SOUTH AFRICAN JOURNAL OF S P O R T S M E D IC IN E S P O R T G E N E E S K U N D E JO U R N A L O F T H E S.A. SPO R T S M E D IC IN E A SSO C IA T IO N T Y D S K R IF VAN D IE S.A. S P O R T G EN EE SK U N D E -V E R E N IG IN G N a tio n a l A d v iso ry B oard E d ito r in C hief: Clive Noble A sso cia te E d ito rs: P r o f TD Noakes D aw ie van Velden A d v iso ry B oard: T r a u m a to lo g y : Etienne Hugo P h y s io th e r a p y : Joyce Morton N u tr itio n : M ieke Faber B io k in e tic s : M artin Schwellnuss E p id e m io lo g y : D erek Yach R a d io lo g y : Alan Scher P h a rm a c o lo g y : John Straughan P h y s ic a l E d u c a tio n : Hannes Botha In te rn a l M e d ic in e : Francois R e lie f In tern a tio n a l A d v iso ry B oard Lyle J M icheli A s s o c ia te C lin ic a l P r o f e s s o r o f O r th o p a e d ic S u rg e r y Chester R Kyle R e a s e a rc h D ir e c t o r , S p o rts E q u ip m e n t R e s e a rc h A s s o c ia te s P r o f H C W ildor Hollm ann P r e s id e n t d e s D e u ts c h e n S p o rta rz te b u n d e s Howard J Green P r o f e s s o r , D e p a r tm e n t o f K in e s io lo g y George A Brooks P r o f e s s o r , D e p a r tm e n t o f P h y s ic a l E d u c a tio n Neil F Gordon D ir e c to r , E x e r c is e P h y s io lo g y Edm und R Burke A s s o c ia te P r o f e s s o r , U n iv e r s ity o f C o lo r a d o VOLUM E 6 NUMBER 2 APRIL/M AY 1991 CONTENTS Editorial Comment Progress in sports medicine .................................. 3 Sports Injuries Tendinitis ...................................................................... 4 Rugby Dislocation o f the cervical spine in a rugby player due to "crashing" o f the s c r u m .................................. 8 Nutrition Iron status and athletic perform ance ..................... 10 Physiotherapy Update The physiotherapy management o f chronic muscle tears o f the calf in long distance runners ................ 14 Conceptions/M isconceptions in Sports M edicine Types o f muscle contraction as biomechanical c o n c e p ts ............................................... .......................... 16 Drugs in Focus Spare your joints ........................................................ 20 Abstracts Abstracts from the Clinical Journal o f Sports Medicine - the official journal o f the Canadian Academy o f Sports Journal .................................. 21 Anabolic Steroids MASA takes stand against dispensing o f anabolic steroids ......................................................................... 23 SASGV j S A S M A P U B L IS H E D BY T H E S O U T H A F R IC A N P h o tographs co u rtesy o f The Im a g e Bank SPO R TS M E D IC IN E A SSO C IA TIO N H A T F IE L D F O R U M W EST 1067 A RC A D IA S T R E E T H A T F IE L D P R E TO R IA , 0083 T h e jo u rn a l o f the SA Sports M edicine A ssociation is p ublished by M e d p h arm Publications, 3rd F loor N oodhulpliga C e n tre, 204B H F V erw oerd D rive, R a ndburg 2 1 9 4 . T el: ( O il) 7 8 7 -4 9 8 1 /9 . T he view s e x pressed in this publication are those o f the authors and not n ecessary those o f the p ublishers. P r i n t e d b y T h e N a t a l W i t n e s s P r i n t i n g a n d P u b l i s h i n g ( o n i p a n y ( P i y ) L t d R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) ^Iffiflyoospor iB ifonazole 1R/13.9.2/204 Solution IR /1 3.9.2/203 Cream Bayer-Miles No matter what the life style, Mycospor provides the patient with powerful penetration and long lasting action. Due to its lipophilic properties, it offers up to 72 hours1 of activity with a single application Once daily Mycospor offers powerful symptomatic relief and reduces the duration of treatment making it highly economical. LONG LASTING PENETRATING POWER. 1. Sanchez, J. L. et al “ Clinical Management of Tinea Corporis/Cruris and Tinea (Pityriasis) Versicolor: Two to Three-week Treatment with Bifonazole 1 % Solution” . Advances in Therapy. Vol. 3. No. 5. September/October 1986.272-280. Bayer-Miles, 27 Wrench Rd, ISAND01600. Reg. No. 53/00355/0 The real test of an antifungal must be its efficacy in conditions that create the infection in the first place R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) EDITORIAL PROGRESS IN SPORTS MEDICINE Since I first became interested in Sports M edicine 30 years ago, many changes have taken place. In my main field o f interest, i.e. traum a­ tology the changes have been remarkable. Take the tom meniscus for example. As a registrar we were taught to do a total menis­ cectomy as the only proper method o f treat­ ing a tom meniscus. Numerous papers since then have shown that this form o f treatment greatly increased the incidence o f osteo- arth-ritis and has led to many an old sports­ man being crippled and even requiring knee replacement. The present technique o f arth­ roscopic partial meniscectomy has greatly reduced the degree o f osteoarthritis and more recently the repair o f peripheral tears o f menisci has resulted in the restoration of normal articular archi-tecture. In the old days a patient was immobilised following this procedure for two to three weeks and was kept in hospital for at least 10 days. Today the usual treatment is early mobilisation and a day in hospital. The operation is even being done on an outpatient basis. M any sportsmen are back at sport within 10 days. Rehabilitation in those days consisted of straight leg raising exercises and then active mobilisation following cast removal. Now early rehabilitation using isokinetic and other techniques only allows return to activity when 90% o f strength has been achieved. This has led to a remarkable reduction in reinjury. The anterior cruciate ligament injuries in the past were often neglected because o f the poor results o f prim ary repair. This neglect led to meniscal injury and progressive ar-ticular cartilage degeneration leading to early osteoarthritis. Modern techniques with isometric positioning o f the reconstruc­ ted ligament has greatly improved the results in cases o f chronic instability. The use o f artificial ligaments has not been clarified but in chronic instability may be a valuable adjunct in salvage cases, i.e. cases where all other techniques have failed. Added to this, the understanding o f initial degeneration in transplanted tendon used in the reconstruction has made the scientific rehabilitation o f these knees far safer. Assessment o f tendon strength has also helped in replacing o f the damaged anterior cruciate ligament. Isometric placement has been improved by the use o f suitable jig s and other similar instruments, a great improvem ent on the "eye-balling" technique o f yesteryear. In acute disruptions o f the anterior cruciate ligament, besides adequate repair, augmen­ tation with a tendon or artificial ligament have greatly improved results. In collateral ligament injuries o f the knee immobilization in plaster casts has greatly restored rehabilitation and return to active sport. M odem techniques using early physiotherapy and strenuous strength- exercise program m es as well as support with side-splint braces in the more severe cases have resulted in early, improved healing and return to sport. A sim ilar situation has occurred in ankle ligament injuries where splinting with such splints as an "aircast" brace have allowed the player more rapid mobilisation but in many cases have protec-ted the player dur­ ing play without