest eliminates player from contest, returning only if asymptomatic for 1 week at rest and exertion Grade II: Transient confusion, no LOC, concussion symptoms or mental status abnormalities last >15 min Remove from contest, no return that day Examine on site frequently for signs of evolving intracranial pathology Re-examine athlete following day Neurological exam by doctor 1 week after asymptomatic before return to sports CT or MRI where headache or other symptoms worsen or persist for >2 weeks Following second grade II concussion, return to play deferred until at least 2 weeks after athlete is symptom free at rest and with exertion Terminating season mandated by any abnormality on CT or MRI consistent with brain swelling, contusion or other intracranial pathology Grade III: Any LOC, either brief (seconds) or prolonged (minutes) Transport from field to hospital by ambulance if unconscious or worrisome signs; consider cervical spine immobilization Thorough neurological exam immediately, including appropriate neuroimaging procedures Admit if any signs of pathology or mental status abnormalities If normal evaluation, may send athlete home Neurological status should be assessed daily thereafter until all symptoms have stabilized or resolved Prolonged LOC, persistent mental status alterations, worsening symptoms or abnormalities on neurological exam requires urgent neurosurgical evaluation or transfer to trauma centre After brief (seconds) grade III concussion, athlete should be withheld from play until asymptomatic for 1 week at rest or with exertion After prolonged (minutes) grade III concussion, athlete should be withheld from play until asymptomatic for 2 weeks at rest and with exertion Following second grade III concussion athlete should be withheld from play for a minimum of 1 asymptomatic month; doctor may elect to extend that period beyond 1 month, depending on clinical evaluation and other circumstances CT or MRI recommended for athletes whose headache or other associated symptoms worsen or persist for >1 week Any abnormality on CT or MRI consistent with brain swelling, contusion or other intracranial pathology should result in termination of the season for that athlete and return to play in the future should be seriously discouraged in discussions with athlete

CT, computerized tomography; LOC, loss of consciousness; MRI, magnetic resonance imaging.

Neuropsychological assessment techniques 1996). They have also been used specifically in have been developed to quantify brain function- soccer players (Abreau & Echemendia, 1996, ing reliably by examining brain–behaviour rela- 1990; Tysvaer & Lochen, 1991). It is possible to use tionships. These techniques and instruments are neuropsychological tools to assess the effect of used to assess the broad range of function, from acute and chronic head injury on cognitive func- simple motor speed to complex problem-solving tion (Alves et al., 1987; Putukian & Echemendia, skills. The techniques have been shown to be 1996). Although currently there are no data to effective in detecting mild head injuries (Rimel et support the theory that heading itself is danger- al., 1981, 1982; Levin et al., 1987; McLatchie et al., ous, more research is needed to investigate both 1987; Tysvaer & Lochen, 1991; Porter & Fricker, the acute and chronic effects of heading in soccer. 584 sport-specific injuries: prevention and treatment

not well tolerated by athletes, can significantly Cervical spine diminish the dental injuries that occur and some Cervical spine injuries are not common in soccer. have advocated their use as an anticoncussive However, given the significant long-term effects device as well. of cervical spine injury, it is important to remem- ber that every head injury is a possible neck Upper extremity injury. Any athlete who complains of consider- able neck pain or stiffness should have radi- Most of these injuries occur in goalkeepers and ographs of the cervical spine. In Scotland, soccer other players falling on an outstretched hand or activity accounted for 6% of all paraplegic and directly on the shoulder. For the most part, they quadriplegic injuries. There have been case are treated as they would be in other athletes, the reports of cervical spine disc herniation (Tysvaer, exception being that it may be easier to return the 1985), cervical spine fracture, and subluxation. athlete to sport-specific activity. Examples of Scopetta and Vaccario (1978) reported a case of the most common injuries that occur in the upper central cord syndrome felt to be associated with a extremity include fractures of the clavicle, shoul- hand-sewn waterlogged ball and insufficient der separations (acromioclavicular joint), shoul- muscle preparation prior to heading. der dislocations (glenohumeral joint), ulnar Minor cervical spine injuries include strains collateral ligament injury (at the metacarpopha- and occasionally sprains. The mechanisms can langeal joint), fractures of the humerus, radial be similar to those in more severe injury or can be head and distal radius, and fractures to the due to a quick upper extremity motion including scaphoid, metacarpals and phalanges. Wrist and the neck. Occasionally, the head strikes another hand injuries are more commonly seen in goal- opponent or the ground and results in a cervical keepers, although the remainder of the injuries sprain or strain. These injuries are best evaluated can occur in any field player. These are covered in with radiographs if there is pain centrally, limita- greater detail in Chapter 15. tion of motion or neurological symptoms. If these symptoms occur acutely, they should be treated Lumbar spine as though they represent a fracture by placing the athlete in a cervical collar and removing her from The two most important entities to discuss are play until X-rays are obtained along with careful disc disease and spondylolysis. It is important to neurological assessment. Once routine radi- differentiate these more serious problems from ographs are obtained and are normal, flexion and the more common muscular strains that occur extension views may help in determining if an commonly in soccer. Annular tears of the inter- instability pattern is present. Further treatment vertebral disc, or degenerative disc disease, are will depend on the type and severity of injury not uncommon and should be considered in the sustained. soccer player who complains of back pain that is made worse with flexion, sneezing, coughing or laughing. The athlete should be questioned Maxillofacial/dental injuries about previous back pain, the presence of radiat- Maxillofacial/dental injuries account for ing symptoms and whether they experience roughly 5% of injuries seen and tend to occur numbness or tingling, weakness and/or any more commonly in goalkeepers. Generally, the difficulty with bowel or bladder function. On injury occurs as a result of contact with an op- physical examination, they often have central ponent, a goal-post or the ground. Significant intervertebral pain, pain with flexion and a posi- dental or ophthalmological injuries should be tive straight-leg test. Their neurological function treated expeditiously by referral to the appropri- should be fully tested. Plain radiographs may be ate specialist. The use of mouth-guards, although normal but occasionally reveal a narrow disc soccer 585

space or other changes consistent with degenera- It generally appears more with flexion-type tive disc disease. In addition, radiographs are activity although it can have a mixed aetiology. It important for assessing the presence of stress is helpful to look for inflexibility patterns, espe- fractures, tumour or infection. MRI is often cially in the hamstrings. Muscular back pain useful in assessing the presence of disc disease is common in soccer players, especially since as well as spinal stenosis and provides better many have significant hamstring inflexibility. demonstration of the soft-tissue structures of Treatment generally includes ice, modalities the spine. such as electrical stimulation to reduce pain and The other important aetiology of back pain in spasm, flexibility exercises and non-steroidal the soccer player is spondylolysis. This is anti-inflammatory medication. Once the acute common in the young athlete, and occurs in pain has subsided, these athletes generally soccer players because of the hyperextension that respond to a neutral spine stabilization pro- sometimes happens while kicking the ball. gramme along with abdominal strengthening. Spondylolysis generally occurs in extension-type Flexibility work is essential in preventing recur- activities and thus is seen in goalkeepers or rent injury. players who jump to head the ball. These athletes often have pain in the paralumbar region and Chest/thorax/abdomen increased pain when bending backwards, spe- cifically when performing one-legged extension. These injuries are uncommon; however, when a Radiographs are very helpful but only if the player jumps to head the ball or when a goal- symptoms have been present for a long time. keeper makes a save, this region of the body is Oblique radiographs will demonstrate a ‘scotty exposed and can be at risk for injury. Rib frac- dog’ with a ‘collar’ or ‘broken neck’, which repre- tures can occur and it is important to assess for sents the defect in the pars interarticularis intra-abdominal organ rupture and specifically defining spondylolysis. It appears that the pres- for spleen or kidney damage. The spleen can be ence of spina bifida increases the risk of spondy- enlarged due to infectious mononucleosis, in lolysis. If there is evidence for spondylolysis, which case it is at risk for rupture. Any evidence flexion and extension views are important in of intravascular compromise (athlete is dizzy, assessing for spondylolisthesis, where one verte- light-headed or becomes unresponsive) should bral body slides forward on to the other. This prompt emergency transportation to a medical implies bilateral spondylolysis. facility. Technetium bone scanning is very useful in There is often undue concern with injury to the detecting these stress fractures early; bone scan breasts as a result of ball contact. When the chest with single photon emission computerized trap is performed correctly, contact is made on tomography (SPECT) is the gold standard. In the upper portion of the sternum. The ball should addition, in the athlete who gives a long history not directly traumatize the breast tissue even if of back pain and presence of spondylolysis on an individual is large-breasted. Injury can occa- radiographs, bone scanning can help determine sionally occur if the ball strikes off-centre or if the if the injury is acute or chronic. Early detection is player is not expecting it and it is struck at close very important because the earlier treatment is range by an opponent. In this situation, the pain initiated, the more likely these injuries are to is generally self-limiting, and these injuries can heal. Treatment includes avoidance of extension be treated as other contusions or haematomas. activities, a neutral spine strengthening pro- Occasionally, nipple irritation occurs from gramme and, if detected early on, an antilordosis rubbing against the shirt or bra and is generally brace. alleviated by using Vaseline lubrication. Female Mechanical back pain secondary to muscle players should be taught proper chest control overuse is also very common in the soccer player. techniques early on so that they realize that this 586 sport-specific injuries: prevention and treatment

body surface can be used safely and without kicking and abduction-type activities can create discomfort. pain. On physical examination, both acute and The kidneys are also at risk when the athlete is overuse bursitis present with localized pain and struck from behind. It is helpful to perform a dip- tenderness over the greater trochanteric region stick on the urine; if blood is present, the athlete and occasionally swelling of the trochanteric should be sent to the hospital for further evalua- bursa. The deep bursa lies underneath the tion. If negative, close assessment with interval gluteus medius muscle, whereas the superficial monitoring of the urine for the presence of blood bursa generally is more easily palpable just over is useful. Intravenous pyelography is helpful for the greater trochanter. Treatment consists of detecting renal abnormalities, and CT is valuable ice, flexibility exercises, non-steroidal anti- for assessing intra-abdominal trauma to the inflammatory medication and corticosteroid spleen and other organs. injection if these measures fail. Paramount in treatment is an assessment for biomechanical or training errors that may be the cause. Groin

Groin pain is common in soccer players, Knee injuries although it tends to be one area where male players have more difficulty than female players ligament injuries for reasons that remain unclear. Common aeti- ologies of injury include osteitis pubis, hernias, Ligament injuries are of particular concern for muscle strains (adductor, abdominal, rectus the female soccer player and represent the most femoris, iliopsoas), stress fractures and fractures, common severe injuries. ACL injuries are often and nerve entrapments. Chronic groin pain, or due to a non-contact injury when the player is athletic pubalgia, is also referred to as Gilmore’s pivoting or landing and are common in the groin in the soccer player (Gilmore, 1993). In soccer player. These athletes often report a female players it is important to consider stress ‘popping’ sensation as their knee buckles, are fractures, especially if any of the features of unable to continue play and have swelling the female athlete triad are present that would within 1–2hours. As apparent from the NCAA put them at increased risk for femoral stress data on female and male soccer players, ACL fractures. tears represent the single most important injury in the female player and occur more often in women than in their male counterparts (see Greater trochanteric bursitis Chapter 15). Greater trochanteric bursitis is common in the It is important that those caring for the female female soccer player and can occur as a result of soccer player look for certain biomechanical direct trauma to the bursa or as a result of problems that may put the female athlete at par- overuse. It is not uncommon for a goalkeeper to ticular risk for ACL injuries. Although much experience acute traumatic bursitis from repeti- research is still being done in this area, it is tive landing on the lateral aspect of the hip. If reasonable to suggest that the soccer player the bursal swelling after an acute event is large, strengthens both the hamstring as well as the aspiration is occasionally warranted. Padding to quadriceps muscles, maintains good flexibility prevent recurrent injury is indicated, along with and preserves cardiovascular fitness to avoid ice and anti-inflammatory medication. Greater fatigue. It is also important that players practise trochanteric bursitis due to an overuse injury is sport-specific skills such as jumping and landing often seen in combination with tight iliotibial so that they become agile and can maintain their band (ITB) structures. Repetitive running, balance. Balance on one leg is particularly useful, soccer 587

especially when one considers the multitude of patellofemoral dysfunction soccer skills that require balancing, pivoting and jumping off one foot. It may be helpful for Patellofemoral dysfunction is extremely com- the soccer player to concentrate on landing from mon in the female athlete and the most common a jump with their knees flexed. All these areas cause of anterior knee pain. It is common in the need further research in order to elucidate the soccer player, and presents and is treated as in causative factors involved in ACL injuries in the other athletes (see Chapter 15). An important female athlete. point to make in terms of rehabilitation is that soccer activity is one of the few examples that meniscal injuries demonstrates the sport specificity of open-chain strengthening exercises. In general, therapists Meniscal injuries are common in soccer players, have moved away from the use of open-chain especially older players. The mechanism of acute exercises because they lack sport specificity. injury is no different from that in other sports, However, in the soccer player open-chain exer- although the rotational forces that occur when cises such as leg extension, short arcs and the ball is kicked can contribute to the occurrence straight leg exercises are sport specific. of this injury. This is particularly true when the ball is crossed into the centre of the field from patellar tendonitis the sideline so that the planted foot is facing the direction the ball will ultimately travel. Hence, Patellar tendonitis is very common in the soccer the planted foot may be at an angle of close to 90° player, generally due to repetitive kicking and from the direction the player may be running. jumping activity. These injuries can be frustrat- The athlete with a meniscal injury often presents ing and painful, but usually respond to treatment with a knee effusion, joint line tenderness, pain that includes ice, flexibility and modalities to in deep flexion and positive McMurray’s as well decrease swelling and inflammation. Occasion- as Apley’s tests. A useful screen is to ask the indi- ally it is helpful to have the athlete work on vidual to assume the squat position and then jumping off their other foot or kick with the other take a few steps. This test may be painful in an foot; in general, activity should be decreased acute injury and thus is better used in the prepar- somewhat. ticipation setting. These injuries are often very disabling espe- iliotibial band friction syndrome cially if there is an ACL injury. In a retrospective study of 77 soccer players with both anterior cru- ITB friction syndrome is common in soccer ciate and meniscal injuries, Neyret et al. (1993) players, especially females. ITB friction can occur found that 5years after a rim-preserving menis- in association with greater trochanteric bursitis cectomy individuals with an intact ACL were as well as patellofemoral dysfunction. Indi- more likely still to be playing soccer (75% vs. viduals often have inflexibility, especially of their 52%), more likely to be happy with their knees lateral leg structures, and an increased Q-angle. (97% vs. 74%) and less likely to have radi- The increased reliance on one-legged activities in ographic evidence of osteoarthritis (24% vs. soccer, as well as the direction of forces when the 77%). Because of the intense demands on the ball is kicked, make this injury a common and lower extremities in soccer, it is imperative that often very painful one. The athlete often initially aggressive rehabilitation occurs after such complains of sharp lateral knee pain during injuries. In addition, because players rely on running or kicking, which can sometimes be numerous one-legged movements for specific reproduced by repetitive resisted knee exten- activities, complete rehabilitation is essential. sions. There is pain in the mid-arc region of 588 sport-specific injuries: prevention and treatment

extension when the ITB courses over the lateral the soccer player, especially at the foot and femoral condyle. Eventually, the athlete may ankle since these structures are integral to complain of aching or radiating lateral thigh participation. pain. Other problems to consider in the differen- tial diagnosis of lateral knee pain include lateral Posterior/anterior tibialis tendonitis meniscus injuries, defects in the trochlear groove articular surface, osteochondral defects and These injuries are commonly due to overuse, lateral collateral ligament insufficiency. It is also although they can result from an acute injury. In important to remember that disc disease of the general, they are easy to detect and treat if atten- lumbar spine can present with radiating lower tion is paid to the normal anatomy of the foot and leg pain or aching. These other disorders can ankle. The anterior tibialis tendon is stretched usually be differentiated by history and physical during the instep kick and the kick with the examination. outside of the foot and flexed during the pass ITB friction syndrome appears frequently in with the inside of the foot. The anterior tibialis association with patellofemoral dysfunction, muscle can be stressed during all these activities. patellar tendonitis and pronation. It is important Similarly, the posterior tibialis tendon can be to assess the biomechanics of the foot and ankle stressed directly or indirectly during passing in addressing these injuries so that they do not and kicking; it can also routinely suffer overuse recur. It is also important to assess for leg length injury due to running activity. Pain is often discrepancies, which can also be a cause of these elicited over these structures and can occasion- injuries. Leg length can be assessed clinically by ally be associated with tenosynovitis as well. measuring from the medial malleolus to the ante- Pain is elicited with resisted motion of the rior superior iliac spine on both sides, although affected tendon. Treatment is geared at provid- often a standing radiograph of the pelvis that ing relative rest, ice, flexibility, taping, anti- includes both femoral heads and iliac crests can inflammatory medication and, most importantly, be used accurately to assess as well as quantify identification of risk factors. the leg length discrepancy. Leg length discrepan- cies should be corrected by instituting a heel lift Ankle sprains in the shoe on the shorter leg. Often only a partial correction is necessary (i.e. if the right leg is 1.4 Ankle sprains account for the majority of injuries cm short, a 7-mm heel lift should be placed in the in soccer; fortunately, they tend to be mild right shoe). Orthotics are occasionally necessary injuries with little time lost from practice or play. to correct for rearfoot and forefoot abnormalities They generally occur secondary to a plantar and can also incorporate a heel lift if a concurrent flexion/inversion mechanism. The kick with the leg length discrepancy exists. outside of the foot can also be a common preced- ing activity. These injuries are no different in soccer than in other sports, but may be very Medial tibial stress syndrome debilitating if not addressed aggressively with Medial tibial stress syndrome is common in early treatment and rehabilitation. Because soccer players, particularly at the beginning of a soccer players rely heavily on their mobility and new season. This is especially true of indoor ‘touch’ on the ball, it may be more difficult to soccer players as their participation intensifies return them to complete functional activity. and also when they move on to artificial turf. The athlete generally presents with localized Medial tibial stress syndrome represents an pain and swelling over the lateral ankle liga- overuse injury that can be a precursor to peri- ments. The ligaments involved include the ostitis as well as stress fracture. It is important anterior talofibular ligament, calcaneofibular lig- to identify risk factors for overuse injuries in ament and posterior talofibular ligament later- soccer 589

ally, and the deltoid ligament medially, along Although ankle sprains occur frequently and are with the distal tibiofibular syndesmosis centrally. generally minor, it is important to address them Usually, the anterior talofibular ligament is the early and emphasize rehabilitation. In addition, most commonly involved, followed by the calca- if significant ankle laxity is detected during the neofibular and posterior talofibular ligaments. preparticipation physical examination, a streng- Close assessment for associated injuries, such as thening and proprioceptive programme should those of the midfoot or forefoot, or fractures be initiated and consideration given to prophy- should be performed. In addition, if the injury lactic taping or bracing. involves the syndesmosis (tenderness over the There is a subgroup of ankle sprains that go on distal anterior tibiofibular ligament, positive to develop ankle impingement syndromes. tibiofibular compression test, pain with passive Impingement syndromes should be considered external rotation of the foot), it can be more diffi- in the setting of anterolateral pain, the absence of cult to treat. Assessment for injuries to the base of instability and history of prior ankle sprains. the fifth metatarsal or peroneal tendons should Athletes often complain of pain while trying to also be carried out and a high index of suspicion pivot or push off from one foot, as well as diffi- for osteochondral lesions or occult fractures culty and pain while kicking the ball with the maintained if the athlete does not respond ap- instep. Impingement syndrome occurs as a result propriately to conservative management. of hypertrophic scar formation, synovium, and Radiographs should be obtained if the individ- fibrocartilage in the anterolateral tibiotalar space ual cannot bear weight or there is tenderness extending from the anterior capsule posteriorly along the posterior medial malleolus or pos- into the lateral gutter. In soccer players McCar- terior lateral malleolus, at the base of the fifth roll et al. (1987) have described these as ‘menis- metatarsal or over the navicular tuberosity. Stan- coid’ lesions after inversion ankle sprains. Stress dard radiographs should include anteroposte- radiographs generally do not reveal significant rior, mortise and lateral views of the ankle ligamentous laxity, although anterior spurring of and anteroposterior view of the foot. Bilateral the tibia may be present and increase the soft- weight-bearing mortise views can help in detect- tissue impingement. ing significant syndesmotic injuries. It is also Knapp and Mandelbaum (1996) have recom- important to consider repeating X-rays or other mended a classification of ankle impingement diagnostic tests if swelling and inability to bear syndrome that describes four grades: (i) normal weight persist despite initially negative evidence radiographs, anterolateral capsular thickening of occult fractures. seen on MRI and verified arthroscopically; Ankle injuries should be treated aggressively (ii) extra-articular or intra-articular osteophytes with a compression dressing, anti-inflammatory with articular surfaces entirely normal; (iii) bony medication, ice and elevation. Crutches should abnormalities involving articular surface (osteo- be used if weight-bearing is painful or normal chondritis dissecans); and (iv) previous intra- gait is altered. Occasionally with significant articular fracture. If aggressive physical therapy injury, immobilization for a short period of time and rehabilitation does not provide resolution may be helpful. Weight-bearing is allowed as of impingement problems, these lesions often tolerated. Range of motion exercise, isometric respond well to arthroscopic débridement. strengthening, proprioceptive work and modali- An impingement syndrome can also occur ties to decrease swelling should be initiated at the posteriorly, especially if an os trigonum is pre- first opportunity. Progressive resistance exercise sent. Other problems to consider in the posterior is initiated as tolerated, with return to sport- ankle include Achilles tendonitis, retrocalcaneal specific activities as soon as possible. The use of bursitis, Haglund’s deformity, posterior tibialis taping or bracing may allow earlier return to tendonitis and tarsal tunnel syndrome. These can play and augment physical therapy measures. usually be detected by careful history and phy- 590 sport-specific injuries: prevention and treatment

sical examination, occasionally supplemented Achilles tendonitis with additional testing. Achilles tendonitis is another common overuse problem seen in soccer players due to repetitive Peroneal tendonitis running, jumping and cutting activities. Overuse Peroneal tendonitis is one of many overuse injuries appear most frequently before the season injuries common in the soccer player. Because starts. The athlete complains of pain in the poste- soccer activities rely on presenting many differ- rior heel associated with jumping activity and ent foot surfaces, the muscles that control ankle can develop a tenosynovitis with palpable crepi- and foot motion are used constantly. When an tus in the tendon sheath. These injuries should be athlete starts the season, overuse injuries are treated aggressively. A stretching programme, common because so many of these movements in association with ice, non-steroidal anti- are specific to soccer. Peroneal tendonitis gener- inflammatory medication and activity modifica- ally presents with pain and occasionally swelling tion, is generally indicated. In addition, using behind the lateral malleolus, with a predictable heel pads bilaterally can help decrease the increase in pain when the player uses the outside tension on the Achilles complex and thus of the foot for passing or shooting. Pain with decrease pain. The athlete should understand resisted eversion also reproduces the symptoms. that a stretching programme is essential in treat- Treatment is designed to decrease swelling, ment. Attention must also be given to potential increase flexibility and investigate precipitat- biomechanical factors that may predispose the ing biomechanical factors. Non-steroidal anti- athlete to this injury. inflammatory medication, ice, stretching and modalities are all useful. In addition, assessment Turf toe and reverse turf toe for orthotics to correct biomechanical problems at the foot and ankle is also important. Turf toe is used to describe a chronic hyperexten- sion of the first metatarsophalangeal joint. This is often due to the repetitive, high-energy forces Plantar fasciitis that occur at this joint in a relatively flexible shoe. Plantar fasciitis may be difficult to treat in soccer Reverse turf toe, commonly called ‘soccer toe’, is players given the high running and jumping due to chronic hyperflexion of the metatarsopha- demands the sport entails. The athlete presents langeal joint when the ball is struck during an with arch pain, initially worse in the morning instep kick or when the foot inadvertently strikes and better after a gentle warm-up. Generally, the ground. Hallux rigidus is commonly asso- these athletes have point tenderness at the ciated with these conditions. These injuries are calcaneal insertion of the plantar fascia. quite painful and can be debilitating for the Athletes usually respond to non-steroidal anti- soccer player. Treatment includes ice, anti- inflammatory medication, ice, stretching and inflammatory medication, range of motion and massage techniques, modalities and arch sup- taping, as well as shoe modifications. ports; treatment should also address biomechan- ical problems. An orthosis that keeps the plantar Fractures fascia stretched throughout the night (night splints) are very useful in treating these injuries, Fractures of the fibula or tibia are uncommon in although they can be somewhat cumbersome to soccer but can occur, especially if shin-guards are use. In those individuals unresponsive to this not worn or are used incorrectly. These injuries management, phonophoresis, iontophoresis or a usually occur as a result of a forceful kick to the localized injection of corticosteroid followed by leg. The use of shin-guards can decrease the risk relative rest is often helpful. of lower leg fractures (Bir et al., 1995). Athletes soccer 591

with tibial fractures are generally unable to toler- Fractures of the fifth metatarsal deserve ate weight-bearing and thus are easy to identify. special attention. These are generally divided Fibular fractures may be more difficult to recog- according to their location, with tuberosity or nize because the fibula is a non-weight-bearing avulsion fractures and shaft and neck fractures bone and thus players commonly carry on after treated very differently from fractures that occur sustaining this type of injury. A fibular fracture at the metaphyseal–diaphyseal junction (so- may take longer to heal because of the reduced called Jones fractures). Fractures that involve the stress on the bone due to its non-weight-bearing styloid process can be either articular or extra- nature. The use of protective shin-guards should articular and occur at the insertion of the per- be enforced to avoid these injuries. These frac- oneus brevis tendon. The foot is often in the tures are treated the same in soccer players as in plantigrade position when the injury occurs. It is other athletes, although return to play may be important to differentiate acute fractures from more difficult because of the high demands on anomalies and variations in normal growth the lower leg musculature in soccer. patterns. Extra-articular fractures can be treated symp- tomatically with shoe modifications, relative rest Metatarsal fractures and return to activity as tolerated. Fracture frag- Metatarsal fractures are common in soccer due to ments can be excised if they remain or become the high demands placed on the lower extremi- painful. Treatment for intra-articular fractures is ties. Non-displaced fractures of the metatarsal controversial. If they are non-displaced, they neck and shaft tend to be quite stable. Sympto- tend to respond to casting and rest from weight- matic treatment with strapping and a supportive bearing (Dameron, 1975; Torg et al., 1984). If the shoe often suffice. A fair amount of mediolateral fracture is large or displaced, they can be treated angulation can be accepted in metatarsal neck with internal fixation. This may allow athletes to and shaft fractures, with no complications unless resume activities sooner than with non-operative cross-union occurs or fragments are displaced. treatment, although given the good results Displaced fractures of the metatarsal neck and with non-operative management the treatment shaft are a different matter and care must be should be individualized. taken with these injuries. The most common Fractures of the Jones type, which occur at the complication of metatarsal fractures is late junction of the metatarsal shaft and base within transfer metatarsalgia, where asymmetry of 1.5cm of the tuberosity, are unique and merit the metatarsal heads in the dorsoplantar plane special attention. These injuries commonly occur can lead to a change in the load-bearing forces in jumping sports when the metatarsophalangeal through the depressed metatarsal heads. Radi- joints are extended and the heel elevated with ographs of the forefoot with the toes extended, loading of the lateral aspect of the foot. These similar to a sesamoid view, can help in making fractures are notoriously difficult to treat con- decisions about the treatment of these injuries. servatively and there is a high incidence of Referral to an orthopaedic surgeon for considera- delayed union, non-union and refracture, espe- tion of open reduction with internal fixation may cially in high-demand athletes (Dameron, 1975; be necessary if closed treatment is not successful. Kavanaugh et al., 1978; Torg et al., 1984). In general, the metatarsal injuries seen in soccer Jones fractures are subdivided according to tend to be mild, and respond well to conservative whether they are acute fractures or whether they management. If there are multiple metatarsal are seen in the setting of chronic stress or previ- injuries or the athlete has sustained a Lisfranc ous injury (Torg et al., 1984). The latter can be rec- fracture–dislocation pattern, careful attention to ognized radiographically or by a history of pain the soft tissue should be maintained for signs of at or near the base of the fifth metatarsal preced- compartment syndrome. ing the fracture (DeLee, 1986). Jones fractures 592 sport-specific injuries: prevention and treatment

that are truly acute can be treated with casting eventually the athlete can no longer participate and rest from weight-bearing; however, in the because of the pain. The athlete often avoids high-demand athlete or others wishing aggres- medical attention until she can no longer partici- sive treatment, percutaneous intramedullary pate in activity without pain. The average time to screw fixation is indicated (DeLee et al., 1983; diagnosis in the study by Matheson et al. (1987) Rettig et al., 1992; Mindrebo et al., 1993). was 13 weeks. Intramedullary screw fixation is also indicated if Predisposing factors to consider include both there is evidence for stress reaction or previous training and equipment errors as well as biome- injury. Delayed unions and symptomatic non- chanical errors. In the study by Matheson et al. unions are treated by curettage and bone grafting (1987), training errors accounted for 22.4% of the via a dorsolateral incision, supplemented with stress fractures. Training and equipment errors intramedullary fixation. The use of an external include an abrupt change in playing surface, an bone growth stimulator can be considered in all abrupt change in the training schedule including these fractures in an attempt to speed healing. increased distance, intensity or speed, or insuffi- Stress fractures of the base of the fifth cient recovery time between sessions (Reeder et metatarsal are treated aggressively as recom- al., 1996). Inappropriate shoes may be implicated mended above. Stress fractures of the other in the development of stress fractures; this may metatarsals can usually be treated conservatively be particularly important in soccer players as with relative rest, activity modification and many of the soccer cleats worn are often poor gradual return to sport-specific activity. at controlling rearfoot and forefoot motion. Bio- mechanical issues include leg length discrepan- cies, foot pronation, femoral anteversion or Stress fractures increased knee valgus (Reeder et al., 1996). These Stress fractures are due to repetitive submaximal problems should be assessed at the time of the forces that ultimately overwhelm the skeletal athlete’s preparticipation physical examination system and lead to fracture. The most common as well as in those who present with an overuse stress fractures seen in soccer players are in the injury or stress fracture. lower extremity. In a study of stress fractures in It is essential to ask female athletes with stress athletes diagnosed by bone scan, Matheson et al. fractures and other overuse injuries about their (1987) reported the most common sites to be menstrual history as well as their overall body the tibia (49.1%), tarsals (25.3%), metatarsals image. Menstrual dysfunction, as well as eating (8.8%), femur (7.2%), fibula (6.6%), pelvis (1.6%), disorders, are associated with low oestrogen sesamoids (0.9%) and spine (0.6%). It is impor- and low bone mineral density and together are tant to differentiate stress fractures from insuffi- known as the female athlete triad (Yeager et al., ciency fractures. In stress fractures, repetitive 1993; Putukian, 1995). Decreased bone mineral submaximal forces overwhelm the reparative density has been associated with an increased process but the bone itself is initially normal. In incidence of stress fractures. insufficiency fractures, normal stresses on a bone On physical examination, athletes with stress that has decreased resistance to fracture because fractures may have localized tenderness at the of an underlying condition such as osteoporosis fracture site and occasionally swelling, erythema lead to fracture. or local warmth. Hopping on the affected limb Stress fractures are often difficult to diagnose may elicit pain. Other positive findings include a because they are not associated with a clear trau- positive compression test (either tibia–fibula or matic injury. They generally present with a dull metatarsal), a positive heel strike (tibia, calca- pain aggravated by activity and relieved by rest. neus, femur, pelvis), pain with one-legged exten- This progresses to pain at the fracture site associ- sion (spondylolysis) or axial loading of the ated with localized swelling and erythema and involved bone (metatarsals). In addition, pain is soccer 593

often elicited with a tuning fork or even with standard, other types of diagnostic test have also ultrasound, which is thought to cause pain been used. Multiple grading systems exist and because damaged periosteum absorbs ultra- two of these (Zwas et al., 1987; Fredericson et al., sound energy and transforms it to heat. This test 1995) are shown in Table 39.4. Grades 1 and 2 are is occasionally useful and has been shown to be generally only minimally symptomatic and 93% accurate in detecting acute fractures (Devas, require 3–4 weeks to heal, whereas grades 3 and 4 1983). are usually symptomatic and require up to 4–6 Radiographs may show small cortical inter- weeks to heal. ruptions followed by periosteal reaction and Treatment of stress fractures requires relative eventually dense callus formation. The initial rest until the fracture heals followed by gradual radiographic changes may appear at 10–14 days resumption of activities. It is important to iden- but are often delayed for more than 3 weeks. tify the potential biomechanical problems, such Technetium bone scanning is useful in athletes as pronation or other foot biomechanics, that pre- with suspected stress fractures who have normal dispose the athlete to recurrent injury. It is often radiographs and in those with old fractures (of useful to assess the athlete closely while running 6–12 months’ duration). Bone scans generally and initiate shoe modifications or orthotics if show areas of increased uptake consistent with necessary. A careful analysis of training patterns stress fracture at 6–72 hours. It is important to and discussion with the staff responsible for remember that bone scans, although sensitive, coaching or strength and conditioning may also are not specific and thus a differential diagnosis be helpful. Athletes can maintain their cardiovas- including osteochondral or acute fractures, cular conditioning by using a stationary bike, Ewing’s sarcoma, eosinophilic granuloma or running in a pool or, if possible, running on an osteogenic sarcoma should be kept in mind. A unloaded harness system treadmill. This allows normal scan usually excludes stress fracture athletes to run with a small percentage of their and allows athletes to return to activity sooner. body weight removed and thus allows them to Although technetium bone scanning is the gold exercise without pain. Pain is the most useful