radically impeding his ability. In these days o f professional sport these improvements have saved players large amounts o f money. A similar situation can be found in all aspects o f sports medicine. H owever in many fields we still have a long way to go. In traumatology the answers to such prob­ lems as "shin splints", and osteitis pubis in runners and other sportsmen are lacking. The prevention and treatm ent o f degen­ erate joint disease in the older sportsman is an example o f another area o f difficulty. I hope I'm around in 30 years time to see the future im provements in sports medicine. D r Clive Noble MBBCh, FCS (SA) Editor-in-Chief ----------------------------------------- 3 SPORTGENEESKUNDE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) SPORTS INJURIES TENDINITIS Clive Noble Tendinitis is a "scrapheap" di­ agnosis in sportsmen. It is a di­ agnosis in many ways which is similar to "having a virus" in general medicine, sometimes correct but very often wrong. Tendinitis certainly does oc­ cur, in fact it is the commonest overload injury in the older athlete. As its name implies, tendinitis affects tendons. Any tendon in the body may be in­ volved. The "itis" part o f its name is only partially correct. Inflammation is a minor part o f the pathology and its function is most likely reparative. Cel­ lular trauma is the major pa­ thology. This, in the chronic case, causes secondary cellular degeneration which in turn causes inflammatory cell re­ pair. This tendon trauma is caused by cellular overloading which may be the result o f a singular large overload result­ ing in rupture or repetitive minor overloading resulting in microtearing and secondary degeneration. It is far more common in the older athlete where the tendon progressively weakens with age. In youth tendinitis is extremely rare as here the growth areas or apo­ physes are the weakest link in the musculo-skeletal chain. Thus in the 9-12 age group traumatic calcaneal apophysitis (Severs Disease) is the most common site o f overloading. In the 13-15 age group trau­ matic upper tibial apophysitis becomes more common. This is usually called Osgood Sch- latters disease named after the men who described it independ­ ently in 1903. In the 16-17 age group the pelvis apophyses become the weakest area. Here, a number o f sites are involved depending on the overloaded muscular group. Usually by the age o f 18 most o f the growth points are fused to the main body o f the bone but in the iliac crest region they may stay open as late as 22 years o f age. After the age o f 18, muscle is more likely to be overloaded causing muscle fibre rupture which may be either partial or complete. From the a g e o f 3 0 , tendon w eakn ess causes the tendon to becom e the fo re ru n n e r in the injury stakes. The affected muscles are usu­ ally those crossing two joints such as the hamstring and quad­ riceps. Muscle rupture on overloading diminishes stead­ ily after the age o f 30 years with the exception o f the calf muscles which may rupture well into middle age. From the age o f 30, tendon weakness causes the tendon to become the forerunner in the injury stakes. Thus tendon in­ jury is a problem o f the ageing athlete. Tendon consists mainly o f collagen and elastin fibres. In the relaxed position it is wavy in appearance but on loading can stretch to approximately 4% o f its total length. On further loading rupturing o f the tendon fibres occurs. Micro­ scopically collagen fibres have a helical pattern and are joined together by cross linkages. The cross linkages are not well developed giving the tendon more plasticity. As ageing occurs these cross linkages are better developed resulting in more rigidity o f tendon tissue. On overloading the cross link­ ages are the first to rupture and then the collagen fibres them­ selves. Elastin fibres rupture last. If the overload is severe, all fibres will tear resulting in rup­ turing o f the tendon itself. If overloading is not as great, microscopic tearing o f the fibres will occur. Repair in the mi­ crotorn tendon is poor largely due to the relative avascularity and low basal metabolic rate o f tendon tissue. This most likely accounts for the long duration symptoms in the area o f great­ est avascularity, eg. + / - 5 cm above the heel in tendo-achilles tendinitis. The other site which is extremely common is the osseo-tendinous junction, eg. tennis elbow. This is most likely a functionally weak area 4 ------------------------------------- SPORTS MEDICINE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) SPORTS INJURIES and is more liable to overload­ ing. With ageing tendon also undergoes a number o f bio­ mechanical changes and a sig­ nificant reduction in water content. It is interesting to note that similar changes occur in inactive tendon. It would ap­ pear that ageing and inactivity are inter-related and it also accounts for the significant in­ jury rate occurring in the age­ ing athlete who commences activity after a long period o f sedentary behaviour. SYM PTOM S M icrotearing Pain is the most common symp­ tom wliich occurs usually on loading the tendon. In the early stages pain may occur at the be­ ginning o f activity but once the tendon inversion "warms up" pain often disappears. In the more severe cases no loading is possible owing to the severity o f the pain, eg. a player has to give up tennis. Stiffness If the limb has been kept in one position for a long period of time, movement may be diffi­ cult owing to pain and stiffness but usually on movement the pain rapidly disappears. In chronic cases actual limitation o f joint movement may also be found. When pain occurs it will often radiate into the muscle which is loading the tendon, eg. down the forearm in tennis elbow and occasion­ ally even up the arm. Signs Two basic signs are important: • Tenderness - is present on palpation and may be ex­ tremely severe. • Production o f pain on stressing the muscle at­ tached to the tendon. This stress test is positive in all cases o f tendinitis, eg. in tennis elbow this may be achieved by asking the patient to extend his elbow fully and to strongly dorsi- flex his wrist. Then by ap­ plying flexor pressure to the extended wrist, pain will occur in the region o f the elbow. The severity o f this pain is to a large extent dependent on the severity o f the degeneration o f tendinitis. In mild cases the patient will complain o f pain but will be able to withstand normal forces on the el­ bow. In cases with moder­ ate pain the wrist will gradu­ ally give way owing to the severity o f the pain. In severe cases, immediately thepatient will be unable to withstand the pressure exerted on the wrist. If rupturing has occurred a defect o f variable extent may be found in the ten­ don. In a total rupture marked weakness o f the muscle will be found and in the achilles tendon rupture, compression o f the calf muscle will not result in the normal movement o f the foot in the relaxed posi­ tion. In recent ruptures it may be difficult to palpate the defect owing to the amount o f swelling and bleeding and in chronic ruptures this may also be difficult owing to the scar tissue formation which has occurred between the ruptured area. How­ ever, marked weakness will still be the order o f the day. DIFFERENTIAL DIAGNOSIS Pain may occur in tendons as a result o f friction between the tendon and its surrounding tis­ sue. In some areas where there is a distinct sheath, this is termed tenosynovitis. In other areas where there is no distinct sheath, paratendinitis occurs. The exact relationship between ten osyn ovitis/p araten din itis and tendon degeneration is not clear. In runners for example, paratendinitis is com m on without any form o f tendinitis being present either macro or microscopically. In some ar­ eas, eg. bicipital groove o f the humerus, tendon degeneration is often accompanied by a teno­ synovitis. This may even lead to rupturing o f the tendon pos­ sibly due to the damage o f its blood supply. TREATM ENT Tendinitis is an extremely dif­ ficult condition ot treat. Thus prevention is most important. Loading must be progressive with overloading either acutely or chronically being avoided at all costs. Strengthening exer­ cises may well be beneficial in avoiding these injuries. Bi­ om echanical abnorm alities should be corrected eg. orthot- ics o f anti-pronation shoes should be used in cases o f achilles tendinitis and tibialis posterior tendinitis. Orthotics also appear to be helpful in cases o f patella tendinitis or if there is excessive patellar mobility in association with -------------------------------------------- 5 SPORTSGENEESKUNDE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) SPORTS INJURIES pronation. When injuries occur the principles are to treat the cause and to treat the result. Thus the cause is by and large overload­ ing, a reduction o f the loading is extremely important. Jar­ ring appears to be a major fea­ ture and therefore in severe cases all jarring should be avoided, eg. a runner should change to cycling while w ait­ ing for healing to take place. In the less severe cases reduction o f loading factors i.e. hill run­ ning and street running, should be done. Loading may also be reduced by the use o f bi­ omechanical devices which take pressure o ff the damaged tendon while allowing the The financial operation of a surgery can be a headache of major proportions. And to keep things from falling apart you need more than a bookkeeper and a P.C. — with all the compromises inherent in generalised business software. You need a customised, single or multi-user system from NORIDATA Not just because its more cost-effective than ordinary P C ' s — but because its hardware and software are tailored specifically for your practice whether player to continue with sport, eg. tennis elbow guard which acts as a counterforce brace taking some o f the load off the tendon during loading activi­ ties such as tennis. In the severe cases, however, these do not appear to have any great value. Elevation o f the heel in the case o f achilles tendinitis appears to similarly reduce the loading. Treatment o f the results is extremely difficult as inflam­ mation plays a minor role in tendinitis. Non-steroidal anti­ inflammatories do, however, appear to be effective espe­ cially in the minor cases. This would most likely be due to the analgesic properties. large or small — specialised prescribing or dispensing. Supported by a nearby practice- management professional who has a world of experience in integrating computers with the medical profession. Computers that are compatible with other systems and expandable in the future without changing software. For the name of that practice- management professional (we have over 50 country-wide) call us at (011) 484-4392 now. Just a 15 minute no obligation demonstration will show you how easy it is to manage your practice painlessly. M edSdve South A frica's m ost used m edical practice m anagem ent system . .. . . . a n d w inner o f the C.S.A. I WO Silver Aw ard f o r an exceptional established S o u th A frican product. NORIDATA Division O f no ais ta n lim ited P O B O X 3 1 4 6 9 B R A A M F O N T E I N 2 0 1 7 Physiotherapy also appears to be o f value in non-severe cases. The use o f steroidal anti-inflamm atories injected locally is controversial. It has been clearly shown that injec­ tion o f cortisone into tendon can cause degeneration o f ten­ don. It is thus important to avoid injections into the tendon but should cortisone be used, bathing the tendon appears to be beneficial. This can be as­ sured by feeling minimal pres­ sure when pushing on the plunger during injection into the region of the tendon. Should it be difficult to push in the plunger this usually means that the needle is in the tendon and therefore would be stopped im­ mediately. A maximum o f three injections should be given. Surgery should only be con­ sidered in cases that have been symptomatic for more than six months, if the symptoms are o f sufficient severity to warrant surgery. In cases o f rupture how­ ever, surgery still gives the best results. In the chronic case, surgery usually consists o f decompression o f the tendon by removing the paratendon and then multiple cuts in the lines o f the fibres o f the tendon to increase its blood supply, or in the case o f osseo-tendinous injury, a release o f the tendon from the bone provided no significant displacement occurs to that bleeding may also allow for more adequate scar tissue formation to occur with further adherence o f the tendon. In general, however, most o f these cases may take as long as four months before healing finally occurs. In less severe cases simple reduction o f activity is usually enough to allow heal­ ing to ultimately occur. □ Let Medsolve cure the biggest problem in practice management. 6 ------------------------------------- SPORTS MEDICINE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) c o PANAMOR’ - 25 Emefic coaieo table! containing tbm cj d o o 'o n a r sodium L r r - J Reg No R 3 1 49 c o PANAMOR' AT* 5 0 E n te tr c o a t e d tablet C o n t a i n i n g 50niq i l d o t e n a c sodium L ± - l Reg No R'3 1/50 c o I PANAMOR' - 75 Injection Each 3ml' ampoule contains 75ma ilicloten.-ic s o o i u i t i with 4 l ! o v a b e n z y l alcohol as preservative L _ J Req. No W/3 1/52 Is y o u r p a tie n t b eing held p riso n er to p a in an d im m obility? T h ere is a re le a se ... non-steroidal anti-inflam m atory RELIEVES PAIN REDUCES INFLAMMAT RESTORES MOBILITY REDUCES THE COST O) TRAUMA THERAPY Available now in three PANAMOR^ - 25 TABL PANAMOR^ AT - 50 T. AND INTRODUCING PANAMOR® - 75 INT£( RELEASE FROM INFLAMMATORY PAIN ’ ■ "• ' * 'pz «- LES, NON( I ^ u) LIMITED m tniiffnrAfttt r » n itffinrA in iiiiu R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) RUGBY DISLOCATION OF THE CERVICAL SPINE IN A RUGBY PLAYER DUE TO "CRASHING" OF THE SCRUM AT Scher IN T R O D U C T IO N The phase o f the game respon­ sible for the highest number of serious rugby injuries to the cervical spine and spinal cord is the scrum. In South A frica,1 New Zealand2 and the United K ingdom ,3 scrumming is re­ sponsible for approximately 40% of these injuries. In a paper published in 19824 I re­ ported on players injured due to "crashing" o f the rugby scrum. D eliberate crashing of the two packs o f forwards is an illegal manoeuvre and should not be allowed to occur. The case history o f a school boy who sustained injury as a result o f this manoeuvre is p re­ sented to emphasize the dan­ gers o f the practice and illus­ trate the mechanism o f injury. C A SE H IS T O R Y A 16 year old school boy play­ ing in a position o f hooker was in the process of binding with his two props prior to a scrum. The other pack o f forwards having already formed up rushed at them, catching