Table 39.4 Two systems of grading stress fractures based on bone scan and MRI

Grade Bone scan* MRI†

1 Small, ill-defined cortical area Periosteal oedema, mild to of mildly increased activity moderate on T2 images

2 Better-defined cortical area of Periosteal oedema, moderate to moderately increased activity severe on T2 images; marrow oedema on T2 images

3 Wide to fusiform, cortical– Periosteal oedema, moderate to medullary area of highly severe on T2 images; marrow increased activity oedema on T1 and T2 images

4 Transcortical area of intensely Periosteal oedema, moderate to increased activity severe on T2 images; marrow oedema on T1 and T2 images; fracture line clearly visible

*Grading system of Zwas et al. (1987). †Grading system of Fredericson et al. (1995). 594 sport-specific injuries: prevention and treatment

guide in terms of progression of activities. Activi- common area is the anterior compartment of the ties should be as specific to the sport as possible. lower leg; these injuries can be diminished with For the soccer player this means allowing the use of shin-guards. Treatment should include weight-bearing as soon as there is no pain and ice, compression wrap and rest from activity. In heading or hitting a ball against a wall gently large contusions of the quadriceps muscle it prior to running. is often useful to flex the knee to roughly 120° Prevention of stress fractures, as with all and apply a compressive wrap in this position overuse injuries, should be the goal of those for 24 hours (Aronen & Chronister, 1992). It is taking care of soccer players. It is important to also reasonable to initiate non-steroidal anti- look for and identify risk factors during the inflammatory medication in an attempt to preparticipation physical examination. This prevent fibrosis and heterotopic bone formation. includes an assessment of not only biomechani- Large haematomas are occasionally evacuated cal or training errors but also menstrual function, surgically via aspiration followed by a compres- body image abnormalities and nutritional pat- sive dressing. This decreases the intramuscular terns. Encouraging a good strengthening and pressure and pain effectively, but should be conditioning programme can help avoid many avoided if possible because there is a high risk of overuse injuries before they occur. infection. Early rehabilitation efforts should be focused on regaining full range of motion, and cardiovascular fitness maintained by using arm Contusions/haematomas isokinetic machines or swimming while ‘drag- These are probably the most common injuries ging’ the involved extremity. Isometric exercise seen in soccer and are usually due to direct can be initiated early in rehabilitation and may trauma with another player or the ball. Most con- help stimulate muscle regeneration. Once the tusions result in acute trauma to, and bleeding of, athlete is able to demonstrate full range of muscle tissue with localized haematoma forma- motion and has no palpable defect or pain with tion. Contusions are generally self-limiting and resisted motion, then a slow return to activity can do not result in a time-loss injury; however, if be allowed. they occur to the head, thorax or abdomen, they It is important to follow these injuries closely can be life-threatening. and observe the range of motion so that com- Muscle contusions can be intramuscular, plications can be avoided. Heterotopic bone where bleeding does not spread outside the formation and myositis ossificans occur in epimysium, or intermuscular, where the haemor- 9–20% of all quadriceps contusions (Saartok, rhage extends to the muscle fascia and subcuta- 1996). Heterotopic bone formation occurs in the neous tissue. The latter are generally benign and muscle, although it can progress to myositis ossi- do not cause problems. Because intramuscular ficans which extends to the bone. These can haematomas are contained within the muscle require several months of treatment. Other sheath they can create increased intramuscular complications of contusions and haematomas pressure and pain and ultimately require surgi- are compartment syndromes and nerve palsies. cal drainage. Acute compartment syndrome is a Therefore, close assessment of these seemingly complication of a large haematoma and must be unimportant injuries is essential. detected should it occur. This is a medical emer- gency as tissue damage may be irreversible if Subungual haematomas and ingrown nails treatment is delayed. The most common location of muscle contu- These injuries are common in the soccer player sions in soccer is the quadriceps muscle, usually and are generally a result of trauma to the nail as a result of direct trauma to the muscle from the within the soccer shoe. Subungual haematomas knee or foot of an opposing player. Another are common when a player is stepped on or has soccer 595

kicked the ground. The athlete complains of sig- recording the circumference of the body part nificant pain, which is a result of blood beneath involved is also helpful. The early treatment of the nail in an enclosed space. This is easily these injuries is with ice, compression for 48 resolved by creating a hole, either by twisting an hours and rest in the flexed position. It is impor- 18-gauge needle slowly until the nail is pierced tant to avoid massage or heat initially because or by heating the end of a paper clip and burning these modalities increase bleeding into the through the nail. Special drills or a jeweller’s drill area and worsen the injury. Non-steroidal can be used for the same purpose. anti-inflammatory medication serves as an Ingrown nails are also common and occur adjunct for pain and prevents fibrosis and should when the nail grows into the lateral skin and be initiated when not contraindicated. Return to becomes embedded. The lateral nail folds then play is allowed when the athlete has full range of become painful after trauma and occasionally motion, full strength and can perform sport- can also become infected. These are often treated specific skills. It will often be difficult to return with digital anaesthetic block followed by partial the athlete to full sprinting activity. During reha- nail removal. Infections are treated by antibiotics bilitation it is important that an attempt is made that provide good skin coverage for Staphy- to match muscle use with speed-specific as well lococcus and Streptococcus. The athlete should be as sport-specific activities. The time to return to instructed on proper nail-cutting techniques and full activity is variable and may range from a few shoe fitting. days to 6–8 weeks. It is unclear if some of the acute muscle strain injuries can be avoided, although there are data Muscular strains/overuse injuries to demonstrate that a muscle with more length Muscular strains/overuse injuries probably rep- requires more tension prior to tearing. This resent the most common injury in soccer, would imply that increased flexibility is benefi- although they do not often result in time lost cial for decreasing the risk of muscle injury. If an from play. These injuries often occur after an athlete is unconditioned and not accustomed to acute load or as a result of chronic overuse. The long practices or high sprinting demands, she major muscle groups involved in soccer players may be at increased risk for acute muscle overuse include the hamstring, quadriceps and adductor and strain. A comprehensive conditioning and muscles. Another common overuse injury is that flexibility programme may be beneficial in to the pes anserinus, where the gracilis, sartorius avoiding these injuries. and semitendinosus tendons converge along the anteromedial aspect of the proximal tibia. This Injuries in the adolescent player structure is often stressed by the pass with the inside of the foot or by direct trauma and is com- Injuries to be concerned about in the adolescent monly associated with a bursitis. Other com- soccer player include apophyseal fractures, monly involved areas are the muscles of the apophysitis and Osgood–Schlatter disease. lower leg and foot. The athlete describes pain Where major tendons originate or insert into when performing a certain movement and occa- bones, accessory growth plates, or apophyses, sionally describes a ‘popping’ sensation. These occur. These areas are generally weaker than the athletes may often have point tenderness in the bone or muscle–tendon junction and as a result muscle belly itself or pain can be reproduced by of stress can be a site of failure in the young resistive testing of the particular muscle group. athlete. The apophyses can be avulsed by a On examination of these injuries, the presence strong contraction of the muscle. In soccer of echymosis, swelling, the amount of point ten- players, these tend to occur in the pelvis. It is derness and the presence of a palpable defect important to consider avulsion fractures if the should be determined and noted. Occasionally, athlete gives a history of significant pain or 596 sport-specific injuries: prevention and treatment

swelling after a forceful contraction, especially if some relief. In addition, shoe modifications may they have difficulty bearing weight. The kicking also be useful. motion places great tension stress on the anterior Osgood–Schlatter disease is very common in inferior iliac spine and the ischial tuberosity due all young athletes involved in jumping activity to rectus femoris and hamstring forces respec- and therefore also in the soccer player. It is not a tively. These fractures most commonly occur in true apophysitis in that it does not occur at the girls aged 14–17 years. Avulsion fractures of the apophyseal growth plate but at the junction tibial tubercle require special mention because between the tuberosity and the tendon when the these are serious injuries that can occur in the tuberosity is transforming from cartilage to bone. adolescent soccer player. The tibial tubercle has a Osgood–Schlatter disease generally presents in separate ossification centre that eventually fuses young girls at the age of 9–13. Pain is generally with the tibial epiphysis prior to full closure of located at the tibial tubercle and is aggravated the growth plate. A fracture in this location can by jumping, running and kicking activities. involve only the tubercle or can extend through On physical examination, localized pain and the epiphysis; if displaced, this injury often swelling is present and pain is elicited with requires early surgical reduction and fixation resisted leg extension. It is important to ensure management. Occasionally, these injuries are not that the quadriceps mechanism is intact. Radi- apparent on plain radiographs and MRI or CT ographs may be helpful in assessing the presence can be useful. of fragmentation and ruling out avulsion frac- Apophysitis is considered an overuse injury of ture. Treatment is generally symptomatic, with the apophyses and in the soccer player is most quadriceps flexibility, ice after activity and often seen at the iliac crest and the calcaneal activity modification as needed. It is important tuberosity. Iliac crest apophysitis often occurs in to reassure the athlete and parents that this females before 14 years of age, when the apophy- condition is self-limiting and will eventually ses usually close. The athlete complains of pain resolve. that is often present along the anterior aspect of Sinding–Larsen–Johansson disease is similar the iliac crest. Radiographs may show increased to Osgood–Schlatter disease except that it occurs widening of the apophyseal line, although this at the inferior pole of the patella. Physical exami- finding may be subtle. Because the muscle struc- nation helps differentiate the location of pain and tures that attach here are integral to soccer activ- radiographs may be confirmatory. The most ity, these injuries often take 4–8 weeks to heal important activity modification is to avoid fully, and activity modification and play as toler- jumping, although depending on the severity of ated by pain are the basic treatment guidelines. symptoms some players may be unable to tol- Calcaneal apophysitis, or Sever’s disease, is erate prolonged running. If the athlete cannot also common in the adolescent athlete, although run without pain, she can still participate in it can also occur as early as 7–8 years of age. The sport-specific skill work. Increasing flexibility pain is generally located at the insertion of the and maintaining cardiovascular fitness with an Achilles tendon at the posterior aspect of the cal- alternative form of exercise such as cycling or caneus. The pain is generally made worse with swimming may be useful as an adjunct to reha- jumping activity. Radiographs may be helpful, bilitation. although it is often difficult to differentiate from normal variants in calcaneal apophyseal ossifica- Conclusion tion centres. Treatment is again conservative, with relative rest, ice and anti-inflammatory Soccer is a tremendously exciting sport that is medication for pain. Often a heel cord stretching growing exponentially, especially for girls and programme, along with bilateral heel lifts to put women. The sport is challenging in that it the Achilles tendon complex at rest, can provide demands high levels of aerobic as well as anaero- soccer 597

bic fitness, requires acquisition and mastery of tions of the proximal portion of the fifth metatarsal. skills, and does not select for a particular body Journal of Bone and Joint Surgery 57A, 788–792. DeLee, J.C. (1986) Fractures and dislocations of the type. Because of the demands of the sport, flexi- foot. In R.A. Mann (ed.) Surgery of the Foot, pp. bility, strengthening and conditioning, and 592–808. Mosby, St Louis. proper nutrition are essential. Soccer enjoys a DeLee, J.C., Evans, J.P. & Julian, J. (1983) Stress fracture low injury rate, especially when played by the of the fifth metatarsal. American Journal of Sports Med- rules, and the injuries that do occur tend to be icine 11, 349–353. Devas, M. (1983) Ultrasonic assessment of stress frac- mild. In the future, research into the more signifi- tures. British Medical Journal 286, 1479–1480. cant injuries, such as ACL and other ligament Dick, R. (1996) NCAA Injury Surveillance System injuries and head injuries, should continue to 1995–1996. National Collegiate Athletic Association, improve the medical care available to soccer Overland Park, Kansas. athletes and increase safe and enjoyable Ekblom, B. (1986) Applied physiology of soccer. Sports Medicine 3, 50–60. participation. Ekblom, B. (ed.) (1994) Football (Soccer). Handbook of Sports Medicine and Science. Blackwell Scientific References Publications, Oxford. Ekstrand, J. & Gillquist, J. (1982) The frequency of male Abreau, F., Templer, D.I., Schuyler, B.A. & Hutchinson, tightness and injuries in soccer. American Journal of H.T. (1990) Neuropsychological assessment of soccer Sports Medicine 10, 75–78. players. Neuropsychology 4, 175–181. Elias, S.R., Roberts, W.O. & Thorson, D.C. (1991) Team Brewer, J. & Davis, J. (1994) The female player. In B. sports in hot weather: guidelines for modifying Ekblom (ed.) Football (Soccer). Handbook of Sports youth soccer. Physician and Sportsmedicine 19, 67–78. Medicine and Science, pp. 95–99. Blackwell Scientific Ergstrom, B., Johannsson, C. & Tornkvist, H. (1991) Publications, Oxford. Soccer injuries among elite female players. American Alves, W.M., Rimel, R.W. & Nelson, W.E. (1987) Uni- Journal of Sports Medicine 19, 372–375. versity of Virginia prospective study of football- Fredericson, M., Bergman, A.G., Hoffman, K.L. & induced minor head injury: status report. Clinics in Dillingham, M.S. (1995) Tibial stress reaction in Sports Medicine 6, 211–218. runners: correlation of clinical symptoms and American College of Sports Medicine (1996) Position scintigraphy with a new MRI grading system. Ameri- stand on exercise and fluid replacement. Medicine can Journal of Sports Medicine 23, 472–481. and Science in Sports and Exercise 28, i–vii. Gainor, B.J., Piotrowski, G., Puhl, J.J. & Allen, W.C. Anon. (1994) Injuries associated with soccer goal posts: (1978) The kick: biomechanics and collision injury. United States 1979–93. Morbidity and Mortality Weekly American Journal of Sports Medicine 6, 185–193. Report 43, 153–155. Gilmore, O.J. (1993) Gilmore’s groin. Sportsmedicine and Aronen, J.G. & Chronister, R.D. (1992) Quadriceps con- Soft Tissue Trauma 3, 2–4. tusions; hastening the return to play. Physician and Jensen, K. & Larsson, B. (1993) Variations of physical Sportsmedicine 20, 130–136. capacity in a period including supplemental training Barkley, K.L. (1997) In Mellion, M. (ed.) The Team Physi- of the Danish soccer team for women. In T. Reilly, J. cian’s Handbook, 2nd edn, pp. 672–684. Hanley & Clarys & Stibbe (eds) Science and Football II, pp. Belfus, Philadelphia. 114–117. E. & F.N. Spon, London. Bir, C.A., Cassatta, S.J. & Janda, D.H. (1995) An analysis Jordan, B.D. & Zimmerman, R.D. (1990) Computed and comparison of soccer shin guards. Clinical tomography and magnetic resonance imaging com- Journal of Sports Medicine 5, 95–99. parisons in boxers. Journal of the American Medical Burslem, I. & Lees, A. (1987) Quantification of impact Association 263, 1670–1674. accelerations of the head during the heading of a Jordan, S.H., Green, G.A., Galanty, H.L., Mandelbaum, football. In T. Reilly, A. Lees, K. Davids et al. (eds) B.R. & Jabour, B.A. (1996) Acute and chronic brain Science and Football: Proceedings of the First World Con- injury in United States national team soccer players. gress of Science and Football, pp. 243–248. E. & F.N. American Journal of Sports Medicine 24, 205–210. Spon, London. Kavanaugh, J.H., Brewer, T.D. & Mann, R.V. (1978) The Colquhoun, D. & Chad, K.E. (1992) Physiological char- Jones fracture revisited. Journal of Bone and Joint acteristics of Australian female soccer players after a Surgery 60A, 776–782. competitive season. Australian Journal of Science and Kelly, J.P. & Rosenburg, J.H. (1997) Diagnosis and Medicine in Sport 18, 9–12. management of concussion in sport. Neurology 48, Dameron, T.B. (1975) Fractures and anatomical varia- 575–580. 598 sport-specific injuries: prevention and treatment

Kirkendall, D.T. (1993) Carbohydrate supplementation tive neuropsychological assessment of active experi- and performance in soccer players. Medicine and enced amateur boxers. Clinical Journal of Sports Medi- Science in Sports and Exercise 25, 1370–1374. cine 6, 90–96. Knapik, J.J., Baumn, C.L., Jones, B.H., Harris, J.M. & Pritchett, J.W. (1981) Cost of high school soccer injuries. Vaughan, L. (1991) Pre-season strength and flexibil- American Journal of Sports Medicine 9, 64–66. ity imbalances associated with athletic injuries in Putukian, M. (1995) Female athlete triad. Sports Medi- female collegiate athletes. American Journal of Sports cine and Arthroscopy Review 3, 295–307. Medicine 19, 76–81. Putukian, M. & Echemendia, R.J. (1996) Managing suc- Knapp, T. & Mandelbaum, B.R. (1996) Ankle sprains cessive minor head injuries. Which tests guide return and impingement syndromes. In W.E. Garrett, D.T. to play? Physician and Sportsmedicine 24, 25–38. Kirkendall & S.R. Contiguglia (eds) The US Soccer Putukian, M., Knowles, W.K., Swere, S. & Castle, N.G. Sports Medicine Book, pp. 360–368. Williams & (1996) Injuries in indoor soccer. The Lake Placid Wilkins, Baltimore. Dawn to Dark Soccer Tournament. American Journal Leatt, P.B. & Jacobs, I. (1989) Effect of glucose polymer of Sports Medicine 24, 317–322. on glycogen depletion during a soccer match. Cana- Reeder, M.T., Dick, B.H., Atkins, J.K., Pribis, A.B. & dian Journal of Sports Science 14, 112–116. Jartinez, J.M. (1996) Stress fractures: current concepts Levin, H.S., Amparo, E., Eisenberg, J.M. et al. (1987) of diagnosis and treatment. Sports Medicine 22, Magnetic resonance imaging and computerized 198–212. tomography in relation to the neurobehavioral Rettig, A.C., Shelbourne, K.D. & Wilckens, J. (1992) The sequelae of mild and moderate head injuries. Journal surgical treatment of symptomatic nonunions of the of Neurosurgery 66, 706–713. proximal (metaphyseal) fifth metatarsal in athletes. Lindenfeld, T.N., Schmidtt, D.J., Hendy, M.P., Mangine, American Journal of Sports Medicine 20, 50–54. R.E. & Noyes, F.R. (1994) Incidence of injury in Rhodes, E.C. & Mosher, R.E. (1992) Aerobic and anaero- indoor soccer. American Journal of Sports Medicine 22, bic characteristics of elite female university soccer 364–371. players. Journal of Sports Sciences 10, 143–144. McCarroll, J.R., Schrader, J.W., Shelbourne, K.D., Rimel, R.W., Giordani, B., Barth, J.T., Boll, T.J. & Jane, Rettig, A.C. & Bisesi, M.A. (1987) Meniscoid lesions J.A. (1981) Disability caused by minor head injury. of the ankle in soccer players. American Journal of Neurosurgery 9, 221–228. Sports Medicine 15, 255–257. Rimel, R.W., Giordani, B., Barth, J.T. & Jane, J.A. (1982) McLatchie, G., Brooks, N., Galbraith, S. et al. (1987) Moderate head injury: completing the clinical spec- Clinical neurological examination, neuropsychol- trum of brain trauma. Neurosurgery 11, 344–351. ogy, electroencephalography and computed tomo- Saartok, T. (1996) Contusions and hematomas. In W.E. graphic head scanning in active amateur boxers. Garret, D.T. Kirkendall & S.R. Contiguglia (eds) The Journal of Neurology, Neurosurgery and Psychiatry 50, US Soccer Sports Medicine Book, pp. 318–325. Williams 96–99. & Wilkins, Baltimore. Maehlum, S., Dahl, E. & Daljord, O.A. (1986) Frequency Saltin, B. & Costill, D.L. (1988) Fluid and electrolyte of injuries in a youth soccer tournament. Physician balance during prolonged exercise. In E.S. Horton & and Sportsmedicine 14, 73–79. R.L. Terjung (eds) Exercise, Nutrition and Metabolism, Matheson, G.O., Clement, D.B., McKenzie, D.C., pp. 150–158. Macmillan, New York. Taunton, J.E., Lloyd-Smith, D.R. & MacIntyre, J.G. Schmidt-Olsen, S., Jorgensen, U., Kaalund, S. & Soren- (1987) Stress fractures in athletes: a study of 320 son, J. (1991) Injuries among young soccer players. cases. American Journal of Sports Medicine 15, 46–58. American Journal of Sports Medicine 19, 273–275. Mindrebo, N., Shelbourne, D., Van Meter, C.D. & Scopetta, C. & Vaccario, M. (1978) Central cervical cord Rettig, A.C. (1993) Outpatient percutaneous screw syndrome after heading a football. Lancet i, 1269. fixation of the acute Jone’s fracture. American Journal Sortland, O. & Tysvaer, A.T. (1989) Brain damage in of Sports Medicine 21, 720–723. former association football players. Neuroradiology Neyret, P., Donell, S.T., DeJour, D. & DeJour, H. (1993) 31, 44–48. Partial meniscectomy and anterior cruciate ligament Sortland, O., Tysvaer, A.T. & Storli, O.V. (1982) Changes rupture in soccer players. A study with a minimum in the cervical spine in association football players. 20-year follow-up. American Journal of Sports Medicine British Journal of Sports Medicine 16, 80–84. 21, 455–460. Sullivan, J.A., Gross, R.H., Grava, W.A. et al. (1980) Nilsson, S. & Roaas, A. (1978) Soccer injuries in adoles- Evaluation of injuries in youth soccer. American cents. American Journal of Sports Medicine 6, 358–361. Journal of Sports Medicine 8, 325–327. Pardon, E.T. (1977) Lower extremities are site of most Torg, J.S., Balduini, F.C., Zelko, R.R., Pavlov, H., Peff, soccer injuries. Physician and Sportsmedicine 5, 42–48. T.C. & Das, M. (1984) Fracture of the base of the fifth Porter, M.D. & Fricker, P.A. (1996) Controlled prospec- metatarsal distal to the tuberosity: classification and soccer 599

guidelines for non-surgical and surgical manage- injuries to the brain: a neurologic and electroen- ment. Journal of Bone and Joint Surgery 66A, 209–214. cephalographic study of former players. Acta Neuro- Tysvaer, A.T. (1985) Cervical disc herniation in a foot- logica Scandinavica 80, 151–156. ball player. British Journal of Sports Medicine 19, 43–45. Yeager, K.K., Agostini, R., Nattiv, A. & Drinkwater, B. Tysvaer, A.T. (1992) Head and neck injuries in soccer. (1993). The female athlete triad: disordered eating, Impact of minor trauma. Sports Medicine 14, 200– amenorrhea, osteoporosis. Medicine and Science in 213. Sports and Exercise 25, 775–777. Tysvaer, A.T. & Lochen, E.A. (1991) Soccer injuries to Zwas, S.T., Elkanovitch, R. & Frank, G. (1987) Interpre- the brain. A neuropsychologic study of former soccer tation and classification of bone scintigraphic find- players. American Journal of Sports Medicine 19, 56–60. ings in stress fractures. Journal of Nuclear Medicine 28, Tysvaer, A.T., Storli, O.V. & Bachen, N.I. (1989) Soccer 452–457. Chapter 40

Canoeing and Kayaking

KATHERINE KENAL AND PATRICIA TRELA

Introduction participants in both flatwater and whitewater environments. Several popular forms of pad- Canoeing and kayaking are activities that allow dling sports exist, including canoe sailing, out- participants to enjoy the diversity of the out- rigger canoe, sea kayaking and surf skiing. doors. The popularity of these paddling sports is Competitive marathon regattas involve dis- evidenced by the fact that several European tances from 10km to several hundred kilometres, countries have chosen canoeing as their national while rivers challenge whitewater enthusiasts to sport. Currently, the American Canoe Associa- the extremes of ‘playboating’ during rodeo tion estimates that over 24 million Americans events (Fig. 40.1). are involved in these sports. Originally, canoe- Technological advances in equipment and spe- ing and kayaking provided transportation for cific training programmes have allowed an even hunting, gathering and trade by the Native greater number of women to become involved Americans of North America and the Inuit of the recreationally and competitively. At the 1997 Arctic. By the turn of the century these popular World Championships for flatwater canoe and leisure activities had evolved into competitive kayak in Halifax, Nova Scotia, women competed sports. Consequently, the International Canoe in kayaking at the 200 and 500m distances and, Federation (ICF) was formed in 1924 to provide for the first time, the 1000m distance. Women administrative and technical guidance and to race kayaks over 500m in three events: K1, K2 sanction races for participants throughout the and K4 (K4 having been added to the schedule in world. 1984). The goal is to gain entry to the final race, The sport of canoeing and kayaking was which may take as many as three races spread admitted to Olympic competition in 1936 at out over several days. All competitors start in the XIII Olympic Games in Berlin. Flatwater heats that are not seeded; typically the top three racing has been a part of the Summer Olympic finishers (determined by the number of entries) Games since that time, with women’s kayaking in each heat go directly to the semi-final. The events being added in 1948. However, white- others get a second chance to progress to the water slalom racing has only been a part of semi-final from the repêchage. The semi-finals the official games in 1972, 1992 and 1996. Its determine who will progress to the final; the best entry into the games is left to the discretion of the of the rest compete in a petit-final. In ideal flat- host country. Australia will host whitewater water conditions, without wind or current, slalom racing at the Olympic Games in Sydney in women can complete the 500m race in under 2000. 1min 45s, a feat that requires power and sus- The technical skills required, combined with tained endurance along with precise placement the need for strength and endurance, challenge of each stroke. 600 canoeing and kayaking 601

Fig. 40.1 Women’s four-person flatwater kayak race, Atlanta 1996. (© Allsport / Pascal Rondeau.)

Whitewater slalom competition at the breakage, whereas plastic is heavier but more Olympics takes place in four events. Men durable. Competition boats are typically made of compete in C1, C2 and K1, whereas women fibreglass or Kevlar. Olympic flatwater kayaks compete in K1 only. The 1996 Olympic Games in are narrow, enclosed craft that are fast and unsta- Atlanta were held on a 490-m semi-natural ble. They accommodate one, two or four pad- course with strong currents and rapids. There dlers. They must adhere to the weight, length were a total of 25 gates, 19 downstream and and width regulations of the ICF (Fig. 40.2). No 6 upstream, which required the athlete to concave surfaces or surface treatments that approach the gate against the current. The improve the hull’s wetted surface and therefore athlete’s head, shoulder and torso must pass speed are allowed. The kayaker sits inside the between the gate’s poles. Touching a pole results craft and uses a double-bladed paddle. The in a 5-s penalty, while missing a gate results in a person seated in the bow of a team boat or a 50-s penalty added to the elapsed time of the run. single kayaker steers the boat with a foot- Each racer is allowed two runs and the best time, controlled rudder. including penalties, is taken. These times typi- A spray skirt is used to prevent water from cally approximate 2min. While speed and preci- entering a kayak; in team boats it is used to sion are necessary, there is a much greater skill prevent the spray of paddlers from entering the to conditioning ratio compared with flatwater boat. In a head wind, a skirt streamlines the boat competitions. to prevent wind from entering and slowing it down. The skirt can also trap body heat in the boat and can be used during warm-up and later Equipment removed for the race. In 1936, offset paddle blades were introduced. Perhaps the biggest rev- Kayaks olution in design since has been the invention of The whitewater kayak comes in a multitude of the wing paddle by Stefan Lindeburg, former designs, the uniqueness of the design determin- coach of the Swedish national canoe and kayak ing its action on the river. In general, the boats team. In the mid-1980s this change in blade con- are constructed of fibreglass, Kevlar or plastic. figuration, and a change in paddle shaft com- Fibreglass is lighter but more susceptible to position from wood to the harder but lighter 602 sport-specific injuries: prevention and treatment

Length: 5.2 m Length: 6.5 m Beam: 51 cm Beam: 55 cm Weight: 12 kg Weight: 18 kg

(a) (b)

Length: 11.0 m Beam: 60 cm Weight: 30 kg

(c)

Fig. 40.2 Olympic kayaks: (a) K1, (b) K2 and (c) K4 kayaks.

carbon fibre, altered stroke paddling technique Safety equipment significantly. Safety dictates the use of two other important pieces of equipment. The personal flotation Canoes device (PFD), commonly called a life-jacket, is The canoe, on the other hand, is rudderless and self-descriptive. In addition to providing flota- open-topped, making it particularly vulnerable tion, its insulation properties help prevent to wind and water. It is built from a wide variety hypothermia. It also makes an excellent impro- of materials, including fibre-reinforced plastic, vised splint and can be used effectively to aid in wood and aluminium. As with the kayak, the relocating a dislocated shoulder. Helmets should longer the canoe at the waterline, the faster it will be worn by all whitewater canoeists and kayak- go. Traditional canoes are made for one or two ers. Surveys have shown that head trauma after people to paddle on flatwater but can also handle capsizing comprises >15% of all kayaking acci- small rapids. The paddlers sit freely and comfort- dents (Kizer, 1987). Proper clothing is an impor- ably in these canoes. Whitewater canoeists prefer tant protective factor and is dictated by the a canoe that is relatively closed, or ‘decked’, to environment. minimize water entering the boat in rapids. The paddlers kneel with both knees fixed by straps or Technique a padded brace. The paddle is constructed of varying material depending upon its intended Participation in kayaking and canoeing has use. The longer the race, the lighter the paddle increased significantly in the last couple of desired. Marathon paddles have a bent shaft, decades, both recreationally and competitively. allowing the blade to be angled up to 15°, which Women are training more often and with greater increases power. However, only the power side intensity so that it is important to address the of the blade can be used. Whitewater paddles mechanics of paddling. Studies indicate that have a handle grip that is easy to control and a intense high-volume on-water training, less- wide blade that is protected at its tip. than-optimal mechanics of the paddling stroke and dry-land maximum strength training are the precipitating factors in paddling injuries (Pelham et al., 1995). canoeing and kayaking 603

The mechanics in canoeing and kayaking are to the feet, which are placed close together on the mutually exclusive. In kayaking, the athlete has a footrest just touching the rudder. The knees double-bladed paddle and strokes on both sides should be drawn up towards the chest, enough of the kayak. Traditionally, it has been taught that to facilitate hip and torso rotation and alternate the paddler should put her paddle in the water extension of the knees during the stroke. and pull her body and boat past the blade rather It becomes difficult to adhere to proper tech- than pull the paddle through the water past her nique when paddling on rivers because of the body. Proper technique minimizes slip, the back- challenges of water hydraulics and obstacles. wards movement of the blade in the water. Using The low and high brace are useful techniques for good body rotation from the hips to the shoul- maintaining an upright boat. A low brace is used ders is crucial, because it allows effective use of when there is a slight loss of stability. Force is the large muscle groups of the shoulders, back applied to the back side of the paddle with and legs. This rotation ensures that the paddle elbows kept close to the trunk. The power side of remains vertical longer and is closely linked to the blade is used in a high brace to recover from good balance. At the catch, the entire blade more extreme instability of the boat (Fig. 40.3). should be pushed into the water vertically, as Improper technique places the hands above the close to the side of the boat as possible. About shoulders with the arms in abduction and exter- 25% of the force on the paddle is derived from the nal rotation. In this position, too much opposing top arm (non-control arm) pushing on the shaft, force results in injuries to the shoulder, such as while the other 75% of the force is derived from anterior dislocation and traumatic impingement. the bottom arm (control arm) pulling on the It is important to keep the arms close to the trunk shaft. It is important to relax the grip of the non- and the elbows below shoulder height. control hand as the paddle moves forward, The Duffek stroke (named after Milo Duffek) is allowing the paddle shaft to rotate through this an advanced technique ideal for entering and hand. It is best to achieve maximum power as exiting eddies. Key points for proper technique soon as possible in the stroke and to maintain are never to place the blade behind the body, that power evenly throughout the stroke. The properly rotate the trunk to minimize stress to power is then transferred to the boat via the legs the shoulders and use the upper hand as a pivot

Fig. 40.3 High brace technique: (a) correct and (b) incorrect (a) (b) technique. 604 sport-specific injuries: prevention and treatment

in front of the forehead. When a boat capsizes it is Table 40.1 Common musculoskeletal injuries in necessary to return it to its upright position canoeists and kayakers and this is most commonly achieved using the Site Injury eskimo roll. To increase the paddler’s confidence and prevent injury, proper instruction and indi- Shoulder Impingement syndrome, vidual practice of this manoeuvre is necessary bicipital tendinitis, until it becomes automatic. glenohumeral dislocations/ The conoeist has a paddle with one blade that subluxations Forearm Tenosynovitis of wrist extensor she strokes on her preferred side. Power is gener- tendons, flexor tendonitis, ated as the torso rotates and pulls the blade in a carpal tunnel syndrome, vertical position with the arms and shoulders. forearm compartment syndrome, medial and lateral epicondylitis of the elbow Orthopaedic injuries Back Thoracic and lumbar muscle strains, lumbar disc herniation Traumatic injuries, overuse injuries and various Pelvic Ischial bursitis, hamstring other medical problems result from the physical tendonitis, sciatic nerve demands of the paddling sports and the adver- compression Miscellaneous Ankle sprains/fractures, sity of the environment in which they take place. prepatellar bursitis, Improper stroke mechanics and repeated over- contusions, finger dislocations loading of the musculotendinous unit leads to the common medical problem of overuse. Com- bined with this is fatigue, which can negatively alter the biomechanics and create an imbalance structures afford static stability. Together they towards inappropriately applied muscular prevent anterior migration of the head of the forces. It must be remembered that nearly half of humerus against the acromion process and all injuries occur out of water as a result of dry- coracoacromial ligament, which would other- land training, scouting, and entering or exiting a wise cause impingement. Normal functioning of body of water. Flatwater racers tend to experi- the scapulothoracic stabilizers is essential for the ence proportionately more overuse injuries, synchrony of scapulohumeral motion. whereas whitewater paddlers are exposed to Optimum strength is essential for the power obstacles and technical manoeuvres that place phase of the flatwater stroke and also during them at risk for traumatic injuries. Orthopaedic slalom strokes, which demand rapid force pro- injuries are categorized in Table 40.1; diagnosis duction as well as rapid changes in direction and complications of orthopaedic injuries are of the forces centred in the shoulder joint (Hein- discussed in greater detail in Chapter 15. richs, 1991). However, women have relatively weaker shoulder girdle muscles than men and are rarely encouraged to strengthen their upper Shoulder impingement body musculature (Arendt, 1996). There The shoulder is considered the most mobile joint is also speculation that the cyclical effects of in the body and also the most vulnerable to women’s hormones on soft tissues may con- injury and overuse. During shoulder motion, sta- tribute to joint laxity. These factors predispose bility of the glenohumeral joint is provided by women to more frequent shoulder injuries than both dynamic and static components. The rotator experienced by men. cuff muscles, besides allowing for abduction and The most common overuse injury is impinge- internal and external rotation, provide the main ment syndrome, irritation of the rotator cuff dynamic stability for positioning the humerus muscles and their surrounding soft tissues. The within the glenoid fossa. Capsuloligamentous combination of hypovascularity, fatigue, poor canoeing and kayaking 605

stroke mechanics and the progressive instability angling the T-grip of the paddle and raising the of a hypermobile joint results in impingement. seat. Chronic inflammation can lead to fibrosis. How- ever, rotator cuff degeneration and tear are prevention rare in this athletic population (Berglund & McKenzie, 1994). Any extremes in internal and Prevention of these injuries needs to address external rotation of the arm can lead to frictional the most common causes. Paddling requires a irritation of the proximal biceps tendon on the precise blend of power and endurance and there- wall of the bicipital groove, resulting in biceps fore weight-lifting is an integral part of the tendonitis. paddler’s overall training programme. However, There are particular positions of the arms those programmes that encourage maximal during strokes and manoeuvres that place the strength training and the use of exercises which shoulder in forward flexion, abduction and inter- place the shoulder in risky positions result in a nal rotation, resulting in repetitive impingement disproportionate number of shoulder injuries, of the soft tissues. The following are a few exam- much to the frustration of athlete, coach and ples of such strokes: (i) maintaining a high physician. Weight-lifting manoeuvres that pro- (upper) pivot arm in the canoe paddler (Pelham duce forced abduction, extension and external et al., 1995); (ii) during the recovery phase of the rotation, such as military press, flys and behind- kayak stroke, a high pivot point is also attained; the-neck pulldown, should be avoided. Other and (iii) during the Duffek stroke, particularly aggravating manoeuvres are the bench press and when the body is far from the plant of the blade dips. In general, paddlers should be instructed to (Walsh, 1989). keep their elbows in the plane of their body or anterior to their body during any weight-lifting treatment exercise (Gross et al., 1993). The conditioning pro- gramme should also incorporate exercises that Modalities, medication and rest can reduce the allow for the development of adequate muscular symptoms. However, specific rehabilitation exer- and joint flexibility. This is necessary for the cises are most beneficial in returning the athlete athlete’s joints to withstand the forces applied by to the water. Strengthening and stabilization the water on the paddle and boat. exercises should be focused on the rotator cuff muscles and parascapular muscles (Kenal & Shoulder dislocations Knapp, 1996). Relative rest with evaluation and elimination of poor biomechanical techniques or Anterior shoulder dislocations and subluxations modifications to equipment are important in are the most common and disabling shoulder reducing the overload to vulnerable structures. If injury in the whitewater slalom athlete. pain is not recalcitrant, relative rest can be Recurrent episodes can lead to permanent laxity, achieved by stroke modification and decreased which may require surgical intervention for stroke intensity. The canoe paddler can pull the further participation. The shoulder is in its most elbow in slightly to increase relative external susceptible position when the hand and elbow shoulder rotation. The kayaker can paddle in are above and behind the shoulder. The down- base position. Both reduce forward reach. The ward force of the paddle against the upward slalom athlete can train on flatwater gates to force of the current pushes the arm beyond reduce force overload. A faulty posture (forward the stabilizing limits of the capsule and liga- head, slumped shoulders, reduced trunk and ments surrounding the glenohumeral joint. The hamstring flexibility) that compromises shoulder increased force ultimately levers the humeral mechanics must be identified and corrected. head out of the glenoid fossa. When the arm is Recommendations to canoe paddlers include abducted to less than shoulder height, the larger, 606 sport-specific injuries: prevention and treatment

stronger muscles maintain joint stability. pain and involuntary muscle spasm. Most tech- However, as the arm is abducted and externally niques require a flat and comfortable area upon rotated above shoulder height, where only a few which to place the injured paddler in the supine weaker muscles are supportive, the shoulder or prone position. This can be difficult to find in becomes more vulnerable to dislocation. These river and wilderness settings and therefore type of injuries can occur during the following reduction with the paddler standing should be manoeuvres: considered (Weiss, 1995). As soon as the diagno- • the high brace, used to prevent the boat rolling sis is made, the paddler bends forward at the (not commonly used by the canoe paddler waist while the rescuer grips the wrist and because mechanical advantage is gained as seat applies steady downward traction and external height increases); rotation. While maintaining traction, the rescuer • the Duffek stroke, used for negotiating holes can slowly forward flex the arm until reduction is and gates; obtained (Fig. 40.4a). If two rescuers are avail- • the roll, used to right a capsized boat; able, scapular manipulation may be performed • accidentally striking a rock with the paddle simultaneously, augmenting reduction (Fig. (often while attempting a roll). 40.4b). Another method uses the injured paddler’s PFD to allow one rescuer to apply both treatment controlled traction and countertraction (Dutkly, 1988) (Fig. 40.5). One should always monitor cir- The on-scene reduction of shoulder dislocation is culation and motor–sensory function to the wrist controversial. However, immediate relief of pain, and hand before and after attempting shoulder curtailment of ongoing injury and subsequent reduction. The paddler’s arm should then be ability to function more actively during evacua- immobilized across the chest with a sling or tion are strong reasons favouring it (Weiss, 1995). swath or by safety-pinning the sleeve of the arm Several techniques have been advocated for across the chest. If the paddler is in a remote area reduction (Reibel & McCabe, 1991). Regardless of and further paddling is necessary, the shoulder technique, the key element is rapid initiation, as can be partially stabilized by wrapping an elastic delayed reduction may become complicated by or neoprene covering around the torso and

Fig. 40.4 (a) The rescuer supports the victim’s chest with one hand and pulls the externally rotated arm down and forward with the other hand. (b) If two rescuers are available, scapular rotation to assist shoulder relocation can be performed by one rescuer, while the second rescuer pulls the arm down and forward. The inferior tip of the scapula is pushed (a) (b) medially. canoeing and kayaking 607

prevention

A conscious effort must be made to alter slalom Thumb pushes inferior and whitewater techniques to avoid vulnerabil- point of scapula medially ity. This is key to prevention. The paddler should stay within their attained level of whitewater experience and only increase the degree of diffi- culty after the basic manoeuvres have been mas- tered. Body weight should be centred over the boat by lifting the upstream hip (pulling the boat’s upstream edge out of the water) without leaning the torso downstream. The preferred method of bracing is the low brace, in which the arm is held in internal rotation and close to the body. It is an inherently stronger and more versa- Assistant pulls tile manoeuvre. The high brace is an extremely down and forward effective stroke, and the risk of dislocation can be Fig. 40.5 Using a life-jacket to assist in countertraction reduced by keeping the hands in front of the for shoulder relocation with the injured paddler’s arm plane of the shoulders and absorbing the shock at 90° flexion. of the force of the water with the muscles not the ligaments. If a vulnerably placed brace cannot be avoided, the torso should be quickly rotated to involved arm to limit abduction and external face the shaft of the paddle squarely. During the rotation. roll or the high brace the arm should be held Rehabilitation programmes should focus on close to the trunk or chest wall, thereby diminish- muscles that reinforce the anterior shoulder ing the torque applied to the glenohumeral joint. (anterior deltoid, subscapularis, pectoralis The forearm should be kept below the level of the major), as the most common dislocation is forehead when performing the Duffek manoeu- directed anteriorly. The rotator cuff muscles also vre. Remember particularly that fatigue greatly need to be strong in order to execute effectively diminishes concentration and muscle strength. the various manoeuvres used in paddling, such as the sudden burst of power needed at the start Wrist and forearm injuries of a K1 sprint, turning a canoe or kayak to avoid an obstacle, or to enter or exit a racing gate. Reha- Power in the stroke is generated most effectively bilitation exercises are similar to those used for using the stronger muscles of the hip, back and shoulder impingement. Taping methods shoulders. This power is transferred to the used by physical therapists may help decrease paddle through the forearm, wrist and hand, pain during humeral elevation by facilitating which tend to have weaker muscles. Since a key normal scapular positioning and stability while principle of efficient paddling is to keep the other strengthening and stability problems are blade vertical for as long as possible during the addressed (Host, 1995). Those paddlers who stroke, hip and torso rotation are crucial to have strengthened their shoulder muscles using proper stroke mechanics. a vigorous rehabilitation programme are less Paddlers frequently suffer overuse injuries to likely to dislocate again. However, those individ- the wrist and forearm with initiation of on-water uals who conduct recovery exercises with less training, during high workloads and in condi- enthusiasm or return too early tend to experience tions of wind and waves. Any deviation of the further problems. angle of the wrist during the pull causes ineffi- 608 sport-specific injuries: prevention and treatment

cient transfer of power to the stroke and puts grip and a smaller diameter shaft has proved undue strain on the elbow, forearm muscles and beneficial. On occasion, chronic recurrent injury wrist tendons. Aggressive gripping of the paddle of the wrist can cause persistent swelling and to control the boat and maintain proper tech- adhesions of tendons. In such recalcitrant cases nique during adverse environmental conditions a surgical decompression procedure may be can also be a source of injury. New technologies necessary. in design and materials, such as offset paddles, wing configuration of the blade, carbon-fibre prevention shafts and lighter, less stable flatwater boats, have significantly altered stroke mechanics. With Preventive measures are the basis for avoiding each change, paddlers may experience the onset these injuries, which can cause an athlete to dis- of new overuse problems that tend to resolve as continue training during the period of recovery they become accustomed to the change. and treatment. Sound stroke mechanics and The control hand of the kayak paddler is most appropriately sized equipment are paramount. commonly affected, as the wrist extensors of this The seat and footrest in the kayak should be posi- hand are subject to more use. This leads to tioned so that the knee bend facilitates torso rota- tenosynovitis of the extensor tendons, the most tion when reaching forward in the stroke. Too frequently reported injury. In turn, stresses can much bend limits hip rotation, a crucial part of be transferred to the lateral elbow, resulting body rotation. Proper overall body rotation is in epicondylitis. Excessive pronation–extension important even when the stroke rate is faster, as during the crossover phase of the kayak stroke in team boats and during starts. Generally, can lead to de Quervain’s tenosynovitis, irrita- the higher the seat, the more leverage and the tion to the extensor tendons proximal to the stronger the catch on the water. However, the thumb. Flexor tendonitis is more common in the lower the seat, the more stable the boat. Begin- canoeist who must steer her rudderless boat with ners should start with a lower seat in order to her bottom hand. Overuse secondary to aggres- master technique and gain balance, and then sive gripping of the paddle is responsible for gradually raise the seat over time. A paddle con- other forearm injuries. A tight grip of the paddle structed with a 75–80° offset instead of the tradi- and repetitive excessive flexion of the wrist can tional 90° can reduce wrist stress. Efforts should lead to entrapment of the medial nerve of the be directed at holding the wrist in a neutral posi- wrist, causing tingling, numbness, weakness and tion and avoiding excessive crossover. Flatwater pain, a condition known as carpal tunnel syn- paddlers should maintain a loose grip during the drome. Forearm compartment syndrome can entire stroke, particularly the pull. Slalom kayak- also result from prolonged gripping, the symp- ers should relax the grip whenever possible. For toms being very painful, tight, hard flexor com- stability in the wind and waves, the paddle arc partments, painful resistance of wrist flexion and should be lower and wider and air time kept to a occasionally numbness in the hand. minimum. treatment Back injuries

A conservative approach to therapy is useful for The power of every stroke is generated by the most overuse injuries and is directed at decreas- muscles of the back. In the lower back, they are ing inflammation, stretching, strengthening and used as stabilizers in the sitting position. The relative rest. The wrist can be taped in a neutral potential for injury to this area becomes com- position to immobilize excessive flexion and pounded when prolonged sitting with legs extension. This also serves as a reminder to keep extended and minimal back support leads to the wrist straight during the pull. Using a looser muscle fatigue and stretched ligaments. A strain canoeing and kayaking 609

of the lumbar myofacial tissue can occur with the Exercises involving isometric cocontraction of repeated flexion and rotation inherent in the lower back muscles (multifidus muscles) and mechanics of paddling. It can also occur abruptly abdominal muscles (particularly transversus with an unexpected torsional force, i.e. perform- abdominis) while maintaining the spine in a ing a brace technique that is countered by the static neutral position should help re-educate the force of the water or an immobile object such as a stabilizing role of these muscles (Richardson & boulder. Lifting unbalanced water-laden boats Jull, 1995). These can be performed in various and loading boats on to automobiles can also positions (sitting, standing, quadruped) and lead to injuries. Lower back pain is most monitored with the help of a physical therapist. common during heavy training and is a ubiqui- Ultimately, the athlete should be able to hold tous complaint among paddlers older than 25 a cocontraction of the deep muscles during years of age (Burrell & Burrell, 1982). dynamic functional movements of the trunk. Strains to the muscles of the upper back Abdominal exercises include partial sit-ups (trapezius and rhomboid muscles) can usually be and single and double leg-lifts. Hamstring and treated conservatively with stretching to shorten hip flexor tightness result from prolonged sitting. their course of healing. However, low back pain Hamstring tightness leads to excessive posterior tends to be more chronic in nature. Back pain tilt of the pelvis and lengthening of the lumbar accompanied by pain radiating to the leg or foot, muscles, whereas tight hip flexor muscles weakness, numbness or tingling of the leg or foot promote an anterior pelvic tilt and therefore may or, rarely, bowel or bladder dysfunction suggests cause excessive loading on the facet joints of the disc herniation or rupture. lumbar spine. Appropriate stretching exercises Fractures of the spine have been reported in are warranted. whitewater kayakers and canoeists (Weiss, 1995). Surgery is sometimes required for those with a Cervical spine injuries have occurred in kayakers herniated or ruptured disc who do not respond in conjunction with head trauma sustained after to a long trial of conservative therapy. Experience flipping upside-down. Compression fractures of has shown that athletes may return to full activ- the thoracolumbar spine have occurred from ity following surgery and a prolonged rehabilita- axial loading when a kayaker landed flat after tion period (Walsh, 1985). paddling over a waterfall. Immediate recogni- tion of these types of injuries and prompt on-site prevention immobilization (minicell blocks from kayaks can be used) until a backboard can be obtained is A consistent programme of stretching specific paramount. muscle groups before paddling is key to avoid- ing these injuries. During extended paddling treatment trips, which lead to fatigue of the paraverteb- ral muscles, periodic breaks to stretch are Initial low back trouble is associated with poor recommended. isometric trunk muscle endurance and a hyper- mobile lumbar spine. Recurrent low back pain Pelvic injuries is associated with poor hamstring and back flexibility and weak trunk muscles (Biering- Prolonged sitting and rotational movements in Sorensen, 1984). Therefore, stabilization and the kayak or canoe can lead to a variety of endurance training are necessary in paddlers injuries, such as hamstring tendonitis at the when back pain is present. Lumbar spine hyper- insertion on the ischial tuberosity and ischial mobilities should be stabilized and the trunk bursitis. Both are prevented and managed by strengthened isometrically to promote strength proper padding. Sacral furunculosis can be a while promoting stability (Kenal & Knapp, 1996). troublesome lesion. Preventive measures in- 610 sport-specific injuries: prevention and treatment

clude meticulous attention to hygiene as well as Table 40.2 Common medical problems in canoeists washing and drying all padding before it is used and kayakers again. Topical, or occasionally oral, antibiotics Site Problem may be necessary. Compression of the sciatic nerve in the buttock with numbness to the foot is Head Concussion, exostosis of the ear a chronic complaint that can be relieved by canal, rhinitis, ocular trauma moving the position of the seat slightly, using appropriate ‘doughnut’ padding, or placing a Skin Hand blisters, finger/heel calluses, sunburn, infections, hole in the seat where the compression occurs. lacerations

Miscellaneous Hypothermia, hyperthermia, Miscellaneous injuries pregnancy, gastrointestinal The feet and ankles are frequently injured when infections, entrapments walking along the banks of a river while attempt- ing to put the boat in, take the boat out or portage around a rapid. Ankle strains can be treated ance by using nose clips. Decongestant nasal immediately by putting the ankle in cold water, sprays are very effective but must be limited to compressing it with an Ace Wrap and elevating it short-term use of less than 5 days. These can be whenever possible. An easy exercise to perform used prior to an exposure or immediately after is to write the alphabet (capital letters) in the exiting the water and then again 15min later. air using the foot in a pain-free range without Rinsing the nose with a saline solution helps to moving the leg. Fractured ankles may result from remove contaminants and soothe nasal mem- forced dorsiflexion when the bow of the kayak branes. Alternatively, steroid nasal sprays can be hits an obstruction head-on and the kayaker’s used. heels are pushed under the horizontal toe brace. Chronic recurrent exposure to cold water can Inflammation of the prepatellar bursa occurs lead to reactive changes in the external ear canal very often among paddlers who kneel. Appro- producing exostoses. These can impede hearing priate padding or alternating the side of kneeling and hinder clearance of water and foreign parti- can be preventive. Strict hygiene practices must cles from the canal. Ear plugs may be the neces- be undertaken to avoid infection of the bursa. sary preventive measure.

Medical concerns (Table 40.2) Skin Blisters and calluses on the hands are frequently Head reported in paddlers. Kayakers develop them at Head and facial trauma is more common in the metacarpophalangeal joint of the thumb, whitewater kayakers and canoeists because of whereas canoeists are more likely to have them the potential for flipping upside-down while on the proximal palmar surfaces of the metacar- still in the craft. Trauma to these areas can be pophalangeal joints. Taping and moleskin appli- minimized by wearing a protective helmet and cation reduce the incidence of this potentially tucking forward instead of leaning backward incapacitating problem. Proper padding pre- while rolling. vents formation of blisters and calluses on the Frequent exposure of the nasal passages to dorsum of the foot caused by strap friction. sudden pressure and temperature changes, Sunburn is a common problem, overexposure including the ‘nasal enemas’ associated with flip- to the sun being the accepted reason for the ping kayaks, can lead to rhinitis. If an athlete is increasing incidence of skin cancers. Care should prone to this, then the best treatment is avoid- be taken to apply an adequate sun protectant canoeing and kayaking 611

factor sun lotion, with repeated applications travel expands the scope of potential contami- for prolonged exposures or frequent water nants, and infections of schistosomiasis and exposures. pulmonary blastomycosis have been reported. Simple preventive measures, such as drinking only treated water and being aware of local Miscellaneous endemic diseases and prophylactic measures, are Élite paddlers are now training throughout the recommended. year and environmental concerns become prob- The difficulty of a river generally increases lematic when paddlers are exposed to tempera- with the volume of flow and the average gradi- ture extremes. Immersion in cold water can ent. An increase in the speed and power of the precipitate two adverse reactions. First, sudden water make rapids more difficult, although on cold water immersion produces profound car- occasion this can actually make them easier. diovascular and respiratory responses. There is a Serious injuries and drowning can occur with marked increase in blood pressure and heart rate, entrapments, such as when kayaks become resulting in lethal dysrhythmias (Keatinge & broached (wrapped sideways around an obstacle Hayward, 1981). An immediate and involuntary such as a boulder) or vertically pinned (when a gasp occurs that results in aspiration of water kayak plunges over a drop and the end of the and laryngospasm, followed by hyperventila- boat becomes trapped between rocks beneath the tion. These responses increase the risk of drown- surface). In both these situations the plastic ing in rough water. kayak can fold over on itself, trapping the occu- Second, rapid cooling of the muscles and pant upside-down beneath the surface. The nerves in the extremities can result in loss of potential for entrapment can also occur when strength and coordination. This preclinical swimmers attempt to stand up and walk in swift- hypothermia impairs the ability to swim, main- moving currents: feet can become wedged tain freeboard, avoid obstacles, climb from the between rocks beneath the surface. Swimmers river and use appropriate judgement (Keatinge, and boaters can also become trapped in strainers, 1969). Even when the air temperature is warm, obstacles such as fallen trees or driftwood lodged paddlers negotiating cold rivers should wear between rocks or jutting out from the shore. Pad- sufficient insulation (splash cover and wet suit) dlers should always be accompanied by another and a PFD and ensure that their boats have boater and be knowledgeable about the appro- enough buoyant support (Berglund & McKenzie, priate negotiation of obstacles and rescue tech- 1994). For flatwater paddlers, a good method of niques. prevention is to teach them that there is just as Paddle sports can continue to be a fun and much good water close to the shore as in the rewarding experience during pregnancy. Women middle of the lake. pursuing flatwater training and racing, which Excessive exposure to a hot environment has minimal potential for trauma, should follow coupled with dehydration can lead to hyperther- the guidelines addressed in Chapter 14. How- mic injuries such as heat exhaustion or heat ever, there are a few specific recommendations stroke. Adequate hydration and cooling mea- for whitewater canoeing and kayaking. The indi- sures should be practised. vidual should acknowledge her limitations and The gastrointestinal tract can be exposed to an the level of activity should be well within these in assortment of aquatic-related infections. In the order to avoid trauma. She should also realize USA, Giardia lamblia has been found to be the that by the third trimester an enlarged abdomen most common pathogenic intestinal parasite. will alter her centre of gravity and therefore her Even the most pristine mountain rivers have balance. She should always wear a PFD and been contaminated by infected animals that defe- when the abdomen is larger than the chest a cate in or near the water. Foreign wilderness crotch strap should be worn. 612 sport-specific injuries: prevention and treatment

Dutkly, P. (1988) A simple method of treating shoulder Recommendations for future research dislocations for the whitewater enthusiast. Wilder- ness Medicine 5, 9–13. Research should be directed at developing Gross, M.L., Brenner, S.L., Esformes, I. & Sonzogni, the most appropriate dry-land strengthening J.J. (1993) Anterior shoulder instability in weight programme for both preseason and in-season lifters. American Journal of Sports Medicine 21, 599– training. This programme should focus on 603. strengthening the female paddler’s shoulder Heinrichs, K.I. (1991) Shoulder anatomy, biomechanics and rehabilitation considerations for the white- muscles as a preventive measure against poten- water slalom athlete: Part 1. National Strength and tial injuries. Development camps organized by Conditioning Association Journal 13, 26–35. the national governing body of each country Host, H.H. (1995) Scapular taping in the treatment of should be promoted to allow the introduction of anterior shoulder impingement. Physical Therapy 75, more women into the paddling sports. Finally, 803–812. Keatinge, W.R. (1969) Sudden failure of swimming in the ICF needs to develop gender equity within cold water. British Medical Journal 1, 480–486. international competition. Keatinge, W.R. & Hayward, M.G. (1981) Sudden death in cold water and ventricular arrhythmia. Journal of Forensic Science 16, 459–463. Acknowledgements Kenal, K.A.F. & Knapp, L.D. (1996) Rehabilitation of injuries in competitive swimmers. Sports Medicine 22, Appreciation is extended to Buck Tilton, Director 337–347. of the Wilderness Medical Institute in Pitkin, Col- Kizer, K.W. (1987) Medical aspects of white-water orado and to the United States Canoe and Kayak kayaking. Physician and Sportsmedicine 15, 128–137. Team for their valuable information. Pelham, T.W., Holt, L.E. & Stalker, R.E. (1995) The etiol- ogy of paddler’s shoulder. Australian Journal of Science and Medicine in Sports 27, 43–47. References Reibel, G.D. & McCabe, J. (1991) Anterior shoulder dis- location: a review of reduction techniques. American Arendt, E. (1996) Common musculoskeletal injuries in Journal of Emergency Medicine 9, 180–185. women. Physician and Sportsmedicine 24, 39–48. Richardson, C.A. & Jull, G.A. (1995) Muscle Berglund, B. & McKenzie, D. (1994) Injuries in canoeing control–pain control. What exercises would you pre- and kayaking. In P.A.F.H. Renstrom (ed.) Clinical scribe? Manual Therapy 1, 2–10. Practice of Sports Injury, Prevention and Care. Ency- Walsh, M. (1985) Preventing injury in competitive clopaedia of Sports Medicine, Vol. 5, pp. 633–640. Black- canoeists. Physician and Sportsmedicine 13, 120–128. well Scientific Publications, Oxford. Walsh, M. (1989) Sports medicine for paddlers: the Biering-Sorensen, F. (1984) Physical measurements as cause, care and treatment of paddler’s injuries. Canoe risk indicators for low-back trouble over a one-year 80, 36–38. period. Spine 9, 106–119. Weiss, E.A. (1995) White-water medicine and rescue. In Burrell, C.L. & Burrell, R. (1982) Injuries in whitewater P. Auerbach (ed.) Wilderness Medicine, pp. 1234–1250. paddling. Physician and Sportsmedicine 10, 119–124. Mosby, Boston. Chapter 41

Alpine Skiing

ROSEMARY AGOSTINI

Introduction of the anterior cruciate ligament (ACL) (Ellman et al., 1989; Shealy & Ettlinger, 1996). The reasons Just over 90 years ago, the first organized for this increase in knee injuries are not entirely alpine (downhill) ski competition was held in clear, but may relate to a combination of biome- Kitzbühel, Austria for men. Thirty years later, chanical and anatomical differences in women as women made their first appearance in downhill well as contributions from ski equipment (Shealy competition at the 1935 World Cup races, fol- & Ettlinger, 1996). lowed the next year by the Winter Olympics at Garmisch-Partenkirchen, Bavaria (Wallechinsky, Definitions of alpine ski events 1993). Today, women’s skiing is growing rapidly. In the last 4 years alone, there has been a 104% An understanding of the risks faced by alpine increase in the number of women competing in skiers requires an understanding of the dif- ski programmes at National Collegiate Athletic ferent skiing events. Alpine, or downhill, ski Association (NCAA) Division I colleges in the racing consists of four events, which differ in USA (Anon., 1997). As for recreational skiing, turning radius, speed and length of course marketing data from sports equipment manufac- (Wallechinsky, 1993; White & Johnson, 1993). turers show that 42.1% of the 6–7 million active skiers in the USA are women. Slalom Recognizing a growing demand, the equip- ment makers have responded. Women’s equip- Slalom is the shortest of the alpine events and ment has progressed beyond the ‘pretty paint involves weaving between closely set plastic job’ it once was. Manufacturers have begun to gates on a steep slope. Skiers negotiate these develop higher-performance, lighter-weight and gates by making a series of rapid, short-radius more versatile skis that fit the specific demands turns in quick succession. The event consists of of women. Bindings have been moved slightly two runs, each lasting 35–60s. forward and the skis have softer, more balanced flexes. Ski boots are being made in smaller sizes, Giant slalom with truer fitting lasts and less-stiff shells. However, along with the growing participa- Giant slalom is performed on a longer course but tion has come the inevitable injuries. Overall, the gates are more widely spaced. Skiers attain the incidence of injuries is similar for women moderate speeds and show more fluid progres- and men skiers of comparable skill (Shealy & sion from gate to gate. The course takes 50–90s to Ettlinger, 1996), although women appear to have complete. at least twice the rate of knee injuries, especially 613 614 sport-specific injuries: prevention and treatment

sprains (Shealy, 1993; Bladin & McCrory, 1995; Super giant slalom Davidson & Laliotis, 1996). The total injury rate Super giant slalom is a hybrid of giant slalom and for women is similar to that for downhill skiing downhill, combining speed and the technical (Shealy & Ettlinger, 1996). skill of turning. It involves high-speed, short- radius turns on a longer, winding course, with Physiology of female skiers greater distance between the gates. Runs last from 60 to 120s. Physiological studies of skiers are being carried out but few focus on gender-specific differences. Studies of body fat composition show that Downhill female skiers on the US national alpine team Downhill is the longest and fastest of the alpine average 13.1% body fat compared with 6.1% in events. It has a long course that follows the fall male skiers and 21–29% in non-athletes (White & line of the mountain, with women skiers achiev- Johnson, 1993; Gibbs, 1994). In 1980, these body ing speeds of up to 128km·h–1 while negotiating fat values were 20.6% and 10.2% for female and terrain and turns. Runs last approximately male skiers respectively, showing that lean body 90–140s. mass has increased in these athletes over the past decade. Skiers tend to have a blend of muscle fibre Freestyle skiing types, predominantly the slow-twitch type, to Freestyle skiing is a recent addition to the meet the high aerobic and anaerobic demands Olympics. Not a traditional alpine event, it of the sport (Tesch, 1995). Aerobic demands involves a series of stunts or acrobatics per- are highest in the longer giant slalom event, formed on a downhill slope (Wallechinsky, 1993). although the importance of aerobic power to suc- It consists of several separate events. In mogul cessful competition in the sport is unclear (White skiing, competitors combine ‘stunts’ and fluidity & Johnson, 1993). Anaerobic power appears to while skiing on steep, bumpy (mogul) terrain. contribute about 65% of the energy of alpine Aerial skiing involves flips, twists and other skiing and to be a more important determinant of acrobatics performed from a ski jump. In ballet success (White & Johnson, 1993; Bacharach & skiing, classical ballet moves, such as arabesque, von Duvillard, 1995). are combined with other dance-like movements Alpine skiers demonstrate very high leg on a short, smooth slope. Data on injuries specific strength compared with other athletes, and to this sport have not yet been published but are strength of the leg muscles, particularly the likely to be similar to those for other downhill ski quadriceps and hamstrings, helps predict per- events, and potentially include head and neck formance for both men and women (White & injuries. Johnson, 1993). In addition, élite female skiers show greater eccentric, but not concentric, knee extensor strength, enabling them to perform the Snowboarding slow, forceful eccentric muscle actions needed Snowboarding is another relatively new down- during turns in the slalom (Tesch, 1995). hill sport that is gaining popularity among Being a mountain sport, alpine skiing places its women. Studies show that the injuries sustained participants at altitudes capable of inducing are somewhat different from those in alpine physiological changes. In a recent study by skiing. In snowboarding, impact injuries from Chapman et al. (1998), women were found to falling are seen more commonly than the twist- respond to hypobaric hypoxia in the same way as ing and bending injuries typical of alpine skiing, men, i.e. increase in red cell mass, haemoglobin with less knee injuries but more arm and wrist level and haematocrit, provided they had suffi- alpine skiing 615

cient iron available. At altitude, an increase in red down from an earlier rate of 25% (Bouter & Knip- cell mass is needed to accommodate the lower schild, 1989; Greenwald et al., 1996). amount of oxygen available. If this compensation However, while the overall number of lower- is inadequate (e.g. as in low iron stores and/or leg injuries has declined, the rate of knee injuries anaemia), it could affect training and perfor- has almost tripled since 1972 (Johnson, 1995). mance. Although complete data are not avail- Knee injuries now comprise over 40% of all able, preliminary results from European skiers injuries in some studies, with the ACL being indicate that 20% have low iron stores as most frequently injured (Greenwald et al., 1996). reflected by low ferritin levels (mean 11± The ACL accounts for 30–50% of all knee injuries 5.1ng·ml–1) (N. Meyer, personal communication, (Greenwald et al., 1996) and approximately 15% 1997). In cross-country skiing, which is more of all skiing injuries (R.J. Johnson, personal com- of an endurance sport, 67% of women have munication, 1997). In fact, skiing ranks as one of been shown to have low iron stores (J. Stray- the most dangerous activities as regards the Gundersen & B.D. Levine, personal communica- ACL, with injury rates near those for American tion, 1997). football (Ettlinger et al., 1995) (Table 41.2). Although men and women have similar rates of injury overall, their rates of knee injury do Incidence of injuries vary more. Greenwald et al. (1996) surveyed the Estimates for alpine skiing injuries generally lie injuries over a 5-year period at one large Utah ski in the range of two to four serious injuries per area and found that the knee accounted for 53% 1000 skier-days (Bouter & Knipschild, 1989; of downhill injuries in women but only 30% in Ettlinger et al., 1995). Women have slightly men (P<0.0001) (Table 41.3). In a 2-year nation- greater rates of injury than men (Ekeland et al., wide study by Shealy and Ettlinger (1996), knee 1993; Shealy, 1993) (Table 41.1). The overall inci- injuries were twice as common in women skiers dence of skiing injuries has declined for both as in men (43.5% vs. 22.9%) (Fig. 41.1). On the US men and women over the past several decades, skiing team, 85% of the women have torn their largely because of improvements in skiing equip- ACL compared with 75% of the men (R. Watkins, ment. Most of the decline is in lower extremity Medical Coordinator, USA Skiing, personal com- injuries, which have decreased from 80% of all munication). injuries in 1960 to 55% in 1980 (Bouter & Knip- The causes of injuries also differ between schild, 1989) and to 40% in 1993 (Ekeland et al., 1993). The pattern of injury in the lower extrem- ity has also changed as there are fewer ankle and Table 41.2 Rates of anterior cruciate ligament injury foot injuries (45% in 1960 to 10% in 1980) (Bouter among different activities. (Adapted from Ettlinger et al., 1995) & Knipschild, 1989). Fractures of the tibia now account for only 2% of skiing injuries in women, Activity/study Rate (per population at risk)