them unawares. The hooker's head was caught in an awkward position and forcibly flexed. Immediately afterwards, he developed weakness of the arms and legs and play was stopped. He was rushed to hospital, where examination revealed a quadriparesis at the C6 level with weakness o f the arms and legs. X-rays o f the cervical spine demonstrated anterior dislocation o f C6 and C7 with bilateral locking of facets. He was immediately taken to the­ atre where open reduction of the dislocation together with wiring and bone grafting was performed. This operation was done within 2 hours o f injury. Postoperatively he began to regain muscle power and sen­ sation and made a good recov­ ery, having no residual defect 6 months after the injury. D ISC U SSIO N A T Scher MBChB DMRD Department o f Radiology Tygerberg Hospital and Uni­ versity o f Stellenbosch PO Box 63 Tygerberg 7505 The mechanism o f injury in this case as in other cases re­ ported, is flexion force. Most cervical spinal injuries sus­ tained in the scrum are due to flexion force, whether as the result o f collapse o f the scrum or as in this case, crashing o f Figure 1: A n te rio r dislocation o f C 6 and C7 w ith bilateral locking o f facets, sim ilar to the in ju ry de­ scribed in the case h is to ry (the original X -r a y is unobtainable). the scrum. The force or "impact weight" exerted as the packs meet is considerable and, if the front rows are not correctly posi­ tioned, a dangerous situation may arise. H odge5 has shown experimentally that the force exerted on impact is approxi­ mately 80% o f the maximum generated during the scrum­ mage. Using an 8-man pack with a combined mass o f 727 kg the force recorded on impact was 746 kg. 8 ------------------------------------- SPORTS MEDICINE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) RUGBY Deliberate crashing in an attempt to intimidate or un­ settle the opposing pack is a contravention o f the rules, as clearly stated in The Laws of the Game o f Rugby Football.6 Law 20 deals with the scrum and reads: "It is dangerous play for a front row to form down some distance from its opponents and rush against them". PREVENTION Prevention o f the above inju­ ries depends on educating players to an awareness o f the dangers o f crashing, especially as serious cervical spinal injury is more prevalent in inexperi­ enced players. Vigorous en­ forcement o f the rule quoted is of obvious importance. The referee should ensure that the ball is not put into the scrum until it is properly formed, with the front row players bound. It is encouraging to note that Footnote 5, appended to Law 20 which previously read7 “The referee has no authority to permit delay in putting in the ball be­ cause a player has not suc­ ceeded in getting his head down in the scrum m age’’, has been changed to Footnote 10 in the most recent edition o f the Laws of the game o f Rugby F oot­ ball.6This Footnote now reads, "In the interest o f safety, the referee has authority to perm it a delay in putting in the ball i f a player in thefront row has not succeeded in getting his head 4. down in the scrummage, but otherwise he should ensure that 5 . there is no delay A specific amendment o f the 6. rules which would remove this hazardous practice has been 7 . suggested.8 This is the adop­ tion o f the "staggered scrum" 8 in which the front rows o f each team first bind together and pack down. Only then are the locks and loose forwards al­ lowed to join the scrum. The impact force is thus removed and the total impetus is less than that generated in conven­ tional rugby scrum. □ R E F E R E N C E S 1. S ch er A T . R u g b y injuries to the cervical spinal co rd . S A f r M e d J 1977; 51: 473- 475. 2 . B urry H C , G ow land H. C e rv ical injury in football - a N ew Z ealand survey. Br J S p o rts M e d 1981; 15: 56-60. 3 . W illiam s P and M cK ibbin B. Unstable cervical spine in ju rie s in ru g b y - a 20 y e a r rev iew . In ju ry 1987; 18(5): 329- 332. S car A T . "C rash in g " the rugby scrum - an avoidable cau se o f cervical spinal in ju ry . S A f r M e d J 1982; 6 1 : 919-920. H o d g e K. 1980. Sp in a l Injuries in ru g b y sc ru m s, p p 4 4 -4 8 . D u n ed in , New Z ealan d : U niversity o f O tago. South A frican R u g b y B oard. 1988. The Law s o f the G am e o f R u g b y Football, C ape T o w n : SA R B . South A frican R u g b y B oard. 1988. The L aw s o f the G am e o f R u g b y F ootball, C a p e T o w n : SA R B . N o rto n T . 1980. The Star, New Zeal a n d , 14 Ju ly , p8. SPO RTSG ENEESKU ND E VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) NUTRITION IRON STATUS AND ATHLETIC PERFORMANCE M ie k e F ab er FUNCTIONS OF IRON Iron is an essential component o f the oxygen transportation c o m p o u n d s h a e m o g lo b in , myoglobin, and the cytochromes (W illiams, 1984) as well as various enzymes (Steinbaugh, 1984). An iron deficiency can lead to impaired haemoglobin synthesis and a reduction in oxygen transport (O 'N eil et al, 1986). IRON DEFICIENCY ANEMIA Iron deficiency may be ex­ plained by decreased iron ab­ sorption and increased iron loss (O 'N eil et al, 1986). Iron can be lost through sweat losses, intestinal losses and haematuria. O ther causes for iron deficiency are increased demands for increased total body haemoglobin and poor dietary intake (ADA Report, 1987). Iron deficiency can im pair physical perform ance, particu- Mieke Faber Research Institute fo r Nutritional Diseases, Medical Research Council, Tygerberg larly o f an aerobic nature (Williams, 1984). Iron deple­ tion without anemia can also affect physical perform ance (Steinbaugh, 1984). Such im ­ pairm ent can be manifested as a reduction in total exercise time, increased heart rate, decreased oxygen uptake, increased blood lactate concentrations and de­ creased work tolerance (O 'N eil et al, 1986). Low serum iron, haemato- crit and haemoglobin levels have been reported among athletes (O 'N eil et al, 1986) as well as low iron stores (ADA Report, 1987). Women are more likely to become iron deficient as compared to men because o f a lower energy in­ take and because o f iron losses due to menstruation (Williams, 1984). Deficient iron stores result in weakness, fatigue, pallor, dyspnea on exercise, palpitations and prolonged restoration o f cardiorespiratory function to pre-exercise level (O ’Neil et al, 1986). It has been recommended that female athletes take a multivitamin with iron to in­ sure an adequate intake. It is extremely unlikely for this amount o f iron to cause any side effects (Vitousek, 1979). The American Dietetic As­ sociation recommended that if an individuals iron intake re­ mains low after careful moni­ toring o f the diet, a moderate iron supplement, containing the 18 mg RDA should be taken (ADA Report, 1987). Since ascorbic acid enhances iron absorption, an iron supplement should be taken in conjunction with a source o f ascorbic acid (O ’Neil et al, 1986). It is however recommended that plasm a ferritin levels be checked before supplementa­ tion is prescribed (ADA Re­ port, 1987). Iron supplemen­ tation to individuals with iron deficiency anaemia will in­ crease perform ance capacity (W illiams, 1984). However, iron supplementation has no beneficial effect for an athlete with normal haemoglobin lev­ els (W illiams, 1984). Large doses o f iron supplementation are o f no value to athletes, unless there is a measurable