General population Miyasaka et al. (1991) 40/100000 per year Table 41.1 Injury rates for downhill skiing per 1000 Nielsen & Yde (1991) 30/100000 per year skier visits. (Adapted from Shealy, 1993) American football Hewson et al. (1986) 60/100000 per day Female Male Alpine skiing Feagin et al. (1987) 70/100000 per day Overall 3.44 2.21 Johnson et al. (1993) 50/100000 per day Beginner 9.48 8.38 ISSS* (1986) 30/100000 per day Intermediate 2.60 2.26 Advanced 0.94 0.88 ISSS (International Society for Skiing Safety) data are unpublished. 616 sport-specific injuries: prevention and treatment

males and females. Overall, 70–90% of injuries per million skier-days) and even rarer among are due to falls, with 11–20% due to collisions female skiers (Shealy & Thomas, 1996). Of 329 (Bouter & Knipschild, 1989). Impact injuries, trauma-related deaths in the USA between 1976 resulting from collisions with other skiers or and 1992, only 56 (17.1%) were women. Most objects or from impact with the snow, are more deaths resulted from collisions with fixed objects, common in males, as evidenced by their higher although a higher proportion of females (particu- percentage of fractures, lacerations and disloca- larly preadolescent girls) died from collisions tions (Fig. 41.2, Table 41.3). Twisting or bending, with other skiers, usually being struck by adult resulting in sprains, is a more common mecha- males (Shealy & Thomas, 1996). nism of injury in women (Shealy & Ettlinger, 1996). However, among expert skiers, the rate of Risk factors for injury impact and trauma injuries is greater regardless of gender (Greenwald et al., 1996). Risk factors for downhill skiing injury can be Fatalities are rare among skiers (0.55 deaths divided into several groups, as shown in Table 41.4 (Bouter & Knipschild, 1989). Many of these risk factors are interrelated, making it difficult to Table 41.3 Type of Alpine ski injuries by gender, 1989–93. (Data from Greenwald et al., 1996) isolate the independent contribution of each to an injury, and studies have not defined their rela- Female (%) Male (%) tive importance to female compared with male skiers. Knee 53 30 Upper extremity injury 13 19 Lower extremity fracture 2 3 Personal characteristics Upper extremity fracture 5 8 Laceration 3 11 Children, especially those aged 11–13, and adults Other 2 6 over age 40 tend to have a higher rate of injuries. Miscellaneous trauma 14 18 Children have a nine-fold increased risk of leg Miscellaneous medical 6 5 fractures compared with adult skiers, and a lack

50

45 40

35 30

25

Percentage 20

15 10

5

0 Knee Shoulder Head Lower Thumb Ankle Face Wrist leg

Location of injury

Fig. 41.1 Distribution of ski injuries by gender: women skiers () have almost twice the rate of knee injuries as men ( ). (Data from Shealy & Ettlinger, 1996.) alpine skiing 617

70

60

50

40 Fig. 41.2 Types of injuries in Alpine skiers by gender: fractures, 30

lacerations and dislocations, often Percentage caused by impact injuries, are 20 more common among male skiers ( ), whereas strains and sprains (including knee injuries) are 1.5 10 times more common in women (). (Data from Shealy & Ettlinger, 0 1996.) Sprains/strains Fractures Lacerations Dislocation

Table 41.4 Potential risk factors involved in downhill in other sports, despite expectations, do not skiing injuries. (Adapted from Bouter & Knipschild, appear to lower the risk for injury (Bouter & 1989) Knipschild, 1989). However, the influence of Personal characteristics conditioning may be confounded by increased Age risk-taking among better-conditioned skiers. Gender Common belief holds that injuries tend to occur Physical conditioning more often when skiers are fatigued, usually on Hormonal factors their ‘last run of the day’. However, epidemio- Skill level logical data are not available to support this Ability view. Nevertheless, the glycogen depletion that Experience Lessons occurs in muscle fibres after a day of skiing, plus the additive effects of several days’ skiing, may Equipment predispose to fatigue and injury. A diet that Bindings/settings Boots includes complex carbohydrates may help to Poles maintain glycogen levels and is recommended Behaviour during skiing trips (Gibbs, 1994; Steadman & Fear Scheinberg, 1995). The higher altitudes of ski Risk-taking slopes may predispose skiers to relative hypoxia Alcohol before they become acclimatized, compounding Nutrition the fatigue and risk of injury (Greenwald et al., Fatigue 1996). Environment Snow quality Weather conditions Level of skill and training Difficulty of course Time of day Beginners have a considerably greater risk of Altitude injury, up to 10-fold higher than that of advanced skiers (see Table 41.1) (Shealy, 1993). Experience or the number of seasons skied appears to relate of skill and poorer-quality equipment may be inversely to the risk of injury, even after skill level partly responsible (Bouter & Knipschild, 1989; (beginner, intermediate, expert) is allowed for in Ekeland et al., 1993). calculations (Fig. 41.3) (Bouter & Knipschild, Good physical conditioning and participation 1989; Ekeland et al., 1993). Skiing lessons also 618 sport-specific injuries: prevention and treatment

2.0 n=45/63* Failure of bindings to release during falls or stress is a common mechanism of injury (Bouter 1.5 n=29/52 et al., 1989). Nevertheless, many skiers adjust their release bindings higher than the recom- 1.0 mended setting to prevent premature release, n=48/198** especially during racing (Johnson, 1995). Binding Injury ratio adjustments have been shown to average 85% 0.5 above the recommended settings in individuals who sustain knee injuries and 150% above the 0 0–2 3–4 >5 recommended settings in individuals who Alpine season sustain fractures of the tibia (Bouter et al., 1989). For women, the practice of ‘cranking down’ the Fig. 41.3 Ratio of lower extremity equipment-related binding adjustments may be especially problem- injuries as a function of skiing experience. n, number of atic. Some women racers set their release bind- < < injured/uninjured skiers; *, P 0.01; **, P 0.02. (From ings at levels similar to those used by male racers Ekeland et al., 1993 with permission.) even though the males tend to be 30–45kg heavier. This setting substantially increases the torsion sustained by the female knee before the appear to help lower the risk of injury (Ekeland et ski releases. Release bindings are thus a key focus al., 1993), although some studies dispute this of injury research. finding (Shealy, 1993). Types and mechanisms of injury Equipment Knee injuries Improvements in equipment, such as release bindings and ski boots, have helped reduce Although improvements in ski equipment have the overall rate of leg injuries by 60% since the resulted in a dramatic decline in lower extremity 1970s (Johnson et al., 1980). However, despite injuries since the 1950s, knee injuries still account this reduction, equipment-related injuries still for a significant number of all injuries. Knee account for approximately 20% of all injuries injuries result primarily from the twisting and and 90% of injuries to the lower extremity bending of the leg associated with falls (Ekeland (R.J. Johnson, personal communication, 1997). et al., 1993), although the stresses associated These injuries also tend to be severe (Ekeland et with competitive ski racing also can induce al., 1993). In a study of recreational skiers, knee damage without falls (Ellman et al., 1989; Ekeland et al. (1993) found that 33% of lower Johnson, 1995). Most resulting injuries involve extremity, equipment-related injuries required the knee ligaments. hospitalization, with most of these (60%) involv- ing the knee. anterior cruciate ligament Modern ski equipment, while helping to reduce the number of ankle and tibial injuries, The ACL is the most common site of knee injury, has not reduced risk to the knee. High, stiff ski accounting for 60% of knee injuries in skiers boots, which rigidly fix the ankle and lower leg, (Steadman & Sterett, 1995). Four common mech- and a new style of ski that carves the snow much anisms of ACL injury are seen in skiers, and these more responsively than older models translate differ from those seen in other sports. The first forces from the lower leg to the knee. This stress three mechanisms are common among recre- can be compounded by the use of high settings ational skiers, whereas the fourth usually occurs on release bindings (Johnson, 1995). in competitive skiers. alpine skiing 619

Fig. 41.5 Phantom foot. An internal rotation injury, without hyperextension, occurs when the ski curves Fig. 41.4 Hyperextension, external rotation and valgus inward on its inside edge while a skier falls back or is stress on the knee, leading to possible damage to the sliding after a fall. The tail of the ski acts as a lever to anterior cruciate ligament and other ligament injury. twist the foot and lower leg inward, opposite to the (Adapted from Steadman & Scheinberg, 1994.) natural direction of the foot in this position. (Adapted from Steadman & Scheinberg, 1994.)

1 The first mechanism occurs when the body is medial rotation of the foot relative to the ski moving forward relative to the skis, causing (Ettlinger et al., 1995). This scenario may be the hyperextension of the knee, external rotation of most common mechanism of knee injuries the tibia on the femur and a valgus load to the among skiers (R.F. Johnson, personal communi- knee. Such a situation occurs when a skier cation, 1995). catches a ski-tip on a gate or in the snow. The 4 The final mechanism of injury, known as boot- torsion across the knee joint leads to possible induced ACL injury, is seen mostly among com- ACL injury, as well as to injury of the meniscus petitive skiers. It occurs usually when a skier is or medial collateral ligament (Johnson, 1995; landing from a jump, with the skier off balance Steadman & Sterett, 1995) (Fig. 41.4). and leaning backward relative to the skis. The 2 The second mechanism involves hyperexten- skier instinctively extends the leg and knee in an sion and internal rotation of the knee during a attempt to recover balance. As the skier lands, the forward fall, such as occurs when a skier crosses tail of the ski hits first, pushing the top of the boot the ski-tips or catches the outer edge of the ski in against the calf, while the skier contracts the the snow, turning the ski inward. quadriceps to hold the leg in rigid extension. 3 Internal rotation with hyperflexion of the knee When the boot heel hits the snow, the impact may also be seen in association with a backward drives the boot top forward, pushing the tibia out fall, an injury termed ‘phantom foot’ (Ettlinger et from under the femur (anterior subluxation) and al., 1995; Steadman & Scheinberg, 1995) (Fig. tearing the ACL (Johnson, 1995; Steadman & 41.5). It occurs as the skier falls backward or ‘sits Sterett, 1995) (Fig. 41.6). down’ while the tail of the ski engages the snow with no contact on the front portion. The result is 620 sport-specific injuries: prevention and treatment

factors predisposing to knee injuries in women

Although the precise reason for the higher rates of knee injury sustained by women remains unknown, several factors have been discussed and are being studied (Arendt, in press; see also Chapter 15). These factors may include: • imbalance in muscle strength between the quadriceps and hamstring; • neuromuscular control, including errors in muscle recruitment; • joint laxity; • lower extremity alignment; • pronated foot; • femoral notch dimension; • ligament size. Fig. 41.6 Boot-induced injury to the anterior cruciate In skiing, it is most likely that an interplay of ligament. The skier, losing her balance while jumping, multiple anatomical and biomechanical factors, attempts to recover balance by extending the leg. On combined with extrinsic stresses due to the lever landing, the tail of the ski hits first, pushing the top of action of the skis and inappropriately set bind- the boot against the calf; the skier responds by contract- ing the quadriceps to hold the leg in extension. As the ings, result in the increased risk of injury. boot heel strikes, the impact pushes the top of the boot forward and forces the tibia out from under the femur, prognosis tearing the anterior cruciate ligament. (Adapted from Steadman & Scheinberg, 1994.) Despite serious knee injuries, skiers may return to full competitive activity following rehabilita- tion and, in many cases, fully regain or surpass medial collateral ligament their world standings before the injury (Ekeland & Vikne, 1995). However, the road to complete Injuries to the medial collateral ligament may be rehabilitation can be a long one. An assessment the most common knee injury overall but tend to of the psychological reactions to injury shows be underreported (Warme et al., 1995). Many that social concerns, particularly the loss of minor falls may result in such injuries. These fellowship with team members and lack of sprains typically result from ski rotation with no contact with coaches, are significant sources binding release or from the boot catching in the of stress for injured skiers (D. Gould, unpub- snow after binding release. Combined injuries of lished observation). Factors that injured skiers the anterior and medial collateral ligaments may identify as helping to facilitate their recovery occur (Duncan et al., 1995; Steadman & Sterett, include having injured role models for reference, 1995). undertaking rehabilitation with others and receiving support from coaches, teammates and meniscus friends. Maintaining contact and communication with teammates and coaches helps ease the sense Isolated tears of the medial or lateral meniscus of isolation while waiting for the return to sport. have been reported in skiers (Steadman & Sterett, After being cleared to return to skiing, injured 1995). skiers often must overcome fear of reinjury, learn technical adjustments to compensate for the pre- vious injury and adapt to initially lower perfor- alpine skiing 621

mance expectations (D. Gould, unpublished about 25% of all injuries (Bouter & Knipschild, observation). 1989; Greenwald et al., 1996). prevention thumb

Proposals to reduce the number of knee injuries Skier’s thumb, a sprain or rupture of the ulnar in skiers have focused on better programmes of collateral ligament of the metacarpophalangeal muscular conditioning as well as the develop- joint of the thumb, may be the most common ment of ‘smart’ ski bindings that sense when injury among skiers. It accounts for 7–20% of dangerous forces are being transmitted to the injuries (Bouter & Knipschild, 1989; Warme et al., knee (Johnson, 1995). In one approach, Ettlinger 1995). However, because the injury is not immo- et al. (1995) used videotapes to demonstrate the bilizing, it frequently goes unreported. The mechanisms of knee injuries and the situations injury occurs most often during a fall while the and positions that put the knee at risk, showing hand is grasping the ski pole. As the hand is these to a population of ski instructors and ski jammed into the snow, the thumb is forced back patrol staff. During the 1993–94 winter season, into abduction and hyperextension, stressing the the rate of ACL injuries declined by 62% among ulnar collateral ligament. Alternatively, on the trained skiers compared with the rates for the softer snow in the western USA, skier’s thumb two previous seasons, while there was no decline may occur during a fall when the outstretched in a control group. These authors also found that hand is jammed into soft snow (Fricker & Hinter- many ACL injuries occurred when skiers ‘caught mann, 1995; Steadman & Scheinberg, 1995). the edge of the ski while sliding’ or ‘lost control and fought falling’. Among their recommenda- shoulder tions to skiers for preventing injury are the fol- lowing (Ettlinger et al., 1995; Anon., 1996). Shoulder injuries, including acromioclavicular • Do not fully straighten the legs when falling; sprains, dislocations and bruises, are common keep the knees flexed. among skiers but are significantly more frequent • Do not try to get up until you have stopped and severe among male skiers (Westin et al., 1995; sliding. Greenwald et al., 1996). They typically result • Do not land on your hand; keep the arms up from impact or collision accidents, which are and forward, and do not push off with the hand more common among men (Shealy & Ettlinger, to recover from a fall. 1996). • Do not jump unless you know where and how to land; land on both skis and keep the knees Medical issues flexed. During skiing, ‘safe’ practice is to keep the arms Few studies have focused on the medical issues forward and hands over the skis, keep the skis seen specifically in female alpine skiers, although together with hips above the knees, and maintain skiers can be assumed to share the problems balance and control (Anon., 1996). Other safety common to other female athletes. Pertinent data recommendations include paying attention to must be extracted from broader studies of mixed weather and snow conditions as well as the populations of athletes. boundaries of the ski slope. A study of Canadian athletes preparing for the 1988 Winter Olympics showed that 20% of these female alpine skiers had anaemia and 20% had Upper extremity injuries low serum ferritin levels (Clement et al., 1987). Upper extremity injuries, including sprains and The average rate for anaemia among all female fractures, have increased as lower extremity winter athletes was 8%, with the highest rate of injuries have declined and now account for 50% being seen among female cross-country 622 sport-specific injuries: prevention and treatment

skiers. Dietary counselling may be needed for abdominal injury and skiing should be consid- alpine skiers as well as for athletes in general. ered more carefully. As the uterus expands and Another common problem in female athletes is the woman’s centre of gravity shifts, alterations amenorrhoea, although no studies have identi- in balance become a theoretical risk (Farrell, fied its incidence specifically among alpine skiers 1986). The hormone relaxin, produced during (Ronkainen et al., 1984). Likewise, no published pregnancy, promotes ligamentous relaxation and studies have considered eating disorders in increases joint laxity, although the effect on female skiers, although these athletes are under injuries is unknown. the same societal stresses to remain thin as other Although it is known that fetal birth weight young women. However, a check of the Swiss decreases with increasing altitude (Unger et al., alpine ski team has identified several women 1988), the effect of transient exposure to with amenorrhoea or oligomenorrhoea, includ- increased elevations is unknown. A pregnant ing one with an eating disorder (N. Meyer, per- woman unacclimatized to higher altitudes sonal communication, 1997). should avoid intense exercise during the first 3 or Exercise-induced bronchospasm may be 4 days at altitudes above 1980m; those exposed aggravated by cold dry air, especially in asthmat- to altitudes above 3048m should ascend no more ics or endurance athletes, i.e. cross-country than 305m a day in order to avoid altitude sick- skiing (Sue-Chu et al., 1996). Metered-dose ness (Kulpa, 1994). Mild altitude sickness may inhalers for asthma may not work well in the occur at altitudes above 2438m and exhibits cold and should be kept warm in an inside symptoms of headache, difficulty sleeping, easy pocket. A form of motion sickness, termed ‘ski fatigue and nausea. sickness’, that can be relieved with vestibular suppressants has been described among some Social issues women downhill skiers (Hausler, 1995). In young women and men who regularly travel away from home to compete, social behaviour Pregnancy and coaching relationships should be monitored In 1989, Ulrike Maier won the super giant slalom regularly. Young athletes are psychologically world championship when she was in the early vulnerable. Relationships with coaches may be second trimester of pregnancy (tragically, she very positive or problematic, and the potential died in a skiing accident 5 years later). Although for abuse, including sexual abuse, must be few women ski competitively while pregnant, considered. Recommendations might include a many pregnant women can be assumed to par- ‘buddy’ system, so that one athlete cannot be iso- ticipate in recreational skiing (Farrell, 1986). The lated, athlete-advocates, parent-chaperones and risks of skiing for pregnant women remain a code of ethics for coaches (see Chapter 23). largely unknown and unstudied. Official guide- lines, such as those issued by the American Conclusion and recommendations for College of Obstetricians and Gynecologists future research (1994), recommend general exercise during preg- nancy but do not address skiing specifically. Increasing numbers of women are now partici- The risk of abdominal trauma posed by skiing pating in alpine skiing at both competitive and is minimal. As abdominal or thoracic injuries recreational levels. The overall rate of injuries is account for only 5.6% of injuries in female alpine similar for women and men of comparable skill, skiers (Shealy & Miller, 1991), skiing should pose although women appear to have at least twice little risk during the first trimester provided the rate of knee injuries, especially those involv- there are no complications. By the second trim- ing the ACL (Shealy & Ettlinger, 1996). Addi- ester, the larger uterus becomes more at risk for tional research is needed on the mechanisms of alpine skiing 623

ACL injury in female athletes generally and York; Dr Jim Stray-Gundersen MD, Dallas; and downhill skiers specifically. Dr Richard Watkins MD, USA Skiing, Park City, Improvements in the design of ski equipment Utah. In addition, the author is grateful to Ms have already lowered the high rate of ankle and Anne Robertson, librarian at the Virginia Mason leg injuries, but a new generation of equipment Medical Clinic, for her research assistance; Starr will be needed to address the problem of knee Kaplan of Seattle for her medical illustrations; injuries (Johnson, 1995). To prevent injury, an and Mr Mike Bokulich of Narberth, Pennsylva- education programme that teaches skiers about nia for his help in writing the manuscript. the positions and mechanisms that put the knee at risk of injury appears to offer an effective solu- References tion (Ettlinger et al., 1995; Anon., 1996), although funding will be needed to develop and imple- Anon. (1996) ACL Awareness ’96. Videotape, parts 1 and ment the programme further. In addition, skiing 2. Vermont Safety Research, Underhill Center, Con- organizations need to recognize the safety necticut, USA. American College of Obstetricians and Gynecologists aspects of the release binding (Johnson, 1995) (1994) Exercise During Pregnancy and the Postnatal and consider rule changes that do not penalize Period. American College of Obstetricians and Gyne- racers when ski release occurs. cologists, Washington, DC. Medical issues among female alpine skiers are Anon. (1997) Title IX: equity in sports: short of the goal largely unstudied, and the menstrual disorders (schools close gender gap and women sports show revenue gains). USA Today, 4 March, section C, p. 6. and eating behaviours seen in other female ath- Arendt, E.A. (in press) Anterior cruciate ligament letes are also possible in this group of athletes. In injuries in women. addition, the influence of hormonal factors on Bacharach, D.W. & von Duvillard, S.P. (1995) Inter- the risk of injury should be investigated further. mediate and long-term anaerobic performance of As in other sports, factors that enhance perfor- elite Alpine skiers. Medicine and Science in Sports and Exercise 27, 305–309. mance are always a key subject for study; in Bladin, C. & McCrory, P. (1995) Snowboarding injuries: skiing these include nutrition, equipment, train- an overview. Sports Medicine 19, 358–364. ing, iron and mineral supplementation, psy- Bouter, L.M. & Knipschild, P.G. (1989) Causes and pre- chology and coaching. There are still many vention of injury in downhill skiing. Physician and more unanswered questions than answered ones Sportsmedicine 17, 81–94. Bouter, L.M., Knipschild, P.G. & Volovics, A. (1989) but we are now beginning to formulate the Binding function in relation to injury risk in down- questions. hill skiing. American Journal of Sports Medicine 17, 226–233. Chapman, R.F., Stray-Gundersen, J. & Levine, B.D. Acknowledgements (1998) Individual variation in response to altitude training. Journal of Applied Physiology 85(4), 1448– The author is grateful to the many people with 1456. whom she had conversations about this chapter Clement, D.B., Lloyd-Smith, D.R., Macintyre, J.G., and who generously shared their knowledge Matheson, G.O., Brock, R. & Dupont, M. (1987) Iron and data. They include Karen Briggs, Steadman- status in Winter Olympic sports. Journal of Sports Hawkins Foundation, Vale, Colorado; Deanne Science 5, 261–271. Davidson, T.M. & Laliotis, A.T. (1996) Snowboarding Eakin, Olin Skis, Seattle, Washington; Dr Dan injuries: a four-year study with comparison with Gould, University of North Carolina, Greenbor- alpine ski injuries. Western Journal of Medicine 164, ough, North Carolina; Dr Robert Johnson MD, 231–237. University of Vermont, Burlington, Vermont; Duncan, J.B., Hunter, R., Purnell, M. & Freeman, J. Nanna Meuer, Trainer, Swiss Alpine Women’s (1995) Meniscal injuries associated with acute ante- rior cruciate ligament tears in alpine skiers. American Ski Team; Dr Steve Springmeyer MD, Virginia Journal of Sports Medicine 23, 170–172. Mason Medical Center, Seattle, Washington; Ekeland, A. & Vikne, J. (1995) Treatment of acute com- Dawn Straw, Women’s Sports Foundation, New bined knee instabilities and subsequent sport per- 624 sport-specific injuries: prevention and treatment

formance. Knee Surgery in Sports: Traumatology and Issues in Active and Athletic Women, pp. 191–199. Arthroscopy 3, 180–183. Hanley & Belfus, Philadelphia. Ekeland, A., Holtmoen, A. & Lystad, H. (1993) Lower Miyasaka, K.C., Daniel, D.M., Stone, M.L. et al. (1991) extremity equipment-related injuries in alpine recre- The incidence of knee ligament injuries in the general ational skiers. American Journal of Sports Medicine 21, population. American Journal of Knee Surgery 4, 3–8. 201–205. Nielsen, A.B. & Yde, J. (1991) Epidemiology of acute Ellman, B.R., Holmes, E.M., III, Jordan, J. & McCarty, P. knee injuries: a prospective hospital investigation. (1989) Cruciate ligament injuries in female Alpine ski Journal of Trauma 31, 1644–1648. racers. In R.J. Johnson, C.D. Mote Jr & M.-H. Binet Ronkainen, H., Pakarinen, A. & Kauppila, A. (1984) (eds) Skiing Trauma and Safety: Seventh International Pubertal and menstrual disorders of female runners, Symposium, pp. 105–111. American Society for skiers, and volleyball players. Gynecologic and Obstet- Testing and Materials, West Conshohocken, Pennsyl- ric Investigation 18, 183–189. vania. Shealy, J.E. (1993) Snowboard vs. downhill skiing Ettlinger, C.F., Johnson, R.J. & Shealy, J.E. (1995) A injuries. In R.J. Johnson, C.D. Mote Jr & J. Zelcer method to help reduce the risk of serious knee (eds) Skiing Trauma and Safety: Ninth International sprains incurred in alpine skiing. American Journal of Symposium, pp. 241–254. American Society for Sports Medicine 23, 531–537. Testing and Materials, West Conshohocken, Pennsyl- Farrell, M.J.D. (1986) Skiing for two. Skiing February, vania. 101–103. Shealy, J.E. & Ettlinger, C.F. (1996) Gender-related Feagin, J.A., Lambert, K.L., Cunningham, R.R. et al. injury patterns in skiing. In C.D. Mote Jr, R.J. (1987) Consideration of the anterior cruciate liga- Johnson, W. Hauser & P.S. Schaff (eds) Skiing Trauma ment injury in skiing. Clinical Orthopaedics and and Safety, 10th edn, pp. 45–57. American Society for Related Research 216, 13–18. Testing and Materials, West Conshohocken, Pennsyl- Fricker, R. & Hintermann, B. (1995) Skier’s thumb: vania. treatment, prevention, and recommendations. Sports Shealy, J.E. & Miller, D.A. (1991) A relative analysis of Medicine 19, 73–79. downhill and cross-country ski injuries. In C.D. Mote Gibbs, P. (1994) Skiing. In R. Agostini (ed.) Medical and Jr & R.J. Johnson (eds) Skiing Trauma and Safety: Orthopedic Issues in Active and Athletic Women, pp. Eighth International Symposium, pp. 133–143. Ameri- 347–354. Hanley & Belfus, Philadelphia. can Society for Testing and Materials, Philadelphia. Greenwald, R.M., France, E.P., Rosenberg, T.D. & Shealy, J.E. & Thomas, T. (1996) Death in downhill Toelcke, T. (1996) Significant gender-differences in skiing from 1976 through 1992: a retrospective view. Alpine skiing injuries: a five-year study. In C.D. Mote In C.D. Mote Jr, R.J. Johnson, W. Hauser & P.S. Schaff Jr, R.J. Johnson, W. Hauser & P.S. Schaff (eds) Skiing (eds) Skiing Trauma and Safety, 10th edn, pp. 66–72. Trauma and Safety, 10th edn, pp. 36–44. American American Society for Testing and Materials, West Society for Testing and Materials, West Con- Conshochocken, Pennsylvania. shohocken, Pennsylvania. Steadman, J.R. & Scheinberg, R.R. (1995) Skiing Hausler, R. (1995) Ski sickness. Acta Oto-laryngologica injuries. In J.A. Nicholas & E.B. Hershman (eds) The 115, 1–2. Lower Extremity in Spine and Sports Medicine, 2nd edn, Hewson, G.F., Mendini, R.A. & Wang, J.B.L. (1986) Pro- pp. 1361–1384. C.V. Mosby, St Louis. phylactic knee bracing in college football. American Steadman, J.R. & Sterett, W.I. (1995) The surgical treat- Journal of Sports Medicine 14, 262–266. ment of knee injuries in skiers. Medicine and Science in Johnson, R.J., Ettlinger, C.F., Campbell, R.J. et al. (1980) Sports and Exercise 27, 328–333. Trends in skiing injuries: analysis of a six-year study Sue-Chu, M., Larsson, L. & Bjermer, L. (1996) Preva- (1972–1978). American Journal of Sports Medicine 8, lence of asthma in young cross-country skiers in 106–113. central Scandinavia: difference between Norway Johnson, R.J., Ettlinger, C.F. & Shealy, J.E. (1993) Skier and Sweden. Respiratory Medicine 90, 99–105. injury trends 1972–1990. In R.J. Johnson, C.D. Mote Jr Tesch, P.A. (1995) Aspects on muscle properties and use & J. Zelcer (eds) Skiing Trauma and Safety: Ninth Inter- in competitive Alpine skiing. Medicine and Science in national Symposium, pp. 11–22. American Society for Sports and Exercise 27, 310–314. Testing and Materials, West Conshohocken, Pennsyl- Unger, C., Weiser, J.K., McCullough, R.E., Keefer, S. & vania. Moore, L.G. (1988) Altitude, low birth weight, and Johnson, S.C. (1995) Anterior cruciate ligament injury infant mortality in Colorado. Journal of the American in elite Alpine competitors. Medicine and Science in Medical Association 259, 3427–3432. Sports and Exercise 27, 323–327. Wallechinsky, D. (1993) The Complete Book of the Winter Kulpa, P. (1994) Exercise during pregnancy and post Olympics, pp. 117–152. Little, Brown, Boston. partum. In R. Agostini (ed.) Medical and Orthopedic Warme, W.J., Feagin, J.A. Jr, King, P., Lambert, K.L. & alpine skiing 625

Cunningham, R.R. (1995) Ski injury statistics, rapid method for reduction. American Journal of 1982–1993, Jackson Hole Ski Resort. American Journal Sports Medicine 23, 369–371. of Sports Medicine 23, 597–600. White, A.T. & Johnson, S.C. (1993) Physiological Westin, C.D., Gill, E.A., Noyes, M.E. & Hubbard, M. aspects and injury in elite Alpine skiers. Sports Medi- (1995) Anterior shoulder dislocation: a simple and cine 15, 170–178. Chapter 42

Softball

MARGARET M. BAKER

Introduction local variations in rules and equipment. Once the Amateur Softball Association (ASA) was created, A wintry November day in Chicago, 1887, led to playing rules were formalized. The ASA has also the birth of the game we now know as softball. done much to provide guidance on a national Inclement weather forced some would-be base- level in the USA and to promote widespread par- ballers into the Farragut Boat Club gymnasium. ticipation in the sport. Their efforts to devise a game of indoor base- Over the ensuing decades, thousands of ball resulted in an old boxing glove being leagues and millions of teams have appeared. laced together to form a soft ‘ball’. A smallish Participation by women and girls has rocketed. ‘diamond’ was marked off on the gym floor with Less than one generation ago, females rarely chalk and the two teams began to play. They dis- played softball. In the early 1970s, fewer than covered, that blustery day, what millions of 10000 girls played softball in American high players around the world now know to be true: schools; by the 1990s, that number exceeded this new sport was incredibly fun to play and 220000. Currently, softball is the fourth most almost anyone can participate. popular sport among high-school girls in the In the spring, the young Chicago softballers USA (Fig. 42.1). Over the last 5 years alone, took their sport outdoors. They named the game women’s participation in softball has doubled. ‘indoor-outdoors’, and its appeal began to Women’s and girls teams now dominate fast- spread. By the turn of the century, communities pitch leagues, comprising 75% of all teams in the across the USA were playing variations of the USA. Over 40 million players enthusiastically game. The city of Minneapolis embraced this participate across the USA, making softball the new pastime, adapting it for use in the fire most popular recreational sport in America. department to keep firefighters fit during idle Every culture on earth plays some sport with a time. One of the local fire companies organized a stick and a ball, and the International Softball team called the Kittens. The now popular game Federation supports growing interest world- became known as Kitten League Ball, then Kitten wide. Its intense popularity and commitment Ball for short. from countless devoted individuals led to The actual name softball did not appear until women’s fastpitch softball finally becoming an 1926 when it was suggested by a YMCA official Olympic sport at the Centennial Games in from Denver. Participation in softball boomed, Atlanta in 1996. and by the time of the Chicago World’s Fair Tour- From humble beginnings the sport of softball nament in 1933 teams were competing in fast- has grown to huge proportions. An estimated 23 pitch, slowpitch and women’s divisions. At this million games are played annually in the USA time, some confusion existed because of all the alone. As with other active sports, athletes do 626 softball 627

day of escalating healthcare costs, what is known is that decreasing the injury and cost burden is critical. The goal of this chapter is to educate the reader in an effort to minimize the incidence and impact of softball injuries. Injury prevention is the cor- nerstone, through an understanding of proper biomechanics and by creating a safer environ- ment for play (for clarification of biomechanical terminology, see Chapter 6). Regardless of an athlete’s training, education and equipment, some injuries will undoubtedly occur due to the sheer numbers of athletes participating in soft- ball around the world. Sport-specific injuries and appropriate treatment are discussed in this chapter and are related to the mechanism of injury. Treatment of the myriad of upper and lower extremity traumatic musculoskeletal injuries is not the focus of this chapter, as it is covered elsewhere in this volume and exten- sively in orthopaedic texts (Browner et al., 1992; Green & Swiontkowski, 1992; DeLee & Drez, 1994; Stanitski et al., 1994; Rockwood et al., 1996). Finally, pertinent concerns about equipment Fig. 42.1 Softball is one of the most popular sports in safety and areas for future research are also the USA among high-school girls. discussed. incur injuries from time to time. In the USA, the Functional anatomy and technique National Electronic Injury Surveillance System estimates that softball causes more injuries Windmill pitch leading to emergency room visits than any other sport (Janda et al., 1992). The rate of softball Before one can attempt to diagnose, treat or injury severe enough to require emergency atten- prevent sports overuse injuries, an understand- tion is estimated to be 2.26 injuries/1000 players ing of basic biomechanics must be gained. It is per day, or one injury in every 14.7 games critical to understand what normal healthy (Shesser et al., 1985). This rate is about half that bones, muscles and joints should be doing for recreational ski injuries (Ellison, 1973) and during a specific skill. Only then can we really 40% that of recreational soccer (Ekstrand et al., comprehend how things go awry to cause injury. 1983). However, the gross numbers of injury in Unfortunately, the vast majority of sports medi- softball are higher than other sports because of cine literature in this area deals with baseball. A the sheer number of participants. In addition to tiny percentage deals specifically with softball, emergency treatment, countless softball players although most of these articles discuss injuries in seek attention for their injuries at outpatient slowpitch softball. Very little has been published clinics and with private physicians. Because of relating to fastpitch: only one article in the the difficulty compiling the statistics on non- medical literature, to our knowledge, specifically emergency injury, the true magnitude of the addresses the biomechanics of the windmill human and economic impact is unknown. In this pitch (Alexander & Haddow, 1982). 628 sport-specific injuries: prevention and treatment

In general, ballistic skills involve transferring facing the target, weight balanced evenly momentum from the body to a relatively small between both feet, feet about shoulder width projectile. The pitcher’s goal is to maximize the apart and slightly staggered with pivot foot horizontal velocity of the projectile and repro- forward. The lead foot (contralateral to the ducibly to hit a target. Her object is, after all, to throwing arm) should be pointing towards the strike out the batter. The thrower accelerates target. The trail or pivot foot contacts the front body parts in sequence in order to impart edge of the pitching rubber, pointing at about 45° maximal momentum to the ball, although in to the target. During a conventional windup, competition not every pitch is intended to be both hands stay together anteriorly. The trunk thrown at full speed. Different pitches also have flexes as weight is transferred to the trail foot and quite different finger positions and grips. To both shoulders begin to flex. Another common simplify the mechanics, only a ‘generic’ fastball variation is the full-motion windup, where the pitch is detailed here. For the purposes of discus- hands separate and the shoulders swing into sion, the windmill pitch is broken down into extension. Regardless of the style of windup, it six phases (Fig. 42.2): windup, stride, overhead, should be relaxed and require little or no muscu- acceleration, release and follow-through. lar effort. A pitcher’s windup mostly serves to Individual pitchers have great variability in initiate timing of the subsequent sequence of the initial phase of the windmill pitch, the events. windup. This first phase of the pitch includes any The second phase of the windmill pitch begins motion prior to initiation of the stride. The same as the throwing shoulder begins circumduction pitcher may even wind up differently depending and the lead foot leaves the ground in the stride on the defensive situation. The windup, in truth, (Fig. 42.3). As the pitcher strides forward, trailing does little to propel the ball towards the batter. If leg drive translates the body’s centre of mass the shoulder is brought into full extension, towards the catcher. Also, the centre of mass is tension on the anterior soft tissues may theoreti- lowered, releasing stored potential energy. These cally provide improved muscular contractility changes in centre of mass are ultimately trans- during later shoulder flexion. Numerous studies ferred into ballistic energy of the ball. The pelvis using electromyography (EMG) have been pub- rotates from perpendicular to the flight path to a lished detailing overhand pitching, but there are more open position. Both shoulders flex, bring- none on the windmill pitch to substantiate this ing the arms in front of the trunk. The path of the theory. The windup begins with the pitcher throwing arm begins its oval-shaped arc in a

Fig. 42.2 Windmill pitch: windup, stride, overhead, acceleration, release and follow-through. softball 629

Fig. 42.3 Windmill pitch: early stride phase. Fig. 42.4 Windmill pitch: early overhead phase.

plane very close to the body. With the arc close to from extension of the trail leg as it pushes off the the body, the release point is more reproducible rubber. This force is transferred to the pelvis and and less stress is placed on the shoulder and then the trunk as forward rotation towards the elbow. target begins. A critical key to force production is During the overhead phase, the internally often the trunk. If little trunk rotation occurs, leg rotated throwing shoulder continues to acceler- drive cannot be effectively applied to the upper ate to and past the vertical overhead (Fig. 42.4). body and thus increase ball speed. The elbow is just slightly flexed and the wrist During the acceleration phase, the lead foot passively volarflexed. At the top of the arc the plants and points at the catcher when the throw- throwing arm should be fairly straight in order to ing arm is at about the 9 o’clock position during increase leverage and thus generation of torque. the downswing. A common timing problem The contralateral upper extremity moves to hori- occurs when the pitcher transfers weight to the zontal, generally pointing at the target to aid in stride foot too soon. This tends to neutralize leg balance. As the lead leg continues to stride drive if the weight shifts forward too early. forward, the pelvis and trunk rotate completely Proper timing of the weight shift should allow open (facing third base for a right-handed forward leg drive to coincide with downward pitcher). When the arm is overhead it should movement of the throwing arm (Fig. 42.6). As nearly brush the head (Fig. 42.5). The trail foot the pitching arm accelerates downward from now strongly pivots so it is parallel with the overhead, the humerus rotates into full external pitching rubber. Forcible leg drive is generated rotation. When the arm is horizontal in the 630 sport-specific injuries: prevention and treatment

Fig. 42.6 Windmill pitch: early acceleration phase. Fig. 42.5 Windmill pitch: arm vertical overhead. downswing, the position of humeral external up to 2000°·s–1 were measured, equivalent to a rotation, extension and abduction is nearly iden- shoulder circumduction rate of six revolutions tical to the cocking position of the overhand per second. Maximal shoulder distraction forces throw and creates tremendous stress on the of 100–110% body weight were recorded just shoulder. The elbow flexes to approximately 45° prior to ball release. The arm reaches peak and sustains a valgus force. As the pelvis and angular velocity towards the bottom of the arc, trunk initiate turn towards the target, the trailing then begins to decelerate and transfer its momen- leg is still driving off the rubber. The power of the tum to the forearm. At release, the elbow now legs is transferred to the pelvis, then the trunk extends to an average of 20° with the forearm and then the arm. The non-throwing arm can in supination. Peak elbow distraction forces of also assist in power generation by actively up to 65% body weight have been noted. pulling down and backwards to assist in forward Momentum is transferred to the ball with a rotation of the trunk as the throwing side moves violent flick of the wrist into volarflexion at the forward. The summation of all the forces from instant of release. Ball release should occur from the non-throwing arm, legs and trunk are trans- the hip, with the elbow just behind the hip and ferred to the throwing arm in order to gain the arm vertically downwards but close to the maximal acceleration. Biomechanical parame- trunk (Fig. 42.7). Depending on the desired type ters for élite female windmill pitchers were quan- of pitch (rise, drop, fastball, curve), the forearm tified by S. Werner (unpublished data, 1991) at stays supinated or may fully pronate. the US Olympic Training Center. Arm speeds of Follow-through is the final phase of the wind- softball 631

Fig. 42.7 Windmill pitch: ball release. Fig. 42.8 Windmill pitch: follow-through.

mill pitch (Fig. 42.8). This phase serves to decel- in some pitchers that may exceed the tensile erate body segments comfortably, dissipating strength of bone and put them at increased risk energy into large muscle groups as heat in order for stress fractures. to avoid injury. The trail leg has left the rubber, In summary, the windmill pitch is a highly body weight now being borne on the lead leg. A skilled performance of complex biomechanics pitcher’s rotational momentum causes the pelvis that has been poorly studied. It requires full cir- and trunk to close, bringing the trail leg through cumduction of the shoulder, which happens to be to plant perpendicular to the target and in a the most mobile but intrinsically unstable joint in position to field. The throwing shoulder flexes, the body. A coordinated sequence of accelera- with eccentric firing of the posterior rotator tion–deceleration events occur, controlled and cuff and periscapular muscles preventing protected by both concentric and eccentric excess tensile loading of the posterior capsule muscle action. Angular and rotational momen- and labrum. The elbow also passively flexes, tum are transferred from each succeeding being slowed by triceps action, and thus decreas- segment to the projectile. In addition to proper ing distraction force across it (Fig. 42.9). By arm motion, pelvic rotation, trail leg drive and flexing the elbow to absorb energy, less distrac- follow-through are all key elements in reducing tion stress is applied to the shoulder. Pitchers stress on the pitching arm. Skilled performance who maintain a straight elbow in follow-through is dependent on the proper timing of events, tend to experience increased shoulder distrac- and the ability reproducibly to accelerate and tion stress that may predispose them to injury. decelerate body segments without exceeding the The forearm may experience extreme pronation physiological capacity of the tissues. 632 sport-specific injuries: prevention and treatment

Fig. 42.9 Windmill pitch: elbow flexion in follow- through. Fig. 42.10 Overhand throw from short-stop.

Overhand throw

Windmill biomechanics are obviously specific the ball to where the play is. Otherwise, the bio- only to pitchers; the other eight defensive softball mechanics of overhand baseball and softball players use the overhand throw (Fig. 42.10). throwing are analogous. Many sports use an overhead motion to hit or The overhand throw is divided into five stages: propel an object (volleyball, javelin, tennis) or to windup, early cocking, late cocking, acceleration propel the athlete (freestyle or butterfly swim- and follow-through (Fig. 42.11). Windup begins ming). Although each sport has its specific when the thrower initiates her first movement pattern, these sports have much in common bio- and ends when the lead leg lifts and the ball is mechanically. By far the most studied and most removed from the glove. Like the windmill extensively described is the baseball pitch. The windup, it is quite variable depending on the literature is replete with detailed descriptions of individual and defensive situation. Minimal baseball pitching mechanics (Atwater, 1980; muscle exertion and tissue stress occur, so the Pappas et al., 1985; Feltner & Dapena, 1986; potential for injury during this phase is low. Fleisig et al., 1989, 1995; Dillman et al., 1993; Early cocking begins when the ball is removed Werner et al., 1993) and EMG analysis (Jobe et al., from the glove. The trail leg is planted, extensors 1984; Gowan et al., 1987; Sisto et al., 1987; Glous- contracting to drive the centre of mass towards man et al., 1988; Glousman, 1993). The classic the target. The body lowers as the lead leg baseball pitching windup is not useful for non- strides, releasing potential energy. The stride pitchers because of the nature of defensive play. should be long enough to generate momentum, Instead, catchers, infielders and outfielders use but not so long that the athlete cannot rotate her an abbreviated ‘windup’ to expedite release of hips and pelvis properly. Maximum stride softball 633

Fig. 42.11 Overhand throw: windup, early cocking, late cocking, acceleration and follow-through.

should be slightly less than the thrower’s height. limb. Muscles, especially the posterior shoulder The pelvis and trunk rotate open, parallel to the musculature, fire eccentrically to dissipate flight path. The scapula is retracted, elbow kinetic energy as heat to avoid injury. The flexed, and shoulder abducted, internally rotated humerus continues to flex horizontally and and extended. The contralateral upper extremity rotate internally. The elbow passes from about extends towards the target. Early cocking ends 20° flexion at ball release to 45° during follow- when the lead leg plants. through. Wrist volarflexion and pronation occur, Late cocking begins as the pelvis and trunk ini- while the trunk flexes. The trail leg passively tiate rotation towards the target. Muscular con- lifts off the ground and then swings forward to traction translates into angular velocity as the plant. lower extremity segments accelerate. The legs In summary, the overhand throw is also a coor- transfer their momentum to the pelvis, then the dinated sequence of events that is a total body trunk and then each more distal segment of the activity. Sequential activation of body segments throwing extremity. In late cocking, the throwing acts as a link system transmitting energy that shoulder achieves maximal combined external starts in the legs and ends in the throwing hand. rotation (90–120° between the glenohumeral Dramatic shoulder external rotation and elbow and scapulothoracic joints). Tremendous tensile valgus stress occur in late cocking and accelera- stresses are generated at the shoulder anterior tion. During follow-through, muscle and liga- capsule, labrum and rotator cuff. A maximum mentous forces must counteract forward velocity varus torque of up to 120N·m has been measured to decelerate the arm within the physiological at the elbow (Werner et al., 1993). tolerance of the tissues. Improper biomechanics Acceleration is the fourth phase of the over- will, over time, lead to tissue overload and hand throw. This begins with rapid internal rota- overuse injury. tion of the humerus and ends with ball release. Acceleration is explosive, lasting only about Hitting 50ms and causing peak angular velocities of 9198°·s–1 (Pappas et al., 1985). As the coiled shoul- Compared to the tremendous amount of work der is powerfully derotated, the elbow extends that has been done in the development of train- and wrist flexes and pronates. During accelera- ing and rehabilitation protocols for throwing ath- tion, considerable muscular activity is seen in the letes, there has been little study of hitting. Like subscapularis, serratus anterior, pectoralis major, throwing, batting is a coordinated sequence of latissimus dorsi and triceps. muscle activity beginning with the lower extrem- The goal of follow-through is to decelerate the ities, followed by the trunk and terminating in 634 sport-specific injuries: prevention and treatment

Fig. 42.12 Batting swing: windup, pre-swing, swing and follow-through.

the upper extremities. Understanding the biome- chanics of hitting should help physicians, coaches and players design specific training, conditioning and rehabilitation protocols to optimize performance and minimize injuries. The batting swing is divided into four phases: windup, pre-swing, swing and follow-through (Fig. 42.12). Windup begins with a stride as the lead heel leaves the ground and ends as the lead toe establishes ground contact. Weight first shifts to the trailing leg. The body is rotated in a clock- wise direction for a right-handed batter, initiated by the upper extremities and followed by the pelvis. The pelvis rotates to a maximum closed position of 28° 0.35s before ball contact (Welch et al., 1995). Next the pelvis begins to derotate coun- terclockwise, while the trunk and shoulders con- tinue to coil clockwise to a maximum of 52° relative to the ball’s flight path. Subsequently the shoulders and trunk derotate counterclockwise, following the lead of the pelvis. The arms keep coiling clockwise around the trunk as windup finishes. Pre-swing begins as the lead foot plants. Mean Fig. 42.13 Batting swing: late pre-swing. stride length should be about 380% of hip width and 12° closed (Welch et al., 1995). Weight shifts forward to the lead leg. The gluteus maximus The swing phase begins as the posterior and hamstrings fire maximally in this phase deltoid of the lead shoulder fires maximally, (Shaffer et al., 1993). This creates a counterclock- which initiates uncoiling of the upper extremi- wise acceleration of the pelvis around the axis of ties. The hands and bat now begin to move the trunk. The arms and shoulders remain maxi- forward. Maximal activity is seen in the erector mally coiled, the hands holding the bat near ver- spinae and abdominal oblique muscles so that tical (Fig. 42.13). power is transmitted from the legs as the body softball 635

and external rotation. Muscular activity of the abdominal obliques and quadriceps femoris, especially the vastus medialis obliquus (VMO), remain high during follow-through. In summary, little emphasis has been placed on the study of the batting swing in the sports medicine literature. Some limited data from elec- tromyogram (EMG), force plate and cinemato- graphic analysis have been collected. These early results have outlined the basic biomechanics of the hitting swing and reinforced the need for strengthening the erector spinae, abdominal obliques, posterior deltoid, gluteals, hamstrings and VMO. Attention should be given to eccentric as well as concentric muscle strength training.

Injury mechanisms

Injuries due to windmill pitching

Despite the fact that softball is the most popular recreational sport in America, there is a paucity of information on sport-specific injuries. Most of the literature that does exist deals with injuries Fig. 42.14 Batting swing: late swing phase with ball contact. from slowpitch softball; only a handful of articles pertain to fastpitch. Apparently, the traditional view has been that softball is less physically demanding than baseball and thus more ‘suit- uncoils. The bat accelerates from perpendicular able’ for females. An underhand pitching motion to the ground to parallel during ball contact in was assumed not to generate much speed and late swing (Fig. 42.14). The rotational velocity of put little stress on the arm compared with the the bat has been measured at up to 1588°·s–1, with overhand throw. Anyone who has witnessed a linear speeds of 29m·s–1 prior to impact (Welch et competitive women’s fastpitch game knows that al., 1995). Triceps brachii now fire to extend the this is a fallacy. Female fastpitchers can attain ball elbows. The trailing elbow extends near full at speeds upwards of 160km·h–1 and have been the point of impact, transferring the last amount known repeatedly to strike out male major- of angular velocity to the uncocking bat. Acting league baseball stars. like a block, the lead leg supports about 84% of Perhaps the false belief that windmill pitching body weight, with the knee flexed 15°. The trunk is not stressful has led to competitive fastpitchers is positioned in slight extension, continuous with often being assigned to pitch consecutive the lead leg acting as a stable post for continued double-headers, long batting practices and mul- rotation. tiple tournament games. For baseball, even at the Follow-through begins after ball contact. The Little League level, rules limit pitching time in body slows itself and the bat via eccentric muscle order to minimize overuse. Such rules are not in action, which diffuses energy through large effect to protect softball pitchers. One study has muscle groups. The pelvis, trunk and shoulders verified that fastpitchers have significant injuries finish full counterclockwise rotation, with the related to pitching (Loosli et al., 1992). High- lead shoulder ending in maximal abduction calibre pitchers in National Collegiate Athletic 636 sport-specific injuries: prevention and treatment

Association (NCAA) tournament championship forearm pain during pitching without any trau- teams were surveyed. A total of 26 injuries were matic event. They had tenderness and slight identified in 20 of 24 pitchers; 82% of injuries that swelling over the mid-ulnar shaft. Radiographs involved time lost from practice or games were showed a transverse incomplete fracture line in upper extremity injuries. The athletes pitched an each, with periosteal new bone formation. Cross- average of 139 innings per season (average of sectional computerized tomography of the ulna 19.9 complete games). The vast majority of in six normal volunteers was performed. The injuries (81%) were from overuse, most fre- diameter of the ulnae were smallest at mid-shaft, quently the shoulder (rotator cuff, tendonitis, exactly where the stress fractures had occurred. biceps, trapezius strain) and elbow (tendonitis, The investigators concluded that extreme prona- ulnar neuritis, arthralgia). The exact mechanisms tion of the forearm during follow-through of injury and details of the diagnosis were not resulted in torsional shear on the ulna. Fatigue specified in this study so it is somewhat difficult fracture occurred when bone remodelling and to determine the aetiology. Extreme shoulder repair could not compensate for repetitive abduction, extension and external rotation microtrauma. during the acceleration phase of the windmill Unpublished data from team physicians at the pitch may produce transient anterior gleno- 1996 Olympic Games and NCAA Champion- humeral subluxation similar to the overhand ships also identified an incidence of spine prob- throw. This can result in secondary impinge- lems in female softball players (J. Henderson, ment and labral tears. Elbow valgus stress just personal communication, 1997). Hyperextension prior to ball release may be responsible for of the spine in pitchers during ball release and ulnar neuritis and flexor–pronator tendonitis. exaggerated lordosis in first- and third-base Improper arm deceleration in follow-through fielders in the crouch position was felt to con- could produce trapezius strain. Further study tribute. Posterior element stress was indicated into windmill biomechanics as related to the by specific injuries, including lumbar spondyl- aetiology and incidence of injury is definitely olysis, facet syndrome, interspinous ligament warranted. strain and sacroiliac joint dysfunction. Anterior Radial neuropathy has been reported in com- element stress was indicated by other injuries, petitive windmill pitchers (Sinson et al., 1994). including lumbar degenerative disc disease and Patients complained of posterior shoulder sore- thoracic endplate apophysitis. Other miscella- ness and progressive weakness without ante- neous conditions identified were sacrospinalis cedent trauma. Neurological examination and spasm, sacral torsion and lumbodorsal fasciitis. EMG were positive for radial nerve palsy at the Further research in this area would better clarify level of the triceps. The two pitchers in the report such sport- and position-specific conditions and did not improve with non-operative treatment allow appropriate training and rehabilitation and ultimately underwent surgical exploration techniques to be developed. and neurolysis. Their radial nerves were found to be scarred and thinned; one had a neuroma. Both Injuries due to overhand throwing patients improved postoperatively. The authors postulated that the nerve may be injured because Literally hundreds of published articles and texts of the traction forces during the pitch, especially address injuries specific to overhand throwing. in individuals with tethering of the nerve by an The majority of these studies are centred on base- anomalous fibrous arch at the lateral head of the ball pitchers, although non-pitchers also sustain triceps. these injuries but with a lesser incidence. Since One other article specific to fastpitch reported overhand throwing injuries and their diagnosis, three cases of ulnar stress fractures in pitchers treatment and rehabilitation have been so well (Tanabe et al., 1991). Patients presented with delineated in the literature, I briefly outline them softball 637

here and provide references for more in-depth are occasionally seen. Spontaneous fractures of study. the humeral shaft due to throwing a softball The shoulder is probably the most frequent (Marymount et al., 1989) or baseball (Branch et al., site of injury for overhand throwers. The gleno- 1992; DiCicco et al., 1993) have been reported. humeral joint is capable of the greatest range of Humeral stress periostitis, an arm equivalent of motion of any joint in the body but is also the shin splints, was shown by Greyson (1995) to most unstable. Extreme shear, compressive and correlate with a positive bone scan. Muscular tensile stresses during the throwing motion often violence has caused avulsion of the triceps, latis- lead to rotator cuff dysfunction and functional simus dorsi, teres major and pectoralis major in instability (Davidson et al., 1995). Instability may overhand throwers. be anterior, inferior, posterior or multidirec- Other assorted conditions about the shoulder tional. For the throwing athlete, instability have been reported in association with over- means pain, fatigue and decreased performance. hand throwing. Nerve compression can occur at Treatment for recurrent shoulder subluxation various sites, including thoracic outlet syn- begins with functional rehabilitation but may drome, quadrilateral space syndrome (Cahill require ligament reconstruction if refractory & Palmer, 1983; Redler et al., 1986) and supras- (Jobe et al., 1991). Glenohumeral instability can capular neuropathy (Ringel et al., 1990; Glennon, result in, or be the cause of, labral tears or detach- 1992). Axillary artery thrombosis can result ment. An athlete with a labral tear often com- from so-called hyperabduction syndrome, with plains of recurrent clicking, catching or locking. pressure from the pectoralis minor causing Several tests on physical examination have been vascular occlusion (Rohrer et al., 1990). This described to aid diagnosis of labral pathology potentially limb-threatening condition pre- (Kibler, 1995). Arthroscopic treatment of labral sents with pain, fatigue and paraesthesias and injuries has been well described (Snyder et al., is diagnosed by arteriogram. Once diagnosed, 1990; Snyder & Wuh, 1991; Glasgow & Bruce, immediate vascular surgical consultation is 1992; Liu et al., 1996). Impingement of the rotator recommended. cuff tendons, subacromial bursa and long head of The elbow is the next most common source of the biceps tendon between the humeral head and problems for the overhand thrower. Tremendous inferior acromion can occur primarily or as a valgus stress may create medial tensile and result of instability (Jobe & Bradley, 1988; Jobe, lateral compressive overload. Bony injuries 1989). Treatment is directed at addressing the include medial epicondyle fracture (so-called instability if that is the primary problem. If Little-Leaguer’s elbow), olecranon stress fracture impingement is primary, arthroscopic decom- (Nuber & Diment, 1992), olecranon osteophytes, pression may be indicated if conservative treat- osteochondritis dissecans of the capitellum and ment fails (Savoie, 1993; Roye et al., 1995). intra-articular loose bodies. Flexor–pronator Impingement may progress to frank rotator cuff strain or tears, as well as ulnar collateral liga- tear; if this occurs in the throwing athlete surgical ment injuries, occur with tensile overload. repair is indicated (Tibone et al., 1986; Snyder & The incidence of ulnar collateral injuries is Wuh, 1991; Warner et al., 1991). most probably underreported, and may partly Articular and bony lesions can also affect the be a cause of failure of surgical treatment throwing athlete’s shoulder. Ossification at the (Andrews & Timmerman, 1995). Ulnar neuropa- posterior–inferior glenoid rim (Bennett lesion) thy and ulnar nerve subluxation in throwers has been described as being associated with pos- has been reported to have excellent outcome terior labral injury and possible partial rotator with surgical transposition (Wojtys et al., 1986; cuff tear (Ferrari et al., 1994). Physeal fractures, Rettig & Ebben, 1993), although care must be snapping scapulae, glenohumeral loose bodies taken not to overlook concomitant occult valgus and humeral head or glenoid chondral injuries instability. 638 sport-specific injuries: prevention and treatment

from sprinting to complete stop in the space of a Injuries due to collision/impact few yards (Fig. 42.16). The injury mechanisms for The bulk of the literature on softball injuries has sliding may include impact, shear and torque. been concerned with sliding injuries (Fig. 42.15). Rapid energy transfer to the small joints and Much attention has been given to sliding injuries bones of the leading extremity puts the ankle and because of their large public and occupational hand at risk, since the momentum of the entire health impact. Sliding-related injuries have been body must be dissipated as the runner hits a reported to comprise 42–71% of all softball fixed object. Sliding feet first may cause marked injuries (Wheeler, 1984; Janda et al., 1992). The axial loading, plantar flexion, version or rota- average cost of a sliding injury requiring an tional forces to the ankle. Ankle fractures (Fig. emergency visit has been estimated to be 42.17) and sprains comprise the most frequent US$1223 (Janda et al., 1988). Since softball is the major sliding injuries (Nadeau & Brown, 1990). most popular recreational sport in the USAand is Treatment of ankle and other musculoskeletal also responsible for the most visits to the emer- injuries related to collision and impact is no dif- gency room, the economic impact of sliding ferent from that outlined in standard ortho- injuries is staggering. The armed forces in the paedic and sports medicine texts. USA use softball as a major part of the Morale, Injuries to the knee also occur during feet-first Welfare and Recreation Program. Statistics from sliding and collisions between players. Twisting the US Army reveal that more man-days are lost on the flexed knee as it impacts the ground because of softball injuries each year than any causes meniscal injuries. Valgus, deceleration other sport (Wheeler, 1987). The army study also and external rotation stress in the extended knee reported that ankle fractures have been the as it hits a fixed base can tear the anterior cruciate leading cause of sports-related hospital admis- ligament. Impact on the anterior surface of the sions over a 7-year period, and in their prospec- flexed tibia may rupture the posterior cruciate tive studies all ankle fractures were the result of ligament. Patellar subluxation, dislocation and sliding. osteochondral fractures are not uncommon. The Sliding during base running is the act of using best aid to diagnosis is a thorough examination at the ground and a base to decelerate the body the time of injury before the onset of swelling and

Fig. 42.15 Sliding is a frequent cause of softball injuries. softball 639

Fig. 42.16 The feet-first slide.

dard and not specific to softball. Anecdotal reports of cervical spine injury have also been attributed to head first-sliding when the head impacts an opponent (American Academy of Pediatrics Committee on Sports Medicine, 1994). Other collision and impact injuries include those in which a player is hit by a ball, bat, another player or a fixed piece of equipment on the field. The most catastrophic sports injury, death, has been reported for softball. Brunko and Hunt (1988) cited a case of sudden cardiac death in a 30-year-old woman while sliding into second base. Other deaths have been reported during baseball and softball when players have been hit in the head, eye or chest with the ball (Rome, 1995). In the USA between 1986 and 1990, 16 deaths related to softball or baseball occurred in children aged 5–14 (American Academy of Pediatrics Committee on Sports Medicine, 1994). Direct contact with the ball is cited as the most frequent cause of death or serious injury in chil- Fig. 42.17 Ankle fracture-dislocation sustained during sliding. dren and adolescents, with impact to the head being most common, although impact with the immature, relatively elastic chest can also be effusion. In head-first sliding, upper extremity, lethal. head and face injuries predominate. Contusions, Facial injuries account for about 5% of all soft- abrasions, digit fractures and sprains, forearm ball injuries (Shesser et al., 1985). Softball ranks fractures, shoulder dislocations and facial bone second only to skiing as the most frequent cause fractures are common. Again, treatment is stan- of maxillofacial fractures sustained in sports 640 sport-specific injuries: prevention and treatment

(Tanaka et al., 1996). Mandibular, nasal and probability of developing digital ischaemia cor- dental fractures are caused from impact with responds to cumulative playing time (Sugawara balls and bats. Treatment for sports-related facial et al., 1986). I am aware of an identical case of fractures is no different from that for fractures digital ischaemia in the index finger of a colle- from other causes. Baseball and softball seem to giate softball catcher (Fig. 42.18). A rare case of a be the leading cause of sports-related eye injuries digital artery false aneurysm in the thumb of a in children, with about one-third being caused by softball catcher has been reported by Yasuda and impact from a pitched ball. Bat impact has been Takeda (1996). known to cause both facial and extremity injuries. Aluminium bats break less frequently Equipment and safety concerns than wooden bats, although occasionally they do fracture. During one season at a major US univer- Sliding sity, four aluminium bat fractures were docu- mented that resulted in two lacerations from Since most sliding injuries are probably pre- flying fragments (Strauss & Whitehead, 1982). ventable and because sliding accounts for the Ball impact is responsible for numerous contu- brunt of softball injuries, a tremendous reduction sions to the extremities and, occasionally, frac- in the number of injuries is possible if preven- tures and tendinous injuries. The classic mallet tative measures are implemented. Softball and finger is well known to competitive catchers as baseball are steeped in tradition, so banning an injury sustained from impact to a fingertip. sliding is not an option that would be acceptable The terminal slip of the extensor tendon is to devoted players and fans. However, the avulsed from the base of the distal phalanx, with American Academy of Pediatrics has recom- or without a small piece of bone attached. Base- mended a ban on head-first sliding for children ball catchers have also been reported to sustain less than 10 years of age. Presumably, once digital vessel trauma in the glove hand due to players are developmentally mature enough, repetitive ball impact (Lowrey et al., 1976). coaching of proper sliding techniques could be Digital ischaemia typically affects the index accomplished. For adults, sliding is likely to con- finger, and may present as coolness, numbness tinue unrestricted. Part of the global appeal of and paleness especially with cold exposure. The softball is that almost any ‘weekend athlete’ can