iron deficiency. Large iron supplements may cause nau­ sea, gastric upset, constipation and accumulation o f iron in the tissues (Vitousek, 1979). Ex­ cessive iron intake can also inhibit the absorption o f zinc due to their similar physio- c h e m ic a l c h a r a c te r is tic s (McDonald and Keen, 1988). SPORTS ANEMIA Sports anemia or dilutional anemia results from an in- 10 SPO RTS M ED IC IN E VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) NUTRITION crease in red blood cell mass and plasma volume. Causes for sports anemia are adaptive response to maximise oxygen transport, haematuria, haemo­ lysis, iron loss through sweat­ ing, inhibition o f erythropoi- esis, increase in blood volume, decreased iron absorption (O 'N eil e ta l, 1986), increased erythrocyte osmotic fragility, causing reduced red blood cell survival time and a possible shift in the oxygen dissociation curve (ADA Reports, 1987). Sports anemia is both norm- ocytic and normachromic (ADA Report, 1987). W hile some believe that marginal iron in­ takes may play a role in the de­ velopment in sports anemia (ADA Report, 1987), others believe that a deficient iron intake is not the cause since the haemoglobin levels does not respond to iron supplementa­ tion (Vitousek, 1979). Sport anemia is transitory (O 'N eil et al, 1986). Endurance perform ­ ance is not impaired by sports anemia (O 'N eil et al, 1986). No specific treatment is re­ quired and iron supplementa­ tion is unnecessary (O 'N eil et al, 1986). FOOD SOURCES OF IRON Organ meats, especially liver, are by far the best sources o f iron. O ther sources include meats, egg yolk, whole wheat, seafood, green leafy vegetables, nuts and legumes (Williams, 1973). □ R E F E R E N C E S 1. A D A R e p o rts. P ositio n o f the A m erican D ietetic A ssociation: N utrition for p h y si­ cal fitness and athletic perfo rm an ce for adults. J Am D ie t A sso c , 1987; 87: 933- 939. 2 . M cD onald R , K een C L . Iron, zinc and m agnesium nutrition and athletic p e rfo r­ m an ce. S p o rts M e d , 1988; 5 : 171-184. 3. O 'N e il F T , H y n ack - H ankinson M T , G o rm an J. R esearch and application o f c u rre n t topics in sp o rts nutrition. J Am D ie t A sso c , 1987; 8 6 : 1007-1012. 4 . Steinbaugh M . N u tritio n al needs o f fe­ m ale athletes. Clin Sports M e d , 1984; 3: 6 4 9 -6 7 0 . 5 . V itousek S H . Is m ore better? N u tr Today N o v /D e c , 1979; 10-17. 6. W illiam s M H . V itam in and m ineral sup­ p lem ents to athletes: D o they help? Clin S p o rts M ed , 1984; 3 : 6 2 3-637. 7. W illiam s SR . N u tritio n and diet th erap y , 2nd ed itio n . T h e C V M osby C om pany, Saint L o u is, 1973, p i 44. ---------------------------------- 11 SPORTSGENEESKUNDE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) ] R elifen 500 ta b le ts 500 m g N a b u m e to n e . R eg. n o . R / 3 . 1 /265. N a b u m e to n e . S m ith K line B e e ch am P h a rm a c e u tic a ls P O Box 347 B ergvlei 2012. W hen y o u r patient’s in pain, y o u r first responsibility is to take away that pain. Q uickly. Effectively. But doing so could lead to unacceptable gastro­ intestinal side effects and com bination therapy. But now , ten years of precisely targeted molecular research have produced a highly effective, non-acidic anti-inflam m atory. Relifen. Each tablet is made o f 500 mg nabum etone, a non-steroidal anti-inflamm atoi proven in num erous double blind studies to bt effective as other benchm ark N SA ID s. Yet its route of action is totally different. Relifen is a non-acidic pro-drug. In the stom ach, it is relatively inactive. It is absorbed from the duodenum , into the portal blood sup Finally, in the liver, it is metabolised into a pot inhibitor of prostaglandin synthesis. R efe r p a c k ag e in s e n fo r full p re s c r ib in g in f o r m a tio n . F u r th e r in fo rm a tio n is av a ilab le fro m o u r M cd ic al D e p a rtm e n t. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Relieving his pain is pretty sporting of you, old chap. But do you have to get him high on acid? The active metabolite penetrates the synovial luid to reach the inflamed site, giving effective relief rf symptoms. Excretion is by the kidneys, so gastro- ntestinal damage through biliary recirculation and ‘eflux is unlikely. For effective relief from pain and inflammation, vith less chance of gastro-intestinal discom fort, you low have an ideal choice. Relifen. *Kfcn an d th e SB lo g o a rc tra d e m a rk s . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) PHYSIOTHERAPY UPDATE THE PHYSIOTHERAPY MANAGEMENT OF CHRONIC MUSCLE TEARS OF THE CALF IN LONG DISTANCE RUNNERS The Comrades M arothon is just around the com er and it is a good time to discuss the com ­ mon condition o f calf muscle tears. This injury is well docu­ mented by P ro f Noakes in his book "Lore o f Running". Usu­ ally a runner will give a history o f having increased his training o f both distance and speed. Amazingly common is the fact that the veteran runner will confess he is wearing shoes which have lost heel height due to age. Surely the micro trauma which develops in the calf muscle, must be aggrevatred by this loss o f heel height as the foot strikes the ground? The onset o f pain is gradual. The first stage is Grade 1 where the pain is felt after the run and dis­ appears druing rest. Grade 2 pain is felt at the beginning o f the run (as well as after the run) but disappears as the muscles warm -up. By the time the pain has reached Grade 3, i.e. pain during the entire dura­ tion o f the run, the runner is no longer able to train. He either stops running for a short time hoping that the pain will disap­ pear with rest, o r he seeks help. Rest, however, does not cure this problem. The muscle fibres run perpendicular and parallel to each other. If a micro tear develops and is continually traumatized, it will increase in size and heal with scar tissue. Unfortunately as the runner continues to run, the tissue con­ tinues to become inflamed, more scar tissue is formed and the muscle fibres stick to­ gether. The muscle no longer functions biomechanically. On examination the physio­ therapist, palpating with her fingers, will find an exquisitely tender area in the muscle belly, surrounded by an area o f pro­ tective muscle spasm. The treatment for this injury is trans­ verse o r cross frictions. The physiotherapist massages the muscle fibres at right angles to their length, in order to sepa­ rate the muscle fibres, and achieves the result o f a small malleable scar which is no longer a problem. Electrical modalities such as laser, inter­ ferential, ultrasound and pulsed shortwave diathermy are in­ cluded in the treatm ent in order 14 ------------------------------------- SPORTS MEDICINE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) PHYSIOTHERAPY UPDATE to decrease inflammation and prom ote healing. Transverse frictions are only given every second day. They are extremely painful for the patient but are the key to the success o f the treatment. P h y sio th e ra p ists ad v ise runners on their shoes and future training methods. If necessary the runner is refer­ red to an orthotist for further advice. It is felt that one o f the reasons that the long distance runner has a tendency to re- injure the original injury, is that there is a weakness in the muscle group. If the physio­ therapist has access to an iso­ kinetic testing machine, the