Fig. 42.18 Fastpitch catchers can develop digital ischaemia. softball 641

participate. Unfortunately, this also means that stressed at all levels of play. Coaches should skill level and adequacy of proper coaching is work with inexperienced players to help them quite variable. Analysis of injury data reveals that gain an understanding that a late slide is danger- many injuries happen when the decision to slide ous and that it is better not to slide and be called is made late and the slide is initiated too close to out than to slide late and be out of the game per- the base (Wheeler, 1987). Excess momentum is manently. The decision to slide should be made carried to the base and the lead extremity is early, and may be signalled by base coaches and injured at impact. In addition to poor technique, the on-deck batter. The slide should start two to lack of conditioning and alcohol intake may con- three strides before the base. The body should be tribute to the problem. Shesser et al. (1985) found relaxed, since tense muscles limit joint flexibility that 34% of recreational softball injuries were and may predispose to injury. In a feet-first slide, related to alcohol. Unfortunately, a ban on alcohol the hands should be raised overhead to protect would probably be as unpopular among some them from impact. Holding a handful of dirt in recreational ball players as a ban on sliding. The each clenched hand reminds the runner not to fact remains that alcohol impairs both judgement extend the digits, making them less vulnerable and coordination, so consumption is not recom- to injury. Impact with the ground should be mended during sports participation. Other absorbed by the maximum of body surface area options to prevent sliding injuries include in order to dissipate energy. In the feet-first slide, changes in equipment and improved coaching. the buttocks, thighs and lower back should A change in base equipment is a passive pre- impact the ground first. In a head-first slide, the ventative measure that would be independent of chest and thighs provide the best large surface the athlete, skill level and coaching. The rule for contact. Unfortunately, even in professional books of numerous softball organizations in the players initial ground contact is often made with USA specify that bases may be up to 12.7cm in the hands and knees in the head-first slide height and must be fixed to the ground. Standard (Corzatt et al., 1984). This dangerous technique bases are usually bolted to a metal post sunk into predisposes vulnerable small body parts to concrete. This configuration obviously has little injury. Proper sliding technique can be coached ‘give’ when a runner collides with it. Recessed and practised indoors on a gym floor while bases are one alternative, although this would wearing old sweatpants, using talcum powder make it difficult for fielders and umpires to locate and a burlap bag for players to slide on. Once them visually from a distance. Break-away bases athletes are confident that they can slide safely are now available from various manufacturers in on a hard gym floor, they tend to be less hesitant the USA. Models are available for youth, teen, on the ball field and have less trouble initiating a adult and professional levels, each differing in slide at the proper time. rigidity and the magnitude of force required to break away. Janda et al. (1990) showed in a Personal equipment prospective study that use of such break-away bases led to a 98% decrease in the incidence of Head injuries are the most frequent serious sliding injuries. If the use of these bases was injury in softball and baseball. Unfortunately, implemented throughout the USA, 1.7 million there is no formal requirement for a batting injuries could be prevented and US$2.0 billion in helmet, neither is there a manufacturer’s stan- medical costs saved annually. A similar study dard for such a helmet. Little research has even found a comparable rate of injury reduction with been done to quantify the protective capability of a deformable impact-absorbing base (Sendre et batting helmets, unlike the data that has been al., 1994). compiled on testing football and motorcycle To reduce sliding injuries further, instruction helmets. Goldsmith and Kabob (1982) did in proper base-sliding technique should be attempt to quantify and make recommendations 642 sport-specific injuries: prevention and treatment

Fig. 42.19 Batting helmets should be worn on the base Fig. 42.20 Batting helmet with face mask. paths. about the performance of batting helmets. Their resulting in a dramatic decrease in the incidence findings supported the incorporation of shell of dental injury to less than 1% (Wilkins, 1990). and suspension modifications to improve the Studies have shown that mouth-guards are very energy absorption of headgear in order to mini- effective in preventing orofacial and dental mize the possibility of head trauma. Batting injuries (Thompson, 1982; Garon et al., 1986). helmets should be required when batting and Good evidence has also been documented that base running at all levels of play (Fig. 42.19). For mouth-guards decrease the potential for brain additional eye and face protection, shatter- trauma when a blow to the jaw occurs (Hickey et resistant polycarbonate face shields or wire al., 1967). The modern materials used in fabricat- masks can be added (Fig. 42.20). The American ing mouth-guards have resulted in improved Academy of Pediatrics Committee on Sports fit, comfort and compliance rates. New titanium Medicine (1994) recommends such face protec- bats entering the market may increase the risk of tors for functionally one-eyed athletes (corrected orofacial injury to infielders, especially third- vision <20/50 in the worst eye) and for athletes base fielders. After impact with titanium bats, with previous eye injury or surgery. They also ball speeds are 4–12% higher (S. Werner & C. recommend that the catcher wears a helmet, Johnson, unpublished data), although fielders’ mask, chest and throat protectors, as well as non- reaction times have not increased. Athletes, espe- metal spikes. cially infielders, should be educated about the In the USA, players of American football have advantages of mouth-guards and encouraged to been required to use mouth-guards since 1963, use them by physicians, trainers and coaches. softball 643

the incidence of fastpitch softball injury, injury Facility mechanisms in fastpitch, windmill pitching Before a practice or a game, part of good injuries, analysis of the effectiveness of hitting warm-up procedure should always be a walk or technique and visual cues in fastpitch hitting. jog around the field by each player. Athletes Some of the past research on male baseball should look for soft or wet spots, holes, rocks players is applicable to female softball players, and debris. If stationary bases are in use, one although new research on female subjects would should make sure they are secure. Each player be most appropriate. For instance, the only should check the area of her position thoroughly published biomechanical analysis on windmill and get her bearings on distances to poles, pitching used male subjects. Do differences in fences, dugout and other unyielding objects. bone, muscle, and joint structure or laxity about Even when playing at home, it is still a good the shoulder or elbow make a difference in idea to make this check part of the prepar- mechanics or injury risk for women? Should ticipation routine. Softball players tend to be different coaching and training techniques be creatures of habit, and before a game some tailored for women? Should pitching rule have specific individualized routines sur- limitations be imposed? We will not know the rounded with superstition. By encouraging answers to these types of questions until the development of good warm-up habits in research specific to female fastpitch softball is youngsters, coaches may effect a routine that accomplished. lasts a lifetime. Proper field maintenance should Much can also be learned in the realm of include regular dragging and raking of the equipment safety. Universal acceptance of break- infield and rolling of the outfield. Fences and away bases has not occurred despite excellent poles in the playing area should be padded. data showing dramatic reduction of injuries Dugouts should be fenced to protect occupants when such bases are used. The protection from foul balls. For children aged 5–14, the afforded by batting headgear and face shields American Academy of Pediatrics recommends needs to be better quantified. Are the current elimination of the on-deck circle, use of break- batting helmets effective or should alternative away bases and use of low-impact balls to mini- styles be investigated? Before global acceptance mize risk of injury. of titanium bats, should we further investigate material properties and human reaction times? Should the rules require the wearing of face pro- Recommendations for tectors and mouth-guards and, if so, for what age future research groups and what levels of play? Certainly, we Softball has existed as an organized sport for just cannot expect to legislate an end to all sports over 100 years and its worldwide popularity has injuries. Rather, as physicians, trainers, coaches, resulted in it becoming adopted as the newest researchers and administrators the best we can Olympic sport. Baseball has received far more hope to do is learn all we can in an effort to attention in the literature, presumably because of prevent and minimize injuries. Athletes have all the money in professional baseball and the sustained sports injuries ever since the earliest fact that males play baseball and males have sports were played, and will undoubtedly con- done the majority of the research. Very little tinue to hurt themselves from time to time. attention has been given to softball, especially Today’s athletes depend on us to treat their fastpitch softball, so the field is literally wide injuries appropriately and, even more impor- open for future research. The specific areas tantly, tomorrow’s injuries may be prevented by that need further investigation include biome- our efforts. Our best defences in the arena of chanics of the windmill pitch, EMG analysis sports medicine are knowledge and commitment of the windmill pitch, epidemiological study of to our athletes. 644 sport-specific injuries: prevention and treatment

the shaft of the humerus secondary to muscular vio- Acknowledgements lence. Journal of Orthopaedic Trauma 7, 90–93. Dillman, C., Fleisig, G. & Andrews, J. (1993) Biome- I would like to thank Sue Rankin PhD, Sherry chanics of pitching with emphasis upon shoulder Werner PhD, John Henderson DO, Jeannine Gau- kinematics. Journal of Orthopaedic and Sports Physical dreau RN and Kathy Arendsen for technical Therapy 18, 402–408. assistance in the writing of this chapter. My most Ekstrand, J., Gillquist, J., Moller, M. et al. (1983) Inci- sincere appreciation goes to Ann Rosecrants dence of soccer injuries and their relation to training and team success. American Journal of Sports Medicine for editorial assistance, and to the Port Angeles 11, 63–67. High School Roughrider Softball team for photo- Ellison, A. (1973) Skiing injuries. Journal of the American graphic motion studies. Finally, thanks to my Medical Association 223, 917–919. family for all their endless support, ever since my Feltner, M. & Dapena, J. (1986) Dynamics of the shoul- days as a Texas Short-horn on gopher hole field. der and elbow joints of the throwing arm during a baseball pitch. International Journal of Sport Bio- mechanics 2, 235–259. References Ferrari, J., Ferrari, D., Coumas, J. & Pappas, A. (1994) Posterior ossification of the shoulder: the Bennett Alexander, M. & Haddow, J. (1982) A kinematic analy- lesion. American Journal of Sports Medicine 22, sis of an upper extremity ballistic skill: the windmill 171–176. pitch. Canadian Journal of Applied Sports Sciences 7, Fleisig, G., Andrews, J., Dillman, C. & Escamilla, R. 209–217. (1995) Kinetics of baseball pitching with implications American Academy of Pediatrics Committee on Sports about injury mechanisms. American Journal of Sports Medicine (1994) Risk of injury from baseball and Medicine 23, 233–239. softball in children 5–14 years of age. Pediatrics 93, Fleisig, G., Dillman, C. & Andrews, J. (1989) Proper 690–692. mechanics for baseball pitching. Clinical Sports Medi- Andrews, J. & Timmerman, L. (1995) Outcome of elbow cine 1, 151–170. surgery in professional baseball players. American Garon, M., Merkle, A. & Wright, J. (1986) Mouth protec- Journal of Sports Medicine 23, 407–413. tors and oral trauma. Journal of the American Dental Atwater, A. (1980) Biomechanics of overarm throwing Association 112, 663–668. movements and of throwing injuries. Exercise and Glasgow, S. & Bruce, R. (1992) Arthroscopic resection of Sport Sciences Reviews 71, 43–85. glenoid labrum tears in the athlete: a report of 29 Branch, T., Partin, C., Chamberland, P., Emeterio, E. & cases. Arthroscopy 8, 48–54. Sabetelle, M. (1992) Spontaneous fracture of the Glennon, T. (1992) Isolated injury of the infraspinatus humerus during pitching. American Journal of Sports branch of the suprascapular nerve. Archives of Physi- Medicine 20, 468–470. cal Medicine and Rehabilitation 73, 201–202. Browner, B., Jupiter, J., Levine, A. & Trafton, P. Glousman, R. (1993) Electromyographic analysis and (1992) Skeletal Trauma, Vols 1 & 2. W.B. Saunders, its role in the athletic shoulder. Clinical Orthopaedics Philadelphia. and Related Research 288, 27–34. Brunko, M. & Hunt, M. (1988) Sudden death in a young Glousmen, R., Jobe, F. & Tibone, J. (1988) Dynamic elec- adult woman. Journal of Emergency Medicine 6, tromyographic analysis of the throwing shoulder 239–244. with glenohumeral instability. Journal of Bone and Cahill, B. & Palmer, R. (1983) Quadrilateral space syn- Joint Surgery 70A, 220–226. drome. Journal of Hand Surgery 8, 65–69. Goldsmith, W. & Kabob, M. (1982) Performance of Corzatt, R., Groppel, J., Pfautsch, E. & Boscardin, J. baseball headgear. American Journal of Sports Medicine (1984) The biomechanics of head-first vs. feet-first 10, 31–37. sliding. American Journal of Sports Medicine 12, Gowan, I., Jobe, F., Tibone, J., Perry, J. & Moynes, D. 229–232. (1987) A comparative electromyographic analysis of Davidson, P., Elattrache, N., Jobe, C. & Jobe, F. (1995) the shoulder during pitching. American Journal of Rotator cuff and posterior–superior glenoid labrum Sports Medicine 15, 586–590. injury associated with increased glenohumeral Green, N. & Swiontkowski, M. (1992) Skeletal Trauma in motion: a new site of impingement. Journal of Shoul- Children. W.B. Saunders, Philadelphia. der and Elbow Surgery 4, 384–390. Greyson, N. (1995) Humeral stress periostitis. Clinical DeLee, J. & Drez, D. (1994) Orthopaedic Sports Medicine, Nuclear Medicine 20, 286–287. Vols 1 & 2. W.B. Saunders, Philadelphia. Hickey, J., Morris, A., Carlson, L. et al. (1967) The rela- DiCicco, J., Mehlman, C. & Urse, J. (1993) Fracture of tion of mouth protectors to cranial pressure and softball 645

deformation. Journal of the American Dental Associa- (1996) Fractures in Adults, 4th edn. Lippincott-Raven, tion 74, 735–740. Philadelphia. Janda, D., Wojtys, E., Hankin, F. & Benedict, M. (1988) Rohrer, M., Cardullo, P., Pappas, A., Phillips, D. & Softball sliding injuries. A prospective study com- Wheeler, H. (1990) Axillary artery compression and paring standard and modified bases. Journal of the thrombosis in throwing athletes. Journal of Vascular American Medical Association 259, 1848–1850. Surgery 11, 761–768. Janda, D., Wojtys, E., Hankin, F., Benedict, M. & Rome, E. (1995) Sports-related injuries among adoles- Hensinger, R. (1990) A three-phase analysis of the cents: when do they occur, and how can we prevent prevention of recreational softball injuries. American them? Pediatrics in Review 16, 184–187. Journal of Sports Medicine 18, 632–635. Roye, R., Grana, W. & Yates, C. (1995) Arthroscopic sub- Janda, D., Wild, D. & Hensinger, R. (1992) Softball acromial decompression: two- to seven-year follow- injuries. Sports Medicine 13, 285–291. up. Arthroscopy 11, 301–306. Jobe, F. & Bradley, J. (1988) Rotator cuff injuries in base- Savoie, F. (1993) Arthroscopic examination of the ball. Sports Medicine 6, 378–387. throwing shoulder. Journal of Orthopaedic and Sports Jobe, F., Giangarra, C., Kvitne, R. & Glousman, R. (1991) Physical Therapy 18, 409–412. Anterior capsulolabral reconstruction of the shoul- Sendre, R., Keating, T., Hornak, J. & Newitt, P. (1994) der in athletes in overhand sports. American Journal of Use of the Hollywood Impact Base to reduce sliding Sports Medicine 19, 428–434. and base-running injuries in baseball and softball. Jobe, F., Moynes, D., Tibone, J. & Perry, J. (1984) An American Journal of Sports Medicine 22, 450–453. EMG analysis of the shoulder in pitching. American Shaffer, B., Jobe, F., Pink, M. & Perry, J. (1993) Baseball Journal of Sports Medicine 12, 218–220. batting, an electromyographic study. Clinical Kibler, W. (1995) Specificity and sensitivity of the ante- Orthopaedics and Related Research 292, 285–293. rior slide test in throwing athletes with superior Shesser, R., Smith, M., Ellis, P., Brett, S. & Ott, J. (1985) glenoid labrum tears. Arthroscopy 11, 296–300. Recreational softball injuries. American Journal of Liu, S., Henry, M., Nuccion, S., Shapiro, M. & Dorey, F. Emergency Medicine 3, 199–202. (1996) Diagnosis of glenoid labral tears. American Sinson, G., Zager, E. & Kline, D. (1994) Windmill Journal of Sports Medicine 24, 149–154. pitcher’s radial neuropathy. Neurosurgery 34, Loosli, A., Requa, R., Garrick, J. & Hanley, E. (1992) 1087–1090. Injuries to pitchers in women’s collegiate fast-pitch Sisto, D., Jobe, F., Moynes, D. & Antonelli, D. (1987) An softball. American Journal of Sports Medicine 20, 35– electromyographic analysis of the elbow in pitching. 37. American Journal of Sports Medicine 15, 260–263. Lowrey, C., Chadwick, R. & Waltman, E. (1976) Digital Snyder, S. & Wuh, H. (1991) Arthroscopic evaluation vessel trauma from repetitive impact in baseball and treatment of the rotator cuff and superior labrum catchers. Journal of Hand Surgery 1, 236–238. anterior posterior lesion. Operative Techniques in Marymount, J., Coupe, K. & Clanton, T. (1989) Sports- Orthopaedics 1, 207–220. related spontaneous fractures of the humerus. Snyder, S., Karzel, R., DelPizzo, W., Ferkel, R. & Fried- Orthopaedic Review 18, 957–960. man, M. (1990) SLAP lesions of the shoulder. Nadeau, M. & Brown, T. (1990) The prevention of soft- Arthroscopy 6, 274–279. ball injuries: the experience at Yokota. Military Medi- Stanitski, C., DeLee, J. & Drez, D. (1994) Pediatric cine 155, 3–5. and Adolescent Sports Medicine. W.B. Saunders, Nuber, G. & Diment, M. (1992) Olecranon stress frac- Philadelphia. tures in throwers. Clinical Orthopaedics and Related Strauss, R. & Whitehead, E. (1982) Hazards of alu- Research 278, 58–61. minum bats (letter). New England Journal of Medicine Pappas, A., Zawacki, R. & Sullivan, T. (1985) Biome- 307, 829. chanics of baseball pitching. American Journal of Sugawara, M., Ogino, T., Minami, A. & Seiichi, I. (1986) Sports Medicine 13, 216–222. Digital ischemia in baseball players. American Journal Redler, M., Ruland, L. & McCue, F. (1986) Quadrilateral of Sports Medicine 14, 329–334. space syndrome in a throwing athlete. American Tanabe, S., Nakahira, J., Bando, E., Yamaguchi, H., Journal of Sports Medicine 14, 511–513. Miyamoto, H. & Yamamoto, A. (1991) Fatigue frac- Rettig, A. & Ebben, J. (1993) Anterior subcutaneous ture of the ulna occurring in pitchers of fast-pitch transfer of the ulnar nerve in the athlete. American softball. American Journal of Sports Medicine 19, Journal of Sports Medicine 21, 836–840. 317–321. Ringel, S., Treihaft, M., Carry, M., Fisher, R. & Jacobs, P. Tanaka, N., Hayashi, S., Amagasa, T. & Kohama, G. (1990) Suprascapular neuropathy in pitchers. Ameri- (1996) Maxillofacial fractures sustained during can Journal of Sports Medicine 18, 80–86. sports. Journal of Oral and Maxillofacial Surgery 54, Rockwood, C., Green, D., Bucholtz, R. & Heckman, J. 715–719. 646 sport-specific injuries: prevention and treatment

Thompson, B. (1982) Protection of the head and neck. Wheeler, B. (1984) Slow-pitch softball injuries. American Dental Clinics of North America 26, 659–663. Journal of Sports Medicine 12, 237–240. Tibone, J., Elrod, B., Kerlan, R. et al. (1986) Surgical Wheeler, B. (1987) Ankle fractures in slow-pitch soft- treatment of tears of the rotator cuff in athletes. ball: the Army experience. Military Medicine 152, Journal of Bone and Joint Surgery 68A, 887–891. 626–628. Warner, J., Altchek, D. & Warren, R. (1991) Arthroscopic Wilkins, K. (1990) Protective equipment. In J. Sullivan management of rotator cuff tears with emphasis on & W. Grana (eds) The Pediatric Athlete, pp. 257– the throwing athlete. Operative Techniques in 261. American Academy of Orthopedic Surgeons Orthopaedics 1, 236–239. Seminar, Park Ridge, Illinois. Welch, C., Banks, S., Cook, F. & Draovitch, P. (1995) Wojtys, E., Smith, P. & Hankin, F. (1986) Acause of ulnar Hitting a baseball: a biomechanical description. neuropathy in a baseball pitcher. American Journal of Journal of Orthopaedic and Sports Physical Therapy 22, Sports Medicine 14, 422–424. 193–201. Yasuda, T. & Takeda, R. (1996) False aneurysm of a Werner, S., Fleisig, G., Dillman, C. & Andrews, J. (1993) digital artery in a softball catcher evaluated by Biomechanics of the elbow during baseball pitching. sonography: a case report. Journal of Trauma 41, Journal of Orthopaedic and Sports Physical Therapy 17, 153–155. 274–278. Index

Page numbers in bold refer to tables and those it italic refer to figures abdominal examination, 175 pregnancy, 199, 199–200 hormonal changes, 258–9, 260 abdominal injuries, 585–6 postpartum resumption, 204 low-T3 (triiodothyronine) abusive coach/parent–athlete see also endurance training syndrome, 259–60 relationships, 411–12, 421–2, 423 aldosterone, 42 skiers, 622 acceleration, Newton’s laws, 102 alpine skiing see skiing swimmers, 455 accessory navicular bones, 527 altitude, 70–2, 614–15 track and field athletes, 470 acclimatization acclimatization, 71 treatment, 177, 385–8, 399–402, 400 altitude, 71 performance effects, 70 adolescent athletes, 387 warm environments, 63 physiological responses, 70–1, 71 bone loss prevention, 399–400 Achilles tendinitis pregnant athletes, 622 calcium supplements, 386, 400, basketball players, 567, 572 training, 71–2 401–2 cyclists, 546 amenorrhoea, 377–88, 435 fertility restoration, 387–8 distance runners, 478, 479 anorexia nervosa, 380, 398 follow-up, 387 ice skaters, 521, 528 body composition, 356–7, 357, 381 hormone replacement, 386, 400–1 soccer players, 589, 590 regional adiposity, 356–7 intranasal calcitonin, 402 Achilles tendon overuse injury, 210 total body adiposity, 356 nutrition optimization, 386 Achilles tendon rupture, 566 bone mass/mineral density, 283, side effects, 402 actin, 145 385–6, 391, 392, 393, 394, 394 American Physical Education acupuncture, 558 body weight influence, 395 Associaiton, 8 adenosine triphosphate resynthesis see causes, 379–81 amino acid supplements, 323 ATP resynthesis cold environment responses, 68 amphetamines, 327–8, 333, 370 adhesive capsulitis (frozen shoulder), definitions, 173, 378 anabolic steroids, 327, 331–2 226–7 diabetic athletes, 274 masters athletes, 153 adolescent athletes exercise-associated, 381–2 menstrual dysfunction, 380, 383 basketball players, 572–3 female athlete triad, 171, 377 anaemia, 311–18 bone mass, 284, 295 genital tract abnormalities, 378, 381 haematological values, 311 diabetes, 274 gymnasts, 381 laboratory assessment, 177 exercise-related amenorrhoea history-taking menstrual history-taking, 174 treatment, 387 medical interview, 382–3 physical evaluation, 175 soccer players, 595–6 preparticipation examination, 173–4 see also iron deficiency anaemia see also young élite competitors hypothalamic, 378, 379–80 anaerobic glycolysis, 78 adrenal androgens, 159 laboratory investigations, 384–5 anaerobic training, 84 adrenaline, 27, 266 long-term consequences, 396, 398–9 androgen insensitivity (testicular aerobic/anaerobic energy training, 83–4 musculoskeletal injuries relationship, feminization) syndrome, 186–7, physiology, 83–4 396, 397 383 training methods, 83 stress fractures, 395–6 androgen replacement therapy, 159, 161 aerobic energy transfer nutritional status, 381 drug testing, 164–5 carbohydrate intake, 82 energy intake deficit, 122, 382 sports performance effects, 161–3, 162, cardiovascular adaptation, 80–1 increased energy intake response, 163 fluid and electrolyte balance, 83 177, 381, 386 angina pectoris, 245 metabolic adaptations, 81–2 ovarian failure, 380 angular acceleration, 105 training methods, 79–80 performance impact, 385 angular momentum, 105 aerobic interval training, 79–80 physical examination, 383–4 angular position kinematics, 96, 96–7, carbohydrate intake, 82 pituitary abnormalities, 380 97 lactate threshold, 82 ‘post pill’, 383 angular velocity, 97–8 muscular system adaptations, 81 prevalence, 377 anisocoria, 175 aerobic training primary, 173, 378, 381 ankle fracture, 638, 639 concurrent strength training, 85 secondary, 174, 378 ankle impingement syndromes, 589 647 648 index

ankle injuries aspirin, 333 beta-blockers, 330 basketball players, 565–6, 572 Association for Intercollegiate Athletics biomechanics, 93–107 canoeing/kayaking, 610 for Women (AIAW), 441 bone strains, 281 cyclists, 546 asthma centre of gravity/centre of mass, 101–2 gymnasts, 499 menstrual cycle phase effects, 45–6 equipment interactions, 106 ice skaters, 521, 522, 528 swimmers, 458 kinetics, 102–6 preventive conditioning see also exercise-induced lever systems, 99–101 programmes, 524 bronchospasm static/dynamic systems, 93 retraining of proprioception, 528, atenolol, 330 birthweight, 194, 196, 202, 387 529 atherosclerosis, 245 bisphosphonates, 402 soccer players, 589 sudden death, 247 black athletes, historical aspects, 14 softball players, 638, 639 athletic pubalgia (Gilmore’s groin), 586 Blair, B., 410 ankle sprains, 219 Atlanta+ initiative, 15–16 Blankers-Koen, F., 14 basketball players, 565–6 ATP resynthesis, 78 blindness, 307 gymnasts, 500 anaerobic interval training, 84 blood circulation, 241–2 ice skaters, 521 muscular system adaptations, 81 blood pressure jumpers, 474 atrophic vaginitis, 384 aerobic training response, 81 soccer players, 588–90 attentional skills, 110, 111 oral contraceptive effects, 52–3 ankle tenosynovitis, 528 Austin, T., 417 physical evaluation, 175 anorectic agents, 332–3 autonomy, 434 preparticipation examination, 242 anorexia athletica, 364 axillary artery thrombosis, 637 body composition, 123, 353–61 diagnostic criteria, 365–6, 366 amenorrhoea, 356–7, 357, 381 physical symptoms, 370 back injuries assessment for weight goals psychological/behavioural basketball players, 569–70 establishment, 360–1 characteristics, 370 canoeing/kayaking, 608–9 assessment methods, 358–61, 385 anorexia nervosa gymnasts, 499 dual-energy X-ray absorptiometry amenorrhoea, 380 softball players, 636 (DXA), 360, 385 long-term effects on bone mass, 398 back pain hydrostatic weighing, 358, 359, 385 diagnostic criteria, 364–5, 365 canoeing/kayaking, 608–9 problems, 358 medical risks of competition, 372 cyclists, 542, 542–3 serial imaging, 359–60, 385 mortality, 369 discogenic, 463, 464 bone mass relationships, 283 physical evaluation, 175, 384 ice skaters, 521, 531 osteoporosis, 357–8 physical symptoms, 370 rowers, 492 health implications, 356–8 prevalence, 366 soccer players, 584–5 masters athletes, 144–5, 145 psychological/behavioural swimmers, 462–4 sports performance relationships, characteristics, 370 differential diagnosis, 463 353–5, 354 subclinical disorders, 364 imaging investigations, 463–4 swimmers, 453–4 treatment, 372 treatment, 464 weight loss effects, 355 oral contraceptives, 401 synchronized swimmers, 466 body fat percentage see body anterior cruciate ligament injuries, 213, balance board exercises, 528, 529 composition 214, 470 Bankart shoulder lesion, 224 body mass index, 359 basketball players, 568, 573 barrier contraception, 51 haemoglobin concentration gymnasts, 500–1 Bartowicz, P., 551 relationship, 24 incidence, 615 basal body temperature (BBT) curves, 43 body weight intercondylar notch dimensions, 215, base of support, 101, 101 bone density relationship, 395 216 basketball, 409, 563, 564–73 pharmacological aids to alteration, predisposing limb anatomy, 218 ankle injuries, 565–6, 572 331–4 pronated flat foot, 219 back injuries, 569–70 physical evaluation, 174, 175 skiers, 613, 618–19, 619, 620 dental injuries, 572 swimmers, 453 soccer players, 586–7 eye injuries, 571 bone, 280–96 track and field athletes, 474, 475, 476, facial injuries, 571 growth, 281 477 finger injuries, 570 loading characterisitcs of specific anterior tibial tendon bursae, 527, 527 foot injuries, 566–7, 572 sports, 284–5, 285 anterior tibialis tendinitis, 588 hand injuries, 570–1 high-impact sports, 287, 290–4 anthropometry, 93, 94–5 historical aspects, 12 high-magnitude loading sports, sports equipment design, 106 knee injuries, 568–9, 573 285–6, 286 antithrombin III, 52 anterior cruciate ligament, 214, 568, repetitive loading sports, 286–7, anxiety 573 288–9 benefits of exercise, 247 lower leg injuries, 567–8 mechanical adaptation, 281–3, 391 see also competition anxiety management of traumatic bleeding, body weight influences, 357 Apley’s test, 569, 587 572 feedback control, 282–3 apophyseal abnormalities, 463 musculoskeletal injuries, 470 optimal exercise programmes, 282 apophyseal fractures, 595 adolescent players, 572–3 physical loading response, 280, 281, apophysitis, 595, 596 rates, 564 282, 295 appetite suppressants, 270, 333, 369 nose injuries, 571 prepubertal athletes, 284, 284 archery, 4 sudden cardiac death, 572 microfracture healing, 396, 397 arginine supplements, 323 wrist overuse injuries, 229, 230 oestrogen-responsive calcium uptake, arousal regulation training, 112 Bernoulli’s principle, 105 42 arthritic disorders, 219 beta-adrenergic agonists, 332, 458, 481, turnover, 280–1 Ashford, E., 14 493 remodelling cycles, 281 index 649

bone age determination, 385 obesity attenuation, 261 canoes, 602 bone biopsy, 392 observational studies, 252–7, 252, Capriati, J., 417 bone loss (osteoporosis), 391–403 257 carbohydrate intake, 322 body composition, 357–8 breast examination/self-examination, aerobic training, 82 diabetic athletes, 275 175, 176 carbohydrate loading, 321–2 distance runners, 479 breast injury, 585 aerobic energy transfer, 82 female athlete triad, 171 breast support, 174 endurance performance, 27, 27, 28 musculoskeletal injuries, 397 breathlessness, 141 free tryptophan : branched chain stress fractures, 222, 395–7, 472 Briskoe-Hooks, V., 14 amino acid levels, 28, 28 track and field athletes, 470, 472 buccal smear test, 185, 185 gender differences in response, 82–3, treatment/prevention, 399–402, 400 bulimia nervosa 322 bisphosphonates, 402 diagnosis, 370 soccer players, 580 calcium supplements, 400, 401–2 diagnostic criteria, 364–5, 365 cardiac conduction system, 242 intranasal calcitonin, 400, 402 medical risks of competition, 372 cardiac enlargement, 243 oral contraceptives, 400–1 mortality, 369 cardiac output, 25 performace effects, 402 physical examination, 175, 384 masters athletes, 139–40 progesterone-only, 401 physical symptoms, 371 oral contraceptive effects, 53 side effects, 402 prevalence, 366 cardiac size, 25, 29 bone mass psychological/behavioural cardiovascular disease, 147, 244–7 adolescent athletes, 284 characterisitics, 371 exercise in prevention, 245–7 amenorrheic athletes, 283, 385–6, 391, subclinical disorders, 364 type II (non-insulin-dependent) 392 treatment, 372 diabetes, 271 follow-up, 387 bunion, 223, 223, 224 cardiovascular function, 241–8 management, 386, 387 bunionette, 224 aerobic training, 80–1 calcium intake, 127, 283 burnout, 113, 114 evaluation techniques, 242–3 child athletes, 284 cognitive–affective model, 114 manifestations of exercise training diabetic athletes, 275 junior swimmers, 419 (athlete’s heart), 243–4 genetic factors, 283 junior tennis players, 417, 418–19, 560 masters athletes, 135–42 muscle strength relationship, 357–8 young élite athletes, 411 menstrual cycle phase effects, 44–5 oestrogen effects, 42, 283 oral contraceptive effects, 52–3 oral contraceptive effects, 51 caffeine, 333 physical examination, 175 study methods, 283–4 ergogenic effects, 329–30 preparticipation examination, 242–3 swimmers, 455–7 calcaneal apophysitis (Sever’s disease), high-risk athletes, 243 see also bone mineral content; bone 170 history-taking, 173, 242 mineral density adolescent soccer players, 596 wheelchair athletes, 307 bone mineral content, 283, 284–5 basketball players, 572 cardiovascular risk factors, 243, 245, 246 bone mineral density, 283, 284–5 calcaneal beak fractures, 566 diabetes, 275–6 body composition influences, 258, 357, calcaneal stress fractures, 572 cardiovascular system, 241–2 357 calcaneal tuberosity carnitine supplements, 324–5 exercise intensity relationship, 391 bursae, 527 carpal tunnel syndrome, 231 gymnasts, 497 Haglund’s deformity, 528, 589 canoeing/kayaking, 608 laboratory evaluation, 385 calcitonin, intranasal, 400, 402 Casals, R., 551 menstrual irregularity effects, 391–2 calcium, bone uptake, 42 catecholamines, 266 athletes, 392–5 calcium intake, 127–8, 128, 401, 402 maternal exercise in pregnancy, 194–5 effect of body weight, 395 bone mass, 283 centre of gravity/centre of mass, 93, 94, long-term, 398–9, 399 dietary sources, 127, 129 101–2 non-weight-bearing bones, 392, inadequate cervical abnormalities, 384 392–3 estimation, 127 cervical spinal injury, 503 recovery following recovery of management, 127–8 canoeing/kayaking, 609 menses, 398 recommendations, 127 soccer players, 581, 584 weight-bearing bones, 393–4, 394, calcium supplements, 386, 400, 401–2 Charcot’s joints, 275 395 Caldwell, C., 550 child athletes peak bone mass attainment, 398 canoeing, 600–12 bone mass, 284 bone scan, stress fractures, 593, 593 ankle injuries, 610 see also young élite competitors Boston brace, 464, 503 back injuries, 608–9 Chinese athletes, 14 Boston Marathon, wheelchair cold water emersion responses, 611 chromosomal aberrations, 186 competitors, 302, 303 entrapment accidents, 611 Clarke, R., 437 ‘boutonnière’ deformities, 570 equipment, 602 clavicle fracture boxing, 13, 16 head injuries, 610 cyclists, 541 bradycardia, 242 heat illness, 611 soccer players, 584 branched-chain amino acid musculoskeletal injuries, 604, 604–10 clearance for participation, 177, 181 supplements, 323 pelvic injuries, 609–10 guidelines, 178–80 breast cancer, 250–62 pregnant athletes, 611 clenbuterol, 327, 332 epidemiology, 250, 251 safety equipment, 602 clomiphene citrate, 388 physical activity protective effect, shoulder dislocation, 605–7, 606, 607 clothing 250–7, 252 shoulder impingement injuries, 604–5 cold illness prevention, 69–70 assessment methods, 251–2 skin problems, 610–11 canoeing/kayaking, 611 energy balance, 259–60 technique, 604 cycling injuries prevention, 540, 541 hormonal effects, 257–60, 259, 260 water-borne infection risk, 611 streamlining, 105 immune function enhancement, 261 wrist/forearm injuries, 607–8 Coachman, A., 14 650 index

cocaine, 329, 369–70 cycling, 13, 535–47 gestational diabetes mellitus, 265 coefficient of friction, 104 amenorrhoea, 381 hypoglycaemia prevention, 269 coenzyme Q10 (ubiquinone) bike fit, 535–9 in relation to exercise, 266–7, 270, supplements, 325–6 frame, 536, 536–9, 537 270 cognitive restructuring, 111 bone loading effects, 287 hypoglycaemic symptoms, 269 colateral ligament injury, 211 economy of movement, 26 insulin therapy, 266, 269–70 cold acclimatization, 69 foot/ankle injuries, 546 insulin preparations, 271 cold environments, 66–70 footwear, 546 menopause, 274–5 acclimatization, 69 hand/wrist tenosynovitis/tendinitis, mountain climbing, 271 clothing, 69–70, 611 543 osteoporosis, 275 cold illness prevention, 69–70 knee injuries, 544–6 physical training effects, 267, 267, cold water exercise, 66–7, 67 neck/back pain, 542, 542–3 268–9 canoeing/kayaking, 611 overuse injuries, 542–6 blood lipids, 268 exercise responses, 67–8 prevention, 535 glycaemic control, 267, 268 iron deficiency influence, 68–9 pregnancy, 200 insulin sensitivity, 267–8 menstrual cycle effects, 68 rehabilitation, 546–7 screening procedures, 272 thermoregulation, 66 saddle problems, 544 scuba diving, 271 tissue insulation, 67 sustained distance training, 79 specific sport guidelines, 270–1 windchill index, 70 thigh skin chafing, 544 type I (insulin-dependent; IDDM), 265 cold illness prevention, 69–70 traumatic injuries, 540–2 type II (non-insulin-dependent; cold war politics, 12 helmet design, 540, 541 NIDDM), 265 Comaneci, N., 15, 413, 494, 495 protective clothing, 540, 541 benefits of exercise, 271, 271–2 compartment syndrome road rash, 540–1 diarrhoea, 482 acute in soccer players, 594 ulnar neuropathy, 543 diastasis recti, 201, 204 chronic in distance runners, 479 cycling helmets, 540, 541 Didrikson, M., 9, 9, 14 competition anxiety cyproterone acetate, 401 diethylpropion, 333 mental skills training, 112 digital ischaemia, 640, 640 training environments, 115, 116 dancers dilutional pseudoanaemia (sports young athletes, 410 menstrual irregularity anaemia), 311–12 Competitive State Anxiety Inventory-2, amenorrhoea, 381 2,3-diphosphoglycerate, 24 109–10 bone mineral density, 393 disability rights movement, 303 compression of morbidity, 147 musculoskeletal injuries, 397 disabled athletes, 301–9 computed tomography (CT) de Quervain’s tenosynovitis, 230, 476 historical aspects, 301–2 back pain diagnosis, 464 canoeing/kayaking, 608 physiological response to exercise, 305, body composition assessment, 359 cyclists, 543 307 head injury, 582 decathletes, musculoskeletal injuries, 479 research perspectives, 305–8 pituitary imaging, 385 decision-making bodies, 16–17 female athletes, 306–8 concentration, 109 dehydration social constructs, 303 concussion, 582 soccer players, 579 sports participation, 303–5 management guidelines, 583 warm environment exercise, 64, 65 wheelchair competitors congenital adrenal hyperplasia, 190 delayed menarche, 38, 378–9, 381, 387 economy of movement, 305–6 conjunctivitis, 458 gymnasts, 414, 496 stereotypes, 304, 305 connective tissue diseases, 219 delayed muscle soreness, 212 world records, 304 consciousness raising, 431 gymnasts, 500 discogenic back pain, 463, 464 governing body leadership positions, dental staining, 459 discus, musculoskeletal injuries, 476 446 dental trauma distance running contact forces, 102 basketball players, 572 amenorrhoea, 381, 382, 392, 393, 394, contraceptive options, 51 soccer players, 584 395, 396, 396, 397 amenorrhoea management, 386 desert environments, 63 bone mass–menstrual history contusions, 500, 594 desogestrel, 401 relationship, 392, 393, 394, 395, Cooper, C., 550 development 399, 399 coordination, 32–3 diabetic adolescents, 274 female athlete triad, 479 eating-disordered athletes, 371 gymnasts, 414, 496 heat illness prevention, 66, 66 coping responses, 111 ice skaters, 515 iron deficiency anaemia, 480 corneal oedema, 458 physical evaluation, 174–5 musculoskeletal injuries, 397, 477 coronary artery congenital anomalies, pubertal staging, 175, 176 occult gastrointestinal bleeding, 482 247 swimmers, 454, 454–5 stress fractures, 396, 396 coronary artery disease, 245, 358 see also puberty see also marathon running exercise in prevention, 246, 247 diabetes, 147, 247, 265–76, 358 diuretics, 327, 369, 370 corticosteroids acute exercise, 266, 266–7 rapid weight loss, 333–4 inhaled, 481 adolescents, 274 drag forces, 105 tendon sheath injection, 499 amenorrhoea, 274 drug-testing programmes cortisol, 153, 382 blood glucose monitoring, 269 hormone replacement therapy, 159, resistance training response, 31 cardiovascular disease risk, 275–6 164–5 costochondritis, 488–9 clinical screening, 269 masters athletes, 163–4 costovertebral joint dysfunction, 488 complications, 272–3 urine sample provision, gender issues, Cranz, C., 10 dietary intake, 269 191 creatine phosphate supplements, 326 eating disorders, 274 dual-energy X-ray absorptiometry cromolyn sodium, 458, 481 exercise in pregnancy, 273 (DXA) Cushing’s syndrome, 384 foot care, 272 body composition assessment, 360, 385 index 651

bone mineral density assessment, 385, physiology, 23–9 distance runners, 478, 480 392, 394 plasma volume increase, 25, 311–12 track and field athletes, 470, 479–80 dysmenorrhoea, 43, 51, 52, 54, 55, 174 stroke volume, 25 femoral anteversion, 94–5 dysrhythmias, 242 substrate utilization, 26–8 fencing, 7, 9 sudden death, 247 energy balance fenfluramine, 333 aerobic training, 82 ferritin, 313, 315 ear examination, 175 estimation, 120–3 fetal heart rate, 203 ear problems energy efficiency, 120–1 fetal malnutrition, 194 canoeing/kayaking, 610 food intake data, 121 fetal oxygen–haemoglobin dissociation synchronized swimmers, 466 standards, 121 curve, 196 eating disorders, 122, 364–75, 381 reproductive hormone profiles, 259–60 fibromyalgia, 219 adolescent athletes, 387 energy efficiency, 120–1 fibula fractures, 590–1 amenorrhoea, 383, 387 energy intake, 322 finger injuries associated sexual abuse, 345 amenorrhoea, 122, 177, 381, 382, 386 basketball players, 570 definitions, 364 gymnasts, 496 softball players, 640 diabetic athletes, 274 ice skaters, 525 fitness measures (performance diagnosis, 364–6, 370–1 inadequate, 121–2 parameters), 37–8, 38, 77, 136 female athlete triad, 170–1 management, 122–3 Fleming, P., 415 history-taking for preparticipation symptoms, 122 flexibility, 31–2 examination, 174 ephedrine, 328–9 growth/developmental changes, 170 medical aspects, 369–71 anorectic effects, 333 ice skaters, 523–4 long-term effects, 370, 398 epicondylar tendon injuries, 210 masters athletes, 150–1 musculoskeletal injuries relationship, Epstein–Barr virus infection, 175 soccer players, 576 397 equal opportunities, 15–17, 409, 432, 448 swimmers, 459 preconceptional, 387 decision-making bodies, 16–17 flexor halluxus tendinitis, 222–3 prevalence, 366, 366–8, 367 equipment interactions, 106 flow state, 110–11 self-report vs. clinical interview, 367 erythropoietin, 24 fluid consumption tolerance, 83 skill level associations, 367–8 ethical issues, 430–9 fluid and electrolyte balance prevention, 374 gender verification, 189, 190, 191, aerobic training, 83 reasons for development, 369 437–8 progesterone effects, 42 referral, 174 ethinyloestradiol, 56, 400, 401 warm environments, 63, 64, 64, 66 risk factors, 368–9 exercise-induced bronchospasm fluid resistance, 105 sports performance effects, 371–2 alpine skiers, 622 fluoxetine, 333 psychological impact, 371–2 ice skaters, 525 follicle-stimulating hormone (FSH), 39, stress fractures association, 222 rowers, 493 378, 382, 384 subclinical disorders, 364, 366 swimmers, 458 ovulation induction, 388 track and field athletes, 470 track and field athletes, 470, 480–1 food intake data, 121 training environment characteristics, exercise-induced haemolytic anaemia, foot care, diabetes, 272 115, 116 311, 312 foot injuries/foot problems, 223–4 treatment, 177, 372–4 external ear exostosis basketball players, 566–7 competition/training during, 373–2 canoeing/kayaking, 610 cyclists, 546 health maintenance standards, swimmers, 457 ice skaters, 521, 522 373–4 external tibial torsion, 94 foot paraesthesias, 546 young élite athletes, 411, 422, 423 eye examination, 175 foot strike haemolysis, 312 eccentric muscle contraction, 212, 500 eye injuries/eye problems footwear, 223–4 economy/efficiency of movement, 23, 26 basketball players, 571 cyclists, 546 training, 81, 84–5 softball players, 640 skates see ice skates wheelchair competitors, 305–6 swimmers, 458 track and field athletes, 472 elbow injuries synchronized swimmers, 466 force platform, 102 gymnasts, 502, 504 eyewear, 173 forearm injuries rowers, 490–1 canoeing/kayaking, 607–8 electrocardiogram facial injuries softball players, 636 exercise testing, 245 basketball players, 571 French Women’s Sport Federation manifestations of exercise training cycling helmet design, 540 (FSFSF), 6 (athlete’s heart), 243–4 soccer players, 584 friction, 104 endogenous opioid secretion, 382 softball players, 639–40 frostbite prevention, 69, 70 endurance training Fairhall, N., 301 frozen shoulder (adhesive capsulitis), age-related muscle changes, 149–50 fat intake restriction, 123 226–7 carbohydrate loading, 27, 27, 28 management, 124 cardiac output, 25 symptoms, 123–4 galactorrhoea, 383, 384 cardiovascular adaptation, 80–1 fat necrosis, 500 gastrointestinal blood loss, occult, 315, cold environments, 67 fatigue, central, 27–8, 28 482 eating disordered athletes, 371 fatigue resistance, 31 gastrointestinal disorders, 470, 481–2 economy/efficiency of movement, 23, Fédération Sportive Féminine gender issues, 436–7 26 Internationale (FSFI), 6, 7 bias in medical practice, 430–1, 435 haemoglobin dilution response, 25 female athlete triad, 353, 377 decision-making on sports historical aspects, 12–13, 16 long-term consequences, 370, 398–9 participation, 434 lactate threshold, 23, 25 preparticipation examination, 170–1 definitions, 188 · o maximal oxygen uptake (V 2max), 23, soccer players, 592 sports organizations, 445 24–5 stress fractures, 592 stereotypes, 16, 108, 431 652 index

gender issues, Continued growth hormone, 27 motivational training environments, ancient Greek archetypes, 433, 433 age-related decline, 153 115–16, 116 ‘feminine’ body form, 15 anabolic effects, 331–2 safety threshold, 504, 506 historical aspects, 10, 15, 432–4 oestrogen effects, 39, 41 time investment, 414, 497–8 ‘weaker sex’, 10, 23 resistance training response, 31 gynaecological history, 173–4 violent behaviour, 436 gymnastics, 494–507 gender verification, 183–92 age of competitors, 413 H2 blockers, 482 controversies, 188, 189, 190 amenorrhoea, 381 haematocrit, 311 current proposals, 191 artistic, 495 haematomas, 594 abandonment of genetic screening, body composition, 355 haemoglobin 192 body type, 494–5 altitude response, 71 · o ethical issues, 189, 190, 191, 437–8 centre of gravity, 102 maximal oxygen uptake (V 2max) female athletes’ views, 189–90 ‘feminine’ body stereotypes, 16 relationship, 24 historical aspects, 183–4 weight/height, 413, 494, 495, 496–7 normal range, 311 legal aspects, 190–1 bone mineral density, 287, 294, 295, haemolytic disorders, 125 need for education of athletes, 190 393, 497 Haglund’s deformity, 528, 589 physical examination, 184 current performance demands, 494–5 hallux rigidus, 567 purpose, 188, 189, 191 delayed menarche, 38, 496 Hamill, D., 415 scientists’ views, 190 energy intake deficit, 496 hammer throw, musculoskeletal injuries, sex chromatin testing, 184–7 growth, 38, 370, 497, 498, 506 476 Y determinant gene identification by health concerns, 495–6 hamstring strain, 470, 472, 473, 474 PCR, 187, 187 historical aspects, 5, 6, 13 hamstring tendinitis, 609 genital tract abnormalities, 378, 381, 385 musculoskeletal injuries, 413, 414, hand injuries genital tract examination, 384 498–506 basketball players, 570–1 genu valgum, 94, 95 acute fractures/dislocations, 503, cyclists, 541, 543 genu varum, 95 504, 505 overuse tendinitis, 230–1, 231, 543 German Democratic Republic (GDR), 12, anatomical location, 499 soccer players, 584 14 ankle sprain, 500 handball, 12 gestational diabetes mellitus, 265 anterior cruciate ligament injury, 214 anterior cruciate ligament injury, 214 exercise effects, 273–4 apparatus, 499 Hard, D., 550 Gibb, R., 12 emotional component, 506 Harding, T., 410, 415 Gilmore’s groin (athletic pubalgia), 586 flexor halluxus tendinitis, 223 Hartel, L., 301 glucagon, 266 iliac apophysitis, 503 head examination, 175 glucose tolerance incidence, 498–9 head injury, 503 oestrogen effects, 41, 42 knee ligament rupture, 500–1 canoeing/kayaking, 610 oral contraceptive effects, 54 long-term sequelae, 503–4 cycling, 540 glucose transport, 27 lumbar spine overuse, 231 soccer players, 581–3 oral contraceptive effects, 53 muscle strain, 501 health certificates, 188 GLUT-4, 27 osteochondritis dissecans of elbow, health habits assessment, 174 glycogen metabolism 502, 504 heart, 241 endurance performance, 17, 26 osteochondritis dissecans of knee, heart murmurs, 175, 242 menstrual cycle changes, 47 502 manifestations of exercise training oestrogen effects, 39 prevention, 504 (athlete’s heart), 243 soccer players, 580 radial stress syndrome, 229, 230 heart rate, 242 training effects, 81–2 rehabilitation, 506 maximum, age-associated decline, 139 glycogen repletion/stores, 82, 322 reinjury, 499, 506 pharmacological reduction, 330 goal-setting in training, 112, 113, 115 repetitive muscle microstrain, 500 preparticipation examination, 242 golf repetitive soft tissue contusion, 500 heart rate monitoring historical aspects, 4 shoulder dislocation, 501 aerobic training, 79 wrist overuse injuries, 229, 230 shoulder pain, 225 interval training, 84 gonadotrophin-releasing hormone spondylolysis, 502–3, 503 pace training, 83 (GnRH), 38, 377–8, 382 stress fractures, 501–2 pregnancy, 199 ovulation induction, 388 tendinitis, 499–500 heart sounds, 243 gonadotrophin-releasing hormone traction apophysitis of olecranon, heart volume, 25 (GnRH) agonists, 391 502 heartburn, 481 greater trochanteric bursitis, 586 wrist overuse, 229 heat acclimatization, 63, 66 Griffith-Joyner, F., 14, 15 Olympic disciplines, 495 training effects, 64–5 groin pain, 586 psychosocial studies of young élite heat cramps, 481 ground reaction force, 102–4 athletes, 413–15, 423 heat exhaustion, 65, 481 landing, 104, 104 reasons for discontinuing, 413, heat illness running, 103, 103 414–15, 424 canoeing/kayaking, 611 walking, 102–3, 103 reasons for participation, 413, 414 history-taking for preparticipation growth rhythmical, 13, 16, 495 examination, 173 bone, 281 skills, 495 prevention, 65–6 diabetic adolescents, 274 training/competing while injured, soccer players, 579 gymnasts, 38, 370, 497, 498 413, 498, 506 track and field athletes, 470, 481 safe training levels, 506 training programmes heat stroke, 65, 481 physical evaluation, 174–5 athlete-recommended changes, 415 height, 94, 94 preparticipation examination, 170, 170 during rapid growth, 506 gymnasts, 38, 413, 494, 495, 496–7 pubertal, 170, 170 injury–intensity relationship, 498 physical evaluation, 174 index 653

swimmers, 453 symptoms, 69 inhaled corticosteroids, 481 helmets hypothyroidism, 384 insulin, 27, 153, 266, 382 cycling, 540, 541 hypoxic problems, synchronized oestrogen influences, 41, 42 kayaking/canoeing, 602 swimmers, 466 oral contraceptive effects, 53, 54 softball, 641, 642 preparations, 271 Henie, S., 14 ice dancing, 513–14, 514 insulin-like growth factor I, 153, 382 heptathletes, musculoskeletal injuries, ice hockey, 409 insulin therapy, 266, 269–70 479 ice skates, 516, 516–18 dietary management, 269 high jump blades, 517–18 insulin preparations, 271 centre of gravity, 102 boots, 516–17 International Olympic Committee (IOC) flexor halluxus tendinitis, 223 fit, 518 women members, 442, 446 musculoskeletal injuries, 470, 474, 475 lower limb injuries, 521, 522 International Socialist Workers’ Sports high-impact sports ice skating, 510–32 Movement, 9 bone loading characterisitcs, 287, accessory navicular bones, 527 International Special Olympics, 301, 302 290–4 ankle injuries, 528 international sports governing bodies, exercise-induced haemolytic anaemia, retraining of proprioception, 528, 441–9 312 529 intrauterine device, 51 Hill–Sachs shoulder lesion, 224 ankle tenosynovitis, 528 intrauterine growth restriction, 194 historical aspects, 3–17, 432 back pain, 521, 531 iron bioavailability, 125 gender stereotypes, 10, 15, 432–4 bone loading effects, 287 iron deficiency, 124–7, 312–18 gender verification, 183–4 compulsory figures, 510 absorption deficit, 315 medical viewpoints, 10–11, 12 current performance demands, 515–16 altitude acclimatization, 71 softball, 626 equipment, 516, 516–18 skiers, 615 tennis, 550–1 boot fit-related injury, 521, 522 cold environment responses, 68–9 women athletes with disabilities, exercise-induced bronchospasm, 525 dietary inadequacy, 316 301–2 flow state (attentional skills), 110–11 differential diagnosis, 313, 314 hockey, 12 foot/ankle bursae, 527, 527 ferritin levels, 313 hormonal factors free skating, 510–12, 511, 512 gastrointestinal losses, 315 breast cancer risk, 257–8 historical aspects, 4, 9 menstrual losses, 316 physical activity effects, 258–60, 260 ice dancing, 513–14, 514 performance effects, 316–17 strength, 31 injuries, 518–22, 519, 520, 523 prevalence, 313–15 substrate utilization, 27 injury management/rehabilitation, prevention, 318, 318 hormone replacement therapy, 158–65, 526–32 screening, 125, 317–18 380 boot-related injuries, 527–8 stages, 312, 313 amenorrhoea management, 177, 386 harness support, 530, 530 symptoms, 125 adolescent athletes, 387 off-ice activities, 530 treatment, 125, 318, 318 androgens, 56, 159, 161–3, 162, 163 on-ice training, 526 indications, 317 breast cancer risk, 258 principles, 528, 530–2 iron deficiency anaemia, 52, 311 drug-testing programmes, 159, 163–5 trunk stability enhancement, 530–1, alpine skiers, 621–2 oestrogens, 159–61 531 cold environment responses, 68–9 progestins, 161 injury prevention, 522–4 risk factors, 317, 317 hot environments see warm acute injuries, 524 track and field athletes, 470, 480 environments conditioning programmes, 523–4 iron depletion, 312, 313 human growth hormone, 331–2 off-ice training, 524, 530 iron intake, 124, 125 humerus fracture lumbar mobility enhancement, 531–2, dietary sources, 126 soccer players, 584 532 iron overload, 125, 127 softball players, 637 lumbar spine overuse injuries, 231 iron status hunger, 123–4 nutrition, 525–6 indicators, 313, 314 hurdlers, musculoskeletal injuries, 470, pairs, 512–13, 513 ferritin, 313 473 physiological profile, 514–16, 515 training effects, 315 hydrostatic weighing, 358, 359, 385 precision (team) skating, 514, 515 iron supplements, 125, 318, 318 hypermobility syndrome, 217 psychosocial stress, 526 effects on performance, 317 see also joint laxity/hypermobility psychosocial studies of young élite ischial bursitis, 609 hypertension, 147, 245, 358 athletes, 410, 415–17, 423 Islamic women, 15 definitions, 175 sources of enjoyment, 416, 416–17 Islamic Women’s World Games, 15 exercise in prevention, 246 sources of stress, 416, 417 type II (non-insulin-dependent) time committment, 416 Jaeger, A., 417 diabetes, 271, 272 stress fractures, 527 javelin hypertrophic cardiomyopathy, 175, iliac apophysitis, 503 musculoskeletal injuries, 476–7 244–5, 247, 572 iliotibial band syndrome projectile motion, 97, 98 hypoglycaemia prevention, 269, 270 cyclists, 545 joint angular position, 96, 96–7, 97 in relation to exercise, 270, 270 rowers, 491 joint angular velocity, 98 hypoglycaemic symptoms, 269 soccer players, 587–8 joint laxity/hypermobility, 32, 217 hypothalamic amenorrhoea, 379–80, 382 track and field athletes, 471, 479 knee injuries, 218 ovulation induction, 388 imagery use, 109, 110, 112, 113, 426 laxity scale, 217, 217, 218 swimmers, 455 inertia, Newton’s laws, 102 pregnancy, 200–1 hypothermia, 66 inertial forces, 105–6 shoulder pain, 224 canoeing/kayaking, 611 infertility, 387–8 joint moments (torques), 106 causes, 69 inflammation grading system, 210, 211 joint reaction forces, 104 prevention, 69–70 ingrown nails, 594, 595 joint-specific testing, 175, 177 654 index

Jones fractures, 591–2 shoe–surface interface friction, 214 gender differences, 322 Joyner-Kersee, J., 14 skiers, 613, 615, 616, 618–21, 619, 620 menstrual cycle effects, 47 judging criteria, 435 predisposing factors, 620 lipoprotein lipase, 39 judo, 13 prevention, 621 long jump, musculoskeletal injuries, 474 jumpers’s knee, 569, 573 soccer players, 586–8 low-T3 (triiodothyronine) syndrome, jumping softball players, 638 259–60 basketball, 567, 567, 569 synchronized swimming, 465 lumbar apophysitis, 234, 234 ice skating, 511, 511, 512, 512, 513 knee joint laxity, 217 lumbar disc disease landing kinematics, 521 arthrometer measurement, 217, 217 canoeing/kayaking, 609 strength training, 524 knee pain rowers, 492 musculoskeletal injuries, 470, 473–5, ice skaters, 521 soccer players, 584–5 569, 573 swimmers, 464–5, 465 lumbar spine overuse injuries, 231–4 differential diagnosis, 464–5 hyperextension injury, 231, 234 karyotype, 186, 384 sites of pain, 464 ice skaters, 521–2 kayaking, 600–12, 601 treatment, 465 ligament sprain, 231–2 ankle injuries, 610 Korbut, O., 15, 15, 413, 494, 495 muscle strain, 231–2 back injuries, 608–9 rowers, 491–3 cold water emersion responses, 611 lactate metabolism soccer players, 584–5 entrapment accidents, 611 aerobic interval training, 79–80 spondylolysis/spondylolisthesis, equipment, 601–2, 602 age-related changes, 148 231–4 head injuries, 610 breast milk lactic acid, 204 luteal phase defect, 379 heat illness, 611 menstrual cycle effects, 47 bone metabolism, 391, 392 medical problems, 610–11 placenta, 194 management, 388 musculoskeletal injuries, 604, 604–10 pregnancy, 202–3 swimmers, 455 pelvic injuries, 609–10 lactate threshold, 23, 25 luteinizing hormone (LH), 39, 378, 382 pregnant athletes, 611 aerobic interval training, 82 ovulation induction, 388 safety equipment, 602 anaerobic interval training, 84 lysine supplements, 323 shoulder dislocation, 605–7, 606, 607 masters athletes, 141 shoulder impingement, 604–5 pace training, 83, 84 McMurray’s test, 569, 587 skin problems, 610–11 performance relationship, 82 macrocycles of training, 87 technique, 602–4 sustained distance training, 82 macronutrient ergogenic aids, 321–4 Duffek stroke, 603 trainability, 25 magnetic resonance imaging (MRI) eskimo roll, 604 lactation, 204–5 back pain diagnosis, 464 low/high brace, 603, 603 lactose intolerance, 128 body composition assessment, 359–60, water-borne infection risk, 611 landing 385 wrist/forearm injuries, 607–8 anterior cruciate ligament injury, 214 genital tract imaging, 385 kayaks, 601–2, 602 ground reaction force, 104, 104 knee injuries, 569 keratitis, 458 lateral compartment overload syndrome lumbar disc disease, 585 Kerrigan, N., 410 of elbow, 228, 228–9, 229 pituitary imaging, 385 kidney injury, 586 lateral counterforce elbow brace, 558, 558 stress fractures, 478, 501–2, 593 kinaesthetic imagery, 109, 110 lateral epicondylitis (tennis elbow), 227, Magnus effect, 105 kinematics, 93, 94, 95–9 227–8 Maier, U., 622 acceleration, 98 canoeing/kayaking, 608 malleolar bursae, 527 angular position, 96, 96–7, 97 management, 228, 558, 558–9 mallet finger, 570, 640 angular velocity, 97–8 prevention, 559 marathon running observation methods, 95–6 rowers, 490 historical aspects, 4, 12–13 position, 96 tennis players, 556, 556–9 lactate threshold, 82 projectile motion, 98, 98–9 lateral facet syndrome, 491 musculoskeletal injuries, 477 velocity, 97 legal aspects, gender verification, 190–1 see also distance running kinetics, 94, 102–6 lever systems, 93, 99–101 Marfan’s syndrome, 242 fluid resistance, 105 applications, 100–1 marijuana, 369 friction, 104 first-class, 99, 100 masculinization, 435 ground reaction force, 102–4 second-class, 99, 100 historical viewpoints, 11 inertial forces, 105–6 third-class, 99–100, 100 masters athletes, 135, 136, 144 joint reaction forces, 104 levonorgestrel, 53 anabolic steroid effects, 153 muscle forces, 105 life jacket (personal floatation device), arterial oxygen saturation, 140 King, B.J., 550, 551 602 arteriovenous oxygen difference, 140 knee angle measurements, 97 lift forces, 105 athletic accomplishments, 135–6 knee flexors/extensors, age-related ligament injury, 210–11 body composition, 144–5, 145 changes, 149 healing, 211 cardiorespiratory function, 135–42 knee injuries, 213 lumbar spine, 231–2 drug testing, 163–4 basketball players, 568–9, 573 ligaments, hormonal effects on function, flexibility, 150–1 cyclists, 544–6 215, 217 heat tolerance, 141 gymnasts, 500–1 lignocaine, 541 injuries, 152–3 osteochondritis dissecans, 502 lipid profiles lactate threshold, 141 · o hypermobility, 218 exercise effects, 247 maximal oxygen uptake (V 2max), jumpers, 474 diabetes, 268–9, 271 136–9, 137, 150 muscle strength/muscle recuitment, oestrogen effects, 39, 41 maximum cardiac output, 139–40 214–15 lipid utilization muscle function, 144–54 rowers, 491 endurance performance, 26, 27 muscle oxidative capacity, 140 index 655

performance determinants, 136 metabolic rate, 46 strength, 148–9, 150 peripheral blood flow, 140 substrate utilization, 26, 47 training effects, 150 pregnancy outcome, 202 moliminic symptoms, 43 enzyme activities, 81 pulmonary function, 140–1 oestrogen, 38, 39, 378 hypertrophy, 86 sports performance, 151, 151–2, 152 performance effects injury, 211–12 sprint records (100 m), 158, 159 aerobic performance, 48, 49–50, 51 kinetics, 105 training level decline, 142 early studies, 43–4 masters athletes, 144–54 trophic factors, 153 physical training effects, 39 resistance training response, 31 Mauermayer, G., 10 physiology, 38–43, 40, 377–8 strength–bone mass relationship, maxillofacial injuries, 584 progesterone, 38, 378 357–8 · o maximal oxygen uptake (V 2max), 23, respiratory function, 42, 45–6 structure, 145–6 29 restoration following exercise-related muscle conditioning exercises aerobic training, 80 amenorrhoea, 385 postpartum, 204 age-associated decline, 138–9 strength effects, 47–8 pregnancy, 200, 200–1 altitude effects, 70–1, 71 thermoregulation changes, 46, 65, 68 muscle contusions, 594 determinants, 24–5 warm environment exercise, 65 muscle cramps, 466 masters athletes, 136–9, 137, 150 menstrual dysfunction muscle cross-sectional area menstrual cycle effects, 48, 49–50, 51 body fat content relationship, 356 age-related changes, 146, 150 pregnancy, 202 bone metabolism effects see bone resistance training, 30–1 mazindol, 333 mineral density muscle fibre type, 146 medial collateral ligament injury causes, 379–81 age-related changes, 146, 147, 148, 149, skiers, 620 luteal phase defect, 379, 388, 391, 392 150 soccer players, 577 oral contraceptives in management, training effects, 81 medial epicondylar fracture, 637 388 pace training, 84 medial epicondylitis stress fractures association, 222 resistance training, 30–1 javelin throwers, 477 swimmers, 455, 456, 457 muscle fibres, 145 rowers, 490 see also amenorrhoea; muscle mass tennis players, 556 oligomenorrhoea anabolic steroid effects, 331 medial knee pain, 545–6 menstrual history, 173–4 beta2-agonist effects, 332 medial tibial stress syndrome (shin menstrual iron losses, 316 growth hormone effects, 331 splints) mental skills, 109–11 muscle strain, 211, 212 basketball players, 567–8 training, 111–13 gymnasts, 501 distance runners, 478 meralgia paraesthetica, 500 repetitive microstrain, 500 soccer players, 588 mesenchymal syndrome, 210 lumbar spine, 231–2 medical interview, 382–3 mesocycles of training, 87 soccer players, 595 medical viewpoints metabolic intermediate ergogenic aids, musculoskeletal function, wheelchair bias in gender issues, 430–1, 435 324–6 athletes, 307 boxing and wrestling, 16 metabolic rate musculoskeletal injuries, 208–34, 397 historical aspects, 10–11, 12 heat production in cold environments, acute injury treatment, 208 medium-chain triglyceride supplements, 67 amenorrhoea relationship, 385, 397 323–4 menstrual cycle variation, 46 growth-associated risk, 170 medroxyprogesterone acetate, 53, 401 metatarsal fractures, 591–2 history-taking for preparticipation menarche, 170, 170, 274, 399 methandienone (Dianabol), 153 examination, 173 delayed, 38, 378–9, 381, 387 micronutrients, 321 incidence, 581 gymnasts, 414, 496 middle distance runners, 477, 477 joint laxity/hypermobility, 217, 218 swimmers, 454, 454–5 migraine, menstrual, 43, 55 ligaments, 210–11 meniscal tears miserable malalignment syndrome, 218, masters athletes, 152–3 basketball players, 569 218, 219, 221 muscle, 211–12 skiers, 620 mitral valve prolapse, 244 overuse injuries, 208 soccer players, 587 Moffitt, B.J., 550, 551 pathophysiology, 208–12 menopause, 158–9, 378, 380, 435 molimina, 43 rehabilitation, 177 breast cancer risk, 258 moment of inertia, 106 risk factors, 212, 213, 213 diabetic athletes, 274–5 motivation, 109 extrinsic factors, 214–15 training diary, 162, 164 cognitive–affective model of burnout, gender-specific injury, 213–19 menorrhagia, 52, 55 114 intrinsic factors, 215 menstrual cycle, 37, 38–51 training environments, 114–15 skill level of participants, 215 basal body temperature (BBT) curves, young élite athletes, 411 tendons, 209–10 43 motor skills training, 85 young élite athletes, 411 cardiovascular variables, 44–5 mountain climbing, diabetic individuals, psychosocial aspects, 413, 414, 423 cognitive function influences, 43 271 musculoskeletal system examination, cold environment exercise, 68 mouthguards, 173, 584, 642 175 fluid balance, 42 multi-event athletes, 479 general screen, 175, 176 follicle-stimulating hormone (FSH), multiple directional shoulder instability, joint-specific testing, 175, 177 39, 378 224, 224–5 myosin, 145 gonadotrophin-releasing hormone muscle (GnRH), 38, 377–8 age-related changes National Amateur Athletic Federation insulin sensitivity changes, 266 capillarization, 147 (NAAF), 8 luteinizing hormone (LH), 39, 378 endurance activity, 149–50 National Collegiate Athletic Association metabolic changes, 39, 41, 42–3 glycolysis, 148 (NCAA), 441 glycogen storage, 322 sarcopenia, 146–7 National Socialist Germany, 9–10 656 index