run­ ner is not discharged until the muscles have been tested for strength and endurance com ­ paring left and right leg, as well as comparing the muscle bal­ ance between the plantarflex- ors (primarily gastrocnemius and soleus) and the dorsiflex­ ors (primarily tibialis anterior). When the weakness has been identified, an exercise regime is given to the runner. This program m e should include isokinetic and isotonic exer­ cises for rapid results. Finally the runner is taught the correct stretching methods. Many runners feel that to stretch is to waste valuable running time. Stretching, es­ pecially as one gets older and loses some o f o n e's youthful natural elasticity, is essential. The gastrocnem ius passes over the knee joint and the ankle joint, to stretch it, the knee is hyperextended and the foot is dorsiflexed. Soleus on the other hand only passes over the ankle joint. To stretch it, the knee is flexed and the foot is dorsiflexed. Stretching should take place after a 10 minute warm-up run. Each muscle is slowly stretched for 30 seconds. As the inverse stretch reflex is activated, the muscle can be stretched slightly more for another 30 seconds. At the end o f the run, the runner is encouraged to warm- down slowly and not to just stop running. In this way muscle soreness is avoided and muscles are being prepared for the next run. □ SASMA NEWS In this issue the position statement o f the South African Sports Medicine Association is published. This opinion is underscribed by the Medical Association o f South Africa, and is a milestone in the activi­ ties o f the Sports Medicine Association insofar that it expresses the concern o f the health implications o f the use and abuse o f potentially harm ­ ful medications in the quest for better perform ance in sport. Research done in South Africa has shown a dramatic increase in the illegal use o f anabolic androgenic steroids by South African sportsm en.1 It may well be argued whether the authorities are doing enough to combat this evil, because world champion athletes called for strong action against offending athletes: "We consider doping to be the most shameful abuse o f the Olympic ideal: we call for the life ban o f offending athletes, we call for the life ban o f coaches and the so-called doctors who administer this evil". (Sebastian Coe, Olym­ pic Congress at Baden-Baden, 1986). Tydens die 4de Sport- geneeskunde kongres in Sun City, was daar baie vrugbare samesprekings gevoer insake die gebruik van opkikkers in sport. Gesien in die lig van Suid-Afrika se hertoetrede tot wereldsport, is dit belangrik dat daar 'n eenvormige beleid in ons land geform uleer moet word insake die hantering van hierdieneteligeprobleem . Alle sp o rtlig g a m e m oet saam - staan om 'n verenigde front te vorm om hierdie euwel te be- stry tot voordeel van sport en die gesondheid en welsyn van ons sportlui. Geneeshere, aptekers en afrigters moet in- gelig wees insake die nadelige effekte wat die gebruik van opkikkers het op die moraal en ideaal van sport. Persone wat anaboliese stero'iede voorsien aan sportlui, moet genadeloos gestraf word terwyl atlete wat hulle skuldig maak aan hierdie m isdryf die maksimum vonnis opgele moet word in 'n poging om ons sport te vry waar van hierdie euwel. Die Suid-Afrikaanse Sport- geneeskunde Vereniging doen 'n beroep op die sportge- meenskap om kragte saam te snoer om ons huis in orde te kry sodat ons toegerus is op alle terreine om die uitdagings te aanvaar wat intemasionale kompetisies aan ons sportlui bied. ________________________________ 15 SPORTSGENEESKUNDE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) CONCEPTIONS/MISCONCEPTIONS IN SPORTS MEDICINE TYPES OF MUSCLE CONTRACTION AS BIOMECHANICAL CONCEPTS MC Siff Keywords: Muscle contraction, isotonic, isometric, isokinetic, biomechanics. ABSTRACT The terms isotonic, isometric and isokinetic commonly used to describe different types o f muscle contraction are biomechanically inappropriate in most exercise situations. The less impressive terms 'static' and 'dynam ic' offer m ore accurate superordinate categories. The implications for isokinetic physiotherapy machines and rehabilitation are discussed. INTRODUCTION Several terms used in exercise science to refer to the different types o f muscle contraction are not applied with the level o f correctness they w arrant. Among the most casual em ­ ployed are those beginning with the prefix iso-, namely isoki­ netic, isotonic and isometric. Historically, they were invented to describe types o f contrac­ tion in which some property remains the same: velocity, tension or length. The consis­ tency o f these logical words led to their rapid acceptance, with M C S iff PhD School o f M echanical Engineering University o f the Witwatersrand WITS 2050 little criticism o f their precise meaning and scope ever taking place. It is the purpose o f this ar­ ticle to examine and redefine these terms with particular reference to their biomechani­ cal origins, so that their scope may be appreciated more thor­ oughly and they may be used with greater precision in de­ scribing muscular activity. In doing so, the advisability o f continuing to use these terms is considered. ISOKINETIC TERMINOLOGY The term 'isokinetic' is encoun­ tered in two contexts: firstly, exercise physiology textbooks sometimes regard it as a spe­ cific type o f muscle contrac­ tion, and secondly, so-called isokinetic rehabilitation ma­ chines are often used by physiotherapitsts. Use o f this term is dubious in both contexts, for reasons which become clear on exam ­ ining the fundamental bio­ m echanics describing this concept. Isokinetics (Iso - 'sa m e ', kinetics - 'velocity') literally means movement which occurs at constant velocity. If isokinetics is defined to be a specific form o f muscle contraction, along with static (is o m e tric ), and d ynam ic (concentric and eccentric) con­ traction, then it must be asked how isokinetic contraction, also a dynamic activity, differs from concentric and eccentric con­ traction . Concentric refers to muscle contraction which brings the origin and insertion o f a muscle closer, or when muscle action produces a force which over­ comes the load being acted upon. F or this reason, Soviet scientists use the term 'over­ coming' contraction or move­ ment. The term eccentric re­ fers to contraction which increases the distance between 16 ------------------------------------- SPORTS MEDICINE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) CONCEPTIONS/MISCONCEPTIONS IN SPORTS MEDICINE the origin and insertion o f a muscle, or, in other words, when the force o f contraction succumbs to the load. The Soviets call this 'concessive' contraction. Both o f these types o f contraction can occur at varying or constant velocity, so that it is difficult to classify isokinetic contraction as a to­ tally discrete form o f muscle contraction. This means that there can be isokinetic concentric action and isokinetic eccentric action. Isokinetic muscle contraction is not a discrete entity. Isoki­ netic action is merely a particu­ lar case o f dynamic action. The word 'action' has intentionally been chosen here, since dis­ tinction must be made between the external action and the internal contraction o f the muscle. What the textbooks in­ variably refer to is isokinetic action, or constant angular velocity, o f the moving limb, and not the biomechanical process