nausea/vomiting, 481 diabetic athletes, 274–5 osteoporosis see bone loss navicular bursae, 527 menstrual phase changes, 38, 39, 258, otitis externa, 175, 457 navicular trauma 259, 378 otitis media, 457 basketball players, 566 physical activity effects, 259, 260 ovarian failure, 380, 384 soccer players, 576 metabolic effects, 39 ovarian tumour, 384 neck injury, 503 physiological actions, 39, 41–2 overtraining, 88, 89 neck pain, 542, 542–3 serotonin level relationship, 43 cognitive–affective model of burnout, neurological examination, 175 see also sex steroids 114 neurological function, 173 oestrogen implant therapy, 160–1 psychological aspects, 113–14 neuromuscular adaptation, 29, 84–5 oestrogen patch therapy, 160 track and field athletes, 470, 482–3 strength/power training, 86 oestrogen replacement therapy, 153, overuse injuries, 208 neurovascular headache, 43 159–61 cyclists, 542–6 Newton’s laws, 102, 105 oestrogen implant, 160–1 distance runners, 477 noradrenaline, 266 oestrogen patch, 160 gymnasts, 499 norethindrone, 53, 56 oral, 160 hormonal factors, 209 norgestrel, 53 see also hormone replacement therapy; ice skaters, 521–2 nose disorders/injuries oral contraceptives prevention, 522–3 basketball players, 571 olecranon stress fracture, 637 lower extremities, 219–24 canoeing/kayaking, 610 oligomenorrhoea, 379 lumbar spine, 231–4 swimmers, 457–8 bone mineral density, 393, 394 predisposing anatomical limb nose examination, 175 low energy intake, 122, 382 variation, 218 nutrition swimmers, 455 rowers, 487 amenorrhoea management, 177, 381, Olympic Games participation, historical soccer players, 595 386 aspects, 3–17, 432 tendon, 209, 210 calcium deficiency, 127–8, 128 interwar years, 5–11 track and field athletes, 470, 471 diabetes management, 269 National Socialist Germany, 9–10 transitional athletes, 208, 209 fat intake, 123–4 numbers of competitors, 13, 13–14, 15 treatment, 208, 209 gymnasts, 496 opposition, 3–4, 7, 8, 11–12 upper extremities, 224–31 history-taking for preparticipation post-Second World War, 11–17 ovulation, 39, 43, 378 examination, 174 pre-First World War, 3–5 induction, 387 ice skaters, 525–6 Women’s Olympic Games, 5–7 inadequte energy intake, 120–3, 496, Worker’s Olympiads, 9 pace training, 83 525 Olympic ideal, 432 physiological adaptations, 83–4 iron deficiency, 124–7, 126, 316 oral contraceptives, 37, 51–6, 383 Paralympic Games, 301, 302 preconceptional, 387 amenorrhoea management, 386–7 pars interarticularis defects, 463, 464, problems, 120–9 adolescent athletes, 387 493, 570 soccer players, 579–80 bone loss prevention, 400–1 patellar dislocation, 219 nutritional ergogenic aids, 321–6 breast cancer risk, 258 basketball players, 569 amino acid supplements, 323 cardiovascular function, 52–3 patellar tendinitis carbohydrates, 321–2 contraindications, 51 ice skaters, 521 carnitine, 324–5 energy metabolism effects, 53–4, 54, 55 soccer players, 587

coenzyme Q10 (ubiquinone), 325–6 health benefits, 51 track and field athletes, 470, 474 creatine phosphate, 326 menstrual cycle manipulation, 55 patellofemoral syndrome, 220, 220–1 macronutrients, 321–4 menstrual dysfunction management, basketball players, 569, 573 medium-chain triglycerides, 323–4 388 cyclists, 544–5 metabolic intermediates, 324–6 oestrogen effects, 39 ice skaters, 521 micronutrients, 321 performance effects, 54–6 rowers, 491 protein supplements, 323 progestins, 41 soccer players, 587 respiratory system effects, 53 track and field athletes, 470, 471, 474, obesity, breast cancer risk, 258, 261 side effects, 52 477 impact of physical activity, 261, 262 strength effects, 56 paternalism, 434, 436 occult gastrointestinal bleeding, 315, 482 oral oestrogen therapy, 160 decision-making on sports oestrogen orciprenaline, 332 participation, 434–5 adipose tissue production, 261, 358 organizational gender biases, 445, 446–7 Patiño, M.J.M., 186, 186 age-related decline, 153 feminist perspective, 447, 448 pelvic examination, 175, 176, 384 amenorrhoea management, 386–7 ornithine supplements, 323 pelvic floor exercises, 204 adolescent athletes, 387 os trigonum injuries, 566 pelvic injuries, 609–10 bone mass effects, 283, 391 Osgood–Schlatter disease, 170 performance calcium uptake, 42 basketball players, 573 altitude effects, 70 lumbar bone mineral density, 393 ice skaters, 521 amenorrheic athletes, 385 microfracture healing, 396, 397 soccer players, 595, 596 androgen (testosterone) replacement osteoporosis prevention, 400 osteitis pubis, 586 therapy, 161–3, 162, 163 cardiovascular effects, 44 osteoarthritis, 219 body composition relationships, cognitive function influences, 43 diabetic athletes, 275 353–5, 354 exercise-induced elevation, 44 osteochondritis dissecans bone loss/amenorrhoea treatment exposure-related breast cancer risk, growth-associated risk, 170 effects, 402 257 gymnasts eating disordered athletes, 371–2 glycogen metabolism effects, 47 elbow, 502, 504 iron deficiency effects, 316–17 ligament function, 211, 215 knee, 502 lactate threshold relationship, 82 menopausal levels, 158, 159 osteocyte apoptosis, 391, 397 masters athletes, 151, 151–2, 152 index 657

oral contraceptive effects, 54–6 high-intensity exercise, 201–2 cycling, 540, 541 weight loss effects, 355 fetal responses, 203–4 kayaking, 602 performance anxiety, 109, 110 maternal physiological response, softball players, 641–2, 642 pharmacological aids, 330 202–3 protein supplements, 323 performance parameters, 37–8, 38, 77, indications for consulting physician, protein utilization, endurance 136 199 performance, 27 pericardium, 241 medical prescreening, 197–8 pseudoephedrine, 328 periodization of training, 87–8 muscle conditioning exercise, 200, psychogenic amenorrhoea, 380 peroneal tendinitis, 590 200–1 psychological aspects, 108–17 personal floatation device (life jacket), outcome, 202 adaptive training environments, 602 pelvic alignment, 201 114–17 personal safety, 342 postpartum exercise, 204 coping responses, 111 pes anserinus overuse injury/bursitis preconceptional amenorrhoea mental skills, 109–11 cyclists, 546 management, 387–8 training, 111–13 soccer players, 577, 595 resistance exercise, 201 overtraining, 113–14 pharmacological ergogenic aids, 326–34 safety considerations for exercise, 198, psychosocial abuse, 412 phentermine, 333 198–9 psychosocial stress see stress phenylpropanolamine, 328 skiers, 622 pubertal growth spurt phosphocreatinine, 78 uteroplacental blood flow during bone mass, 284 recovery, anaerobic interval training, exercise, 194–6 gymnasts, 497, 498 84 pregnancy testing, 385 history-taking for preparticipation Physical Activity Readiness Medical premenstrual syndrome, 43, 51, 52, 54, 55 examination, 173 Examination for Pregnancy preparticipation examination, 169–81 pubertal staging, 175, 176 (PARmed-X for Pregnancy), 197–8 cardiovascular function, 242–3 puberty, 38 physical examination, 174–7 clearance for participation, 177, 181 delayed, 414 gender verification, 184 guidelines, 178–80 patellofemoral pain syndrome, 221 Pierce, M., 410, 417 female athlete triad, 170–1 preparticipation examination of pituitary abnormalities, 380 growth/developmental changes, 170, development, 170, 170 pituitary imaging, 384–5 170 pubic hair distribution, 383 pituitary tumour, 380, 384, 385 laboratory assessment, 177 pyridoxine, 54 placental lactate metabolism, 194 medical history, 171, 171, 172, 173–4, plantar fasciitis 242 Q-angle, 94, 95, 96 basketball players, 567 objectives, 169 quadriceps contusions, 594 soccer players, 590 opportunistic counselling, 169 quadriceps tendinitis, 545 plasma volume, 24, 25 physical examination, 174–7, 242 quadriceps tendon strains, 474 altitude response, 71 setting, 169 endurance exercise-associated timing, 169 radial neuropathy, 636 increase, 311–12 treatment of abnormal findings, 177 radial physis stress injuries, 229–30, 230 pole vaulting, musculoskeletal injuries, Prevost, H., 550 radius fracture, 584 474–5 progesterone Radke-Batschauer, K., 8, 8 polycystic ovarian disease, 380 actions, 42–3 rating of perceived exertion (RPE), 79 polymerase chain reaction (PCR), Y bone loss treatment/prevention, 391, pregnancy, 199 determinant gene identification, 401 recurrent atraumatic shoulder instability 187, 187 cardiovascular effects, 44 (AMBRI), 224 position kinematics, 96 central thermogenic actions, 46 rehabilitation, 177 posterior tibial tendinitis, 222, 223 exercise-induced elevation, 44 cycling injuries, 546–7 basketball players, 567 exposure-related breast cancer risk, gymnastics injuries, 506 soccer players, 588, 589 257 ice skating injuries, 526–32 track and field athletes, 478 fluid balance, 42 relaxation training, 111, 112, 426 postpartum exercise, 204 glycogen metabolism effects, 47 relaxin, 215, 622 power, age-related muscle changes, 148 menopausal levels, 158 relay runners, musculoskeletal injuries, power in decision-making bodies, 16–17 menstrual phase changes, 38, 258, 259, 472–3 power training, 85 378 reproductive health physiology, 87 physical activity effects, 259, 260 bone mass relationship, 399 training methods, 86 metabolic effects, 42–3 classification of function as illness, pregnancy, 194–205, 399, 435, 436 respiratory function effects, 42, 45 435–6 amenorrhoea, 379, 385 structure, 41 historical viewpoints, 10, 11 bisphosphonates contraindication, 402 progestin challenge test, 384, 388 hormonal basis, 259 canoeing/kayaking, 611 progestins resistance training, 85–6 contraindications for exercise, 198, energy metabolism effects, 53 hormonal factors, 31 198–9 hormone replacement therapy, 161 muscle adaptation, 30–1 diabetes, 273 structure, 41 neural adaptation, 29 exercise prescription, 199–201 see also oral contraceptives pregnancy, 201 aerobic guidelines, 199, 199–200 projectile motion, 98, 98–9 whole muscle hypertrophy, 29–30 muscle conditioning, 201 projection angle, 98 resources, 16 fetal risk due to maternal exercise, projection height, 99 decision-making on sports 194–6, 195 projection velocity, 98–9 participation, 435 protective mechanisms, 196, 197 prolactin, 378, 380, 384 respiratory function heat dissipation during exercise, 196 prolactin-secreting adenoma, 380, 384 history-taking for preparticipation high altitude effects, 622 protective equipment, 173 examination, 173 658 index

respiratory function, Continued scoliosis, 173 gymnasts, 499 masters athletes, 135–42 idiopathic, 234 skiers, 621 menstrual cycle phase influence, 45–6 swimmers, 463 soccer players, 584 oral contraceptive effects, 53 scuba diving softball players, 636, 637 physical examination, 175 diabetic diver, 271 synchronized swimmers, 465–6 progesterone effects, 42 pregnancy, 436 shoulder instability resting energy expenditure (REE), 120 self-confidence, 109, 110, 112 anterior glenohumeral (‘apprehension resting metabolic rate, 147 self-esteem shoulder’), 460–1 retrocalcaneal bursitis training environment characteristics, multiple directional, 224, 224–5 basketball players, 572 115, 116 recurrent atraumatic (AMBRI), 224 soccer players, 589 young élite competitors, 410, 411 softball players, 637 Retton, M.L., 498 self-talk, 109, 111, 426 traumatic unilateral (TUB), 224 reverse turf toe, 590 training, 112, 113 shoulder ligaments, 224, 224 rheumatoid arthritis, 219 semimembranosus tendinitis, 546 shoulder pain, 224–6 rib stress fractures, 488, 489, 490 serotonin, 43 impingement syndromes, 225, 460 Richards, R., 437 sesamoiditis, forefoot, 567 swimmers, 459–62 Richey, N., 551 Sever’s disease see calcaneal apophysitis prevention, 462 rotator cuff, 224, 224 sex certificate, 186, 187 shoulder position, 459–60, 460 rotator cuff injury, 210 sex-change operations, 183–4 treatment, 461, 461–2 rowing, 486–93 sex chromatin, 185 shoulder tendinitis, 554 back pain, 231 sex chromatin testing, 184–7, 185 sickle cell anaemia, 125 bone loading effects, 287 false positive/false negative tests, 186 Sinding–Larsen syndrome dermatological problems, 493 sex chromosome mosaicism, 184–5, 186 basketball players, 573 elbow/wrist injuries, 490–1 sex discrimination, 17, 343, 435 soccer players, 596 exercise-induced bronchospasm, 493 women athletes’ reproductive health, sinusitis, 457–8 hand position, 490, 491 435–6 ski sickness, 622 knee injuries, 491 sex hormone-binding globulin, 159 skiing, 613–23 lumbar spine injuries, 491–3 sex reassignment, 188 amenorrhoea, 622 menstrual disorders sex steroids anterior cruciate ligament injury, 214 amenorrhoea, 381 physiological effects, 39, 41–3 bone loading effects, 287 bone mineral density effect, 393 structure, 41 equipment for women, 613 musculoskeletal injuries, 487–93 sexual abuse, 342–9, 343, 421, 436, 622 events, 613–14 evaluation, 487–8 associated eating disorders, 345 downhill, 614 treatment, 488 contingency theory, 348, 349 freestyle, 614 Olympic events, 486, 487 continuum of sexual violence, 343, 344 giant slalom, 613 phases of stroke, 486, 488, 492 definition, 344 slalom, 613 shoulder injuries, 489–90 disclosure, 344 snowboarding, 614 sustained distance training, 79 feelings of victims, 347 super giant slalom, 614 thoracic spine/rib injuries, 488–9 grooming process, 344 exercise-induced bronchospasm, 622 types of boat, 486, 487 overt signs, 345 injuries weight classes, 486–7 perpetrator cycles of behaviour, 345, equipment-related, 618 Rudolph, W., 14, 15 346 incidence, 615, 615–16, 616, 617 ‘runner’s trots’, 482 preventive guidelines, 348 risk factors, 616–18, 617, 618 running research studies, 342–3, 347–9 iron deficiency anaemia, 621–2 aerobic interval training, 79 risk factors, 344–7, 345, 346 knee injuries, 613, 615, 616, 618–21 body composition, 355 sexual development see development; anterior cruciate ligament, 618–19, bone loading effects, 285, 286–7, 288–9 puberty 619, 620 diarrhoea (‘runner’s trots’), 482 sexual harassment, 343, 421, 431, 436 medial collateral ligament, 620 economy of movement, 26 continuum of sexual violence, 343, 344 meniscus tears, 620 exercise-induced haemolytic anaemia definitions, 344 predisposing factors, 620 (runner’s macrocytosis), 312 shin guards, 590, 591, 594 menstrual cycle phase influences, 44 ground reaction force, 103, 103 shin splints see medial tibial stress physiology, 614–15 injury risk factors, 471–2 syndrome pregnant athletes, 622 sustained distance training, 79 shoe–surface interface friction, 214 psychosocial issues, 622 see also distance running; marathon shotput, musculoskeletal injuries, 476 shoulder injuries, 621 running; sprinting shoulder dislocation thumb injuries, 621 canoeing/kayaking, 605–7 skin examination, 175 sacral furunculosis, 609–10 on-scene reduction, 606, 606, 607 skin problems saddle sores, 544 gymnasts, 501 canoeing/kayaking, 610–11 sailing, 4 shoulder impingement cyclists, 544 salbutamol, 332 canoeing/kayaking, 604–5 history-taking for preparticipation Samuelson, J.B., 23 rowers, 489–90 examination, 173 sarcopenia, 146–7 shoulder pain, 225 rowing, 493 growth hormone response, 153 swimmers, 460 swimmers, 458–9 scaphoid fracture, 571 synchronized swimmers, 465 slide board activities, 530 scapular muscle strengthening exercises, tennis players, 554 snowboarding, 614 461 track and field athletes, 477 soccer, 575–97 Scheuermann’s disease, 463, 464 shoulder injuries abdominal injuries, 585–6 Schmorl’s nodes, 463 cyclists, 541 Achilles tendinitis, 589, 590 index 659

ankle impingement syndromes, 589 preventive measures, 640–1 negative training stress syndrome, 113 ankle sprains, 588–90 stress fractures, 636 skiers, 622 anterior cruciate ligament injury, 214, warm-up routines, 643 tennis players, 559–60, 561 586–7 windmill pitch, 627–31, 628, 629, 630, reduction measures for young ball control, 578 631 players, 561–2 biomechanics, 576–9 injuries, 635–6 young athletes, 410 cervical spine injuries, 581, 584 Soviet Union athletes, 12 see also competition anxiety chest injuries, 585–6 speed training, 84 stress fractures, 173, 222, 395–7 chest trap, 578, 585–6 spondylolisthesis, 231–4, 233 adolescent athletes, 387 breast injury, 585 basketball players, 570 amenorrhoea relationship, 222, 385, contusions/haematomas, 594 gymnasts, 504 395–6, 396 dental injuries, 584 rowers, 492–3 associated bone mass deficit, 283 female athlete triad, 592 swimmers, 463, 464 basketball players, 572 fibula/tibia fractures, 590–1 spondylolysis, 231–4, 232, 233 calcaneum, 572 flexibility, 576 basketball players, 570 female athlete triad, 592 fluid intake during exercise, 579–80 gymnasts, 502–3, 503, 504 femur, 396, 396 greater trochanteric bursitis, 586 ice skaters, 531 fibula, 527 groin injuries, 586 rowers, 492–3 grading, 593 head injuries, 581–3, 583 soccer players, 584, 585 gymnasts, 501–2 heading, 578–9, 582 swimmers, 463, 464 ice skaters, 527 cumulative encephalopathy risk, sports anaemia (dilutional metatarsals, 527, 592 582–3 pseudoanaemia), 311–12 microfracture healing impairment, historical aspects, 6, 12, 13, 16 sports governing bodies, 441–9 396, 397 ingrown nails, 594, 595 gender biases, 444–8 navicular, 527 inside of foot use, 576, 577 organizational structures, 445, 446–7, olecranon, 637 instep kick, 577–8 448 pars interarticularis, 463, 464, 493 knee injuries, 586–8 recruitment mechanisms (‘old-boy’ radial physis, 229–30, 230 lumbar spine injuries, 584–5 networks), 445 ribs, 488, 489, 490 maxillofacial injuries, 584 time/energy committment of soccer players, 592–4 medial tibial stress syndrome, 588 members, 447 softball players, 636, 637 meniscal injuries, 587 women members, 442–4 track and field athletes, 470, 471 metatarsal fractures, 591–2 women’s viewpoints, 447–8 distance runners, 477–8, 478, 479 muscle strain/overuse injuries, 595 sprinting risk factors, 472 musculoskeletal injuries, 470, 580–96 musculoskeletal injuries, 470, 472–3, sprinters, 473 adolescent players, 595–6 473 ulna, 636 incidence, 580, 580–1, 581 training, 78, 84 stress management programmes, 112–13 nutrition, 579–80 squash players, bone mineral density, young élite competitors, 426–7 outside of foot use, 577, 578 287, 294 stress urinary incontinence, 470, 480 patellar tendinitis, 587 stability, base of support, 101, 101 stretching, 212 patellofemoral dysfunction, 587 stance, base of support, 101 stroke volume, 25 performance parameters, 77 strength, 29–31 age-associated decline, 139 peroneal tendinitis, 590 age-related muscle changes, 148–9, 150 altitude response, 71 physiological demands, 575–6 anabolic steroid effects, 331 exercise training response, 80, 243 plantar fasciitis, 590 eating disordered athletes, 371 Strug, K., 494, 495 posterior/anterior tibialis tendinitis, growth/developmental changes, 170 substance abuse, 411 588 hormonal factors, 31 substrate utilization, 322 shin guards, 590, 591, 594 menstrual cycle effects, 47–8 altitude acclimatization, 71 strength conditioning, 576 muscle cross-sectional area, 30–1 diabetes, acute exercise, 266 stress fractures, 592–4, 593 muscle endurance, 31 endurance performance, 26–8 subungual haematomas, 594–5 muscle fibre type, 30–1 menstrual cycle phase influence, 26, 47 turf toe/reverse turf toe, 590 neural adaptation, 29 oestrogen effects, 39, 41–2 upper extremities injuries, 584 oral contraceptive effects, 56 oral contraceptive effects, 53–4, 54, 55 softball, 409, 626–43, 627 whole muscle hypertrophy, 29–30 placental metabolism, 194 collision/impact injuries, 638–40 strength training, 85–7 training effects, 81–2 ankle fracture, 638, 639 bone mineral density, 285, 285–6, 286 subungual haematomas, 594–5 facial injuries, 639–40 concurrent aerobic training, 85 sudden cardiac death, 247, 572, 638 hand/finger injuries, 640, 640 physiology, 86–7 sunburn, 610–11 knee injuries, 638 soccer players, 576 sustained distance training, 79 facilities, 643 swimmers, 462 carbohydrate intake, 82 historical aspects, 626 training methods, 85–6 lactate threshold, 82 hitting, 633–5, 634, 635 stress, 109 muscular system adaptations, 81 musculoskeletal injuries amenorrhoea, 380, 382 ‘swan-neck’ deformities, 570 incidence, 627 assessment at preparticipation sweating mechanisms, 635–40 examination, 174 aerobic training, 83 overhand throw, 632, 632–3 cognitive–affective model of burnout, age-associated decline, 141 injuries, 636–7 114 iron losses, 315 personal protective equipment, 641–2, coping strategies, 111 soccer players, 579 642 ice skaters, 526 warm environments, 63, 64, 64 sliding injuries, 638, 638–9, 639 mental skills training, 112 training effects, 65 660 index

swimmer’s ear, 457 elbow injuries prevention, 559 thoracic outlet syndrome swimming, 453–66 equipment, 552, 552–3, 553, 559 softball players, 637 age of competitors, 453 historical aspects, 4, 4, 9, 550–1 tennis players, 554 anaerobic power, 454 lateral epicondylitis (tennis elbow), throat examination, 175 assistive devices, 462, 464 556, 556–9, 558 thrombosis, 52 body composition, 453 musculoskeletal injuries, 553–9 throwing, musculoskeletal injuries, 475, bone mass, 455–7 physiological demands, 551 475–7 bone loading effects, 287 psychosocial stress, 559–60, 561 thumb injuries chlorine reactions burnout, 560 cyclists, 541 hair bleaching, 459 reduction measures for young skiers, 621 respiratory tract irritation, 458 players, 561–2 thyroid function, 384 cold water exercise, 66–7, 67 training, 551–2 thyroid-stimulating hormone, 384 acclimatization, 69 time committment, 559 tibia fracture, 590–1 dental staining, 459 wrist overuse injuries, 130, 229 tibial tubercle avulsion fractures, 596 ear problems, 457 young players Title IX, 441, 470, 559 eye problems, 458 burnout, 417, 418–19, 560 torque, 105, 106 historical aspects, 4, 9 injuries, 555–6, 556 track and field events, 470–83 lift forces, 105 percentage leaving WTA Tour, 560, exercise-induced bronchospasm, 470, menstrual cycle phase effects, 44 560 480–1 menstrual dysfunction, 381, 455, 456, professional age eligibility rules, female athlete triad, 479–80 457 559–62, 561 gastrointestinal disorders, 470, 481–2 musculoskeletal profile, 459 psychosocial studies of élite heat illness, 470, 481 nasal problems, 457 athletes, 417–19, 418, 423 historical aspects, 5, 7–8, 8, 9, 10, 13 orthopaedic problems, 459–66 tennis balls, 553, 559 iron deficiency anaemia, 470, 480 back pain, 462–4 tennis courts, 553 medical problems, 470 knee pain, 464–5, 465 tennis racquets, 552, 552–3, 553, 559 musculoskeletal injuries shoulder pain, 459–62, 460, 461 tenosynovitis epidemiology, 471 physical characteristics of competitors, hand/wrist, 230–1, 231 event-specific, 472–9 453–4 cyclists, 543 occult gastrointestinal bleeding, 482 pregnancy, 200 ice skaters, 528 Olympic records, 78 psychosocial studies of young élite rowers, 490–1 orthopaedic problems, 470 athletes, 419–21 testicular feminization (androgen overtraining, 482–3 committment profiles, 420, 420–1 insensitivity) syndrome, 186–7, running injury risk factors, 471–2 respiratory problems, 458 383 stress urinary incontinence, 470, 480 sexual development, 454, 454–5 testosterone track start positions, 101 shoulder pain, 225 age-related decline, 153 traction apophysitis, 170 sinusitis, 457–8 anabolic actions, 153 olecranon, 502 skin problems, 458–9 exogenous administration effects, training spinal stress, 462–3 331 altitude effects, 71–2 hyperextension movements, 463, hormone replacement therapy, 56, 159, cardiovascular manifestations, 243–4 463 161–3, 162, 163 energy transformation, 78–84 strength, 454 drug testing, 164–5 aerobic energy, 79–83 sustained distance training, 79 menopausal levels, 158, 159 iron status effects, 315 Switzer, K., 12 menstrual cycle phase effects, 48 masters athletes, 142 sympathomimetic amines, 332 oestrogen replacement therapy menopause, 162 synchronized swimming, 13, 16, 465 influence, 159–60 training diary, 162, 164 hypoxia during underwater resistance training response, 31 neurophysiological aspects of sequences, 466 structure, 41 movement, 84–5 medical problems, 466 thalassaemia, 125 periodization, 87–8 muscle cramps, 466 theophylline, 458 physiological aspects, 77–90 musculoskeletal injuries, 465–6 thermic effect of food (TEF), 120 psychological aspects, 108–17 systemic lupus erythematosus, 219 thermogenesis stimulus–response model, 77–8 cold environments, 67 strength/power, 85–7 tachycardia, 242 acclimatization, 69 taper, 87–8 tapering training, 87–8 pharmacological weight reduction transdermal oestradiol, 39, 41 tarsal tunnel syndrome, 589 aids, 332–3 transsexuals, 184, 437 tendinitis, 210 thermoregulation sex reassignment, 188 cyclists, 543 aerobic training, 83 traumatic unilateral shoulder instability gymnasts, 499–500 age-associated heat intolerance, 141 (TUB), 224 treatment, 499 cold environments, 66 tremor, pharmacological reduction, 330 tendon injury, 209–10 menstrual cycle effects, 46, 65, 68 triple jump, musculoskeletal injuries, inflammation grading system, 210, 211 surface area : body mass ratios, 67 474 treatment, 210 warm environments, 62–3 tropical environments, 63–4 tennis, 550–62 training effects, 65 turf toe, 590 anatomical adaptations, 554–5 thigh angle measurements, 96 tympanic membrane perforation, 175 shoulder range of motion, 554, 555, Thomas, D., 415 type I (slow-twitch) fibres, 30, 146 555 thoracic disc herniation, 488 type IIA (fast-twitch oxidative- backhand stroke technique, 557, 557 thoracic injuries glycolytic) fibres, 30, 146 biomechanics, 554, 554 rowers, 488–9 type IIB (fast-twitch glycolytic) fibres, 30, bone mineral mass, 294 soccer players, 585–6 146 index 661

ubiquinone (coenzyme Q10) training effects, 64–5 46XY female, 186–7 supplements, 325–6 tropical, 63–4 ulnar collateral ligament injuries warm-up, 212 young élite competitors, 409–27 cyclists, 541–2 water-borne infection risk, 611 abusive coach/parent–athlete soccer players, 584 weight cycling, 368 relationships, 421–2, 423 ulnar neuropathy weight gain, pubertal, 170, 170 anecdotal literature, 422–4 cyclists, 543 weight loss burnout, 411, 424 softball players, 636, 637 amenorrhoea, 380, 381, 382 coach’s code of conduct, 426, 426 ultra-endurance athletes, 23, 24 eating disorders prevention, 374 common negative experiences, 421–2, ‘unhappy triad’ injury, 101, 104 exercise benefit, 247 423 unidimensional athletic identity, 412, gymnasts, 16, 496 common positive experiences, 421, 423, 425 health implications, 356 423, 424 upper extremity overuse injuries, 224– performance effects, 355 competing with injuries, 413, 423 31 pharmaceutical aids, 332–4, 369 developmental goals, 426 urinalysis, 177 rapid, 355, 368 disadvantages, 409–10 urinary iron losses, 316 weight-restricted sports, 122 undesirable behaviours, 411–12 uterine abnormalities, 384, 385 weight-lifting, 13 eating disorders, 422, 423 amenorrhoea, 381 figure skating, 415–17 velocity bone loading effects, 286 gymnastics, 413–15 kinematics, 97 lower back strain, 231 individual change strategies, 426–7 vectors, 97, 97 wheelchair basketball, 305 involvement in decision-making, violent behaviour, 436 wheelchair competitors, 302, 303, 304, 424 visual acuity, 175 305, 306 lost childhoods, 423 vital signs, 174–5 movement efficiency, 305–6 motivation, 411, 427 vitamin D intake, 386 research perspectives, 307 organizational changes to sports volleyball wheelchair road racing, 302, 303, 306 programmes, 425–6 anterior cruciate ligament injury, 214 whitewater slalom racing, 600, 601 overemphasis on winning, 411, 426 bone mineral mass, 294 whole muscle hypertrophy, 29–30 prevalence, 409 historical aspects, 12 Wightman, H.H., 550 psychosocial outcome, 410–12, 411 shoulder pain, 225 windchill index, 70 research studies, 412–22 wrist overuse injuries, 229 Witt, K., 15 access problems, 412 Women’s Olympic Games, 5–7 retrospective design, 413 walking work of breathing, 141 self-identity, 412, 423, 425 bone loading effects, 287 Worker’s Olympiads, 9 social support vs. social constraints, ground reaction force, 102–3, 103 World Games for the Deaf, 301, 302 424–5 pregnancy, 200 wrestling, 13, 16 stress management, 426–7 warm environments, 62–6 wrist fracture, 584 swimming, 419–21 desert, 63 wrist impingement syndrome, 229 tennis, 417–19, 559–60, 561 heat illness prevention, 65–6, 66 wrist injuries time committment, 414, 416, 423 masters athletes performance, 141 canoeing/kayaking, 607–8 legislation, 425–6 relative humidity, 63 cyclists, 541, 543 thermoregulation, 62–3 gymnasts, 499, 501–2 Zayak, E., 423 menstrual cycle effects, 46, 65 rowers, 490–1 tolerance (heat acclimatization), 63, 66 wrist overuse tendinitis, 230–1, 231, 543