within the muscle. It is impossible in the clinical or training setting to measure the contraction ve­ locity o f a muscle deep within the body, so that most labora­ to ry an aly sis o f m uscle contraction has been on biop- sied muscle. Even under these circumstances, contraction is usually elicited by electrical stim ulation under ex p eri­ mental conditions, so that it is generally invalid to discuss isokinetic contraction o f muscle during natural movement. ISOKINETIC MACHINES Application o f the term 'isoki­ netic' to specific physiotherapy machines is beset with similar problems. By definition, it is biomechanically impossible to design a purely isokinetic m a­ chine. Since isokinetic means 'constant velocity', then these machines must constrain the patient to move a limb at con­ stant velocity from beginning to end o f range o f the move­ ment. This is impossible, since the patient has to start his limb from rest and push against the machine until it can constrain the motion to approximately constant angular velocity. Now, if any object moves from rest to any velocity, N ew ton's first two Laws o f Motion de­ cree that a force and an accel­ eration must be involved - and the existence o f any accelera­ tion means that there can be no constant velocity. When the patient reaches the end o f the range o f movement, limb and machine arm stop mementar- ily, then change direction. The presence o f any deceleration or change o f direction heralds the absence o f constant velocity. This implies that isokinetic action is not possible during initiation or termination o f any movement. Thus, all isokinetic machines are able to produce approximately isokinetic action only over the middle o f the range o f movement. Conse­ quently, these machines cannot offer realistic evaluation or therapy in the transition zones near the extremes o f the move­ ment range, regions where in­ juries commonly occur. Therefore, there is no such entity as a true isokinetic m a­ chine. So-called isokinetic ma­ chines actually generate resis­ tance which is a function o f the applied muscle force. It would be more accurate for manufac­ turers to refer to their 'isoki­ netic' devices as semi-iso­ kinetic machines. It is unlikely that this will happen, so it is the responsibility o f physiother­ apists to appreciate the limita­ tion o f these machines when they use them therapeutically. One o f the very few occa­ sions when isokinetic action takes place is during isometric contraction. In this case, the velocity o f limb movement is constant and equal to zero. Approximately isokinetic ac­ tion also occurs during mid­ range movement phases in swimming and aquarobics, with water resistance (which is pro­ portional to the square o f ve­ locity o f movement) serving to limit any increase in velocity. ISOTONIC TERMINOLOGY The term isotonic, which means 'sam e to n e', should be limited or avoided under most circum ­ stances, since it is virtually im­ possible for muscle tension to remain constant while joint movement occurs over any ex­ tended range. Constancy is possible only over a very small range under very slow or quasi­ isometric conditions o f move­ ment. Naturally, constant tone also exists when a muscle is at rest, a state referred to as res­ ting tonus. W henever move­ ment occurs, muscle tension in c re a s e s o r d e c r e a s e s , particularly if acceleration is involved or one o f the stretch reflexes is activated. The W est Germans and So­ viets prefer to use the term auxotonic, which refers to muscle contraction involving changes in muscle tension and length.2 Other authors prefer to _________________________________ 17 SPORTSGENEESKUNDE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) CONCEPTIONS/MISCONCEPTIONS IN SPORTS MEDICINE use the term allodynamic, from the Greek 'alios' meaning 'other' o r 'not the s a m e '.1 The term 'dynam ic' is suffi­ ciently precise to describe the type o f contraction in question and should be used whenever the word isotonic is intended to mean any form o f dynamic, or non-isometric, contraction. The term isotonic should be reserved for the highly limited, short movement range situations where muscle tension definitely remains constant. ISOMETRIC CONTRACTION Even the concept o f isometrics is not as simple as it appears. Isometric literally means 'sam e length', a state which occurs only in a muscle at rest. Actu­ ally, it is not muscle length, but jo in t angle which remains con­ stant. Contraction means 'shorte­ n in g ', so th at iso m e tric contraction, like all other forms o f muscle contraction, involves sliding o f actin and myosin muscle filaments relative to one another. Isometric contraction may be defined more accurately by reserving it to mean muscle contraction which occurs when there is no external movement o r change in jo in t angle (or distance between origin and in­ sertion). The term isometric may be replaced by the simple word 'sta tic ', without sacrific­ ing any scientific rigour. Furtherm ore, all isometric contractions are not the same. Distinction may be drawn be­ tween rapid initiation and slow initiation isometric contractions, w here the form er refers to iso­ metric contraction occurring when a muscle contracts rapidly against an imposed load, and the latter refers to contraction produced gradually against a load. Similarly, it is useful to recognise rapid termination and slow termination isometric contractions, which take into account the rate at which the load is withdrawn. Recruit­ ment o f muscle tissue and the various stretch reflexes is different in all o f these cases, so it is important to be aware of these differences when iso­ metric rehabilitation or train­ ing is being considered. CONCLUSION If the term isokinetic, isotonic and isometric are to be used to describe specific types o f muscle activity, then it is essential that the scope and limitations o f each term are appreciated, particularly since casual usage by exercise pro­ fessionals, gymnasium users and equipment manufacturers has led to human movement and physical conditioning being explained and analysed in a bi- omechanically inaccurate man­ ner. Although the term static and dynamic may lack the more authoritative tone o f the iso- prefixed words, they offer the average exercise scientist and fitness professional adequate re- placements for isometric and isotonic, respectively. Isoki­ netic activity may then be regarded as a special case o f dynamic activity in which the resistance is a function o f the applied muscle force. □ R E F E R E N C E S 1. B erger R A . A p p lied E xercise P hysio­ logy. Lea & F eb ig er, Philadelphia 1982: 9. 2. V erkhoshansky Y. F undam entals o j Special Strength Training in S p o rt Fizkul- lurai Sports Pub lishers, M oscow 1977. (S3) V/3.1/62, V/3 .1/238 W .F .I. H/34/128 TILCOTIL® C o m p o n e n ts : TENOXICAM 20 mg Indications: S y m p to m a tic treatm en t of the fo llo w in g painful in fla m m a to ry and d egenera tive d is o rd e rs of the m u scu loskeletal s yste m : rh e u m atoid a rth ritis ; o s te o a rth ritis ; a n k ylo s in g s p o n d y litis ; e xtra - a rtic u la r d is o rd e rs , e .g . te n din itis , b u rs itis , p e ria rth ritis , g o u ty a rth ritis (fo r ta b le ts). Dosage: 20 m g once d a ily at the sam e tim e each d a y. The parenteral fo rm is used fo r one o r tw o d a ys. For treatm en t in itiation in acute g o u ty a rth ritis 40 m g (2 tab lets) once daily fo r tw o d a ys fo llo w e d b y 20 m g once d a ily fo r a fu rth e r five days is re co m m e n d e d . C o n tra-in d icatio n s: K n ow n h yp e rs e n s itiv ity to the d r u g . P atients in w h o m sa licyla tes or oth er n o n ste ro id a l an ti­ in fla m m a to ry d ru g s (N S A ID s ) induce s y m p to m s of asthm a, rh in itis o r urticaria . Patients w h o are s u ffe rin g o r have suffered fro m severe diseases of the upper g a s tro in te s tin a l tra ct, in clu d in g g a s tritis , g a s tric and duodenal ulcer. B efore an aesthesia o r s u rg e ry , ‘T I L C O T I L ’ should not be g iven to patients at risk of kidn ey failu re, o r to patients w ith increased risk of bleedin g. C o n c u rre n t treatm en t w ith s a licyla te s o r oth er N S A ID s s hould be avoid ed . P re g n a n c y and lactation. P recautions: S im u lta n e o u s treatm en t w ith a n tico a g u la n ts and/or oral an tid ia betics s h o u ld be avoided unless the patient can be c lo s e ly m o n ito re d . Renal fu n c tio n (B U N , creatinine, d e ve lo p m e n t of oedem a, w e ig h t g ain , e tc .) s h o u ld be m o n ito re d , w hen g iv in g a N S A ID to the e lde rly o r to patients w ith c o n d itio n s that could increase th eir risk of d e ve lo p in g renal failure. Packs: T a b le ts 20 m g : 10 's , 3 0 ’s. Vial pack co n ta in in g 1 vial active substan ce and 1 am p ou le w a te r fo r in je ctio n . 18 ------------------------------------ SPORTS MEDICINE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) vita-thion com bats fatig u e replenishes energy ENERGY FOR THE FAMILY 2 Sachets in half a glass of water at breakfast for 30 days. ® Reg/No. M/33/250: Eutherapy. Division of Servier Laboratories S.A. (Pty) Ltd. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) DRUGS IN FOCUS SPARE YOUR JOINTS Sport trauma is a common event. Painful joints and muscles and tendons must surely be regarded as an "early warning signal" that all is not well in the musculoskeletal or locomotor systems. The pain, and the often associated tenderness and swelling, are intended by N a­ ture to slow us down, to urge us to take recuperative measures, to "go quiet" - for a sufficient period to allow for the re- es­ tablishment o f full physio­ logical and functional integrity. POW ERFUL PAIN RELIEVERS AVAILABLE Powerful painkillers are avail­ able, and the indiscriminate use of such analgesics is a real con­ cern in sport medicine. Why? Because such analgesics may mask the warning signals so effectively, that excessive ac­ tivity is resumed before healing has had sufficient time to oc­ cur. NON-STEROIDAL ANTI-INFLAMMATORY ANALGESICS The non-steroidal anti-inflam ­ matory analgesics (NSAIAs) are very widely used to provide pain relief in the event o f sport injuries. These medicines in­ terfere with the biochemical and cellular components o f the inflam m atory response to trauma. The damage is the stimulus that evokes the in­ flammation and pain, and these NSAIAs interfere with the chemical mediators o f the in­ flammation and the pain. INFLAMMATION - GOOD AND BAD While it is true that the inflam­ matory response - if too enthu­ siastic, may itself promote dam age, yet it must be regarded as part o f the healing process. Thus, suppression o f the inflammatory response is likely to suppress or delay healing, and because the pain relief if often very notable, physical activity is recom ­ menced prematurely. JOINTS PARTICULARLY AT RISK W hile the repercussions o f such premature physical activity may not be too significant for soft tissue injury, it is con­ sidered to be highly significant for joints - where permanent and recurrent damage may be produced. THE MESSAGES SHOULD BE CLEAR * Pain, swelling, tenderness, inflammation in the mus­ culoskeletal system is a signal to "go slow". • NSAIAs are often excel­ lent pain relievers, that also suppress components o f the inflammatory response. NSAIAs can provide an en­ tirely false sense o f recov­ ery, and so permit prem a­ ture return to full physical activity. » Joints in particular, need time to recover from in­ ju ry , otherwise cumulative permanent damage may accrue. • Circumspect use o f these NSAIAs by well informed persons hold few dangers in terms o f damage to joints and soft tissues of locomotion. • Be sensible - be kind to your joints. Note: The Non-Steroidal Anti-In­ fla m m a to ry A n a lg e s ic s (NSAIAs), constitute all those medicines which function in a manner akin to aspirin to reduce pain, fever and inflam­ mation. NSAIAs currently available in RSA include preparations that contain any one o f the following: aspirin, azapropazone, bumadi-zone, diclo-fe- nac, diflunisal, feno-pro- fen, fenbufen, flurbip­ rofen, ibuprofen, in- dometchacin, keto- pro­ fe n , m e c lo fe n a m a te , mefenamic acid, nabume- tone, naproxen, oxap- rozin, oxyphenbutazone, phenylbutazone, piroxi- cam, sulindac, tenoxicam, tiaprofenic acid, tolmetin.n 20 SPO RTS M ED IC IN E VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) ABSTRACTS ABSTRACTS FROM THE CLINICAL JOURNAL OF SPORTS MEDICINE The official Journal of the Canadian Academ y of Sports Medicine Injury Profiles in W heelchair Athletes: Results o f a Retro­ spective Survey DAR M cC orm ack, DC Reid, RD S teadw ard and DG Syro- tu ik D epartm ent of Physical Education and Sports S tud­ ies, D epartm ent of A th le tic s , and the Glen Sather Sports M edicine Clinic, U n iversity of A lberta, Edm onton, A lberta, Canada Little is known about the nature and m echanism o f sports injuries among wheelchair athletes. The purpose o f this study was to develop an injury profile for this group. A total o f 90 wheelchair athletes were surveyed retrospectively by means of a questionnaire. Three hundred and forty-six injuries were reported in 18 different sports, 107 (30,9% ) o f which occurred in basketball, 106 (30,6% ) in track, and 42 (12,1% ) in road racing. Eighty percent o f the athletes were competitive, with 60% com­ peting at a national level. Most o f the athletes trained 6-10 h/week. Injuries to the soft tissue o f the upper extremities were most common, with the hand involved 21,3% and the shoulder 16,7% o f the time. Blisters and abrasions accoun­ ted for 47,7% o f the injuries. All o f the athletes surveyed sustained injuries, yet little protective gear was worn except for gloves (60%). In view o f the potentially serious long-term complications of some o f these injuries, and the corresponding impact o f the ability o f these athletes to carry out their functions of daily living, prompt diagnosis and treatm ent are m andatory. Despite this, less than one-third (30,8% ) o f all wheelchair ath­ letes sought medical assistance for their sports injuries. Key Words: W heelchair sports - Disabled sports - Spinal cord injury. Clin J Sport M ed 1991; 1(1): 35-40. Muscle RQ and Lactate Ac­ cumulation from Analysis of the VC02-V02 Relationship During Exercise W illiam L Beaver and Karlman W asserm an, Division of Res­ piratory and Critical Care Physi­ ology and M edicine, D epart­ m ent of M edicine, Harbor- IJCLA Medical Centre, UCLA School of M edicine, Torrance, C alifornia, USA. We analyzed the Vc02-v02 rela­ tionship derived from 1 min incremental (15 W /min) exer­ cise tests o f 10 normal subjects. The curve was quite linear below the anaerobic threshold (AT). We deduce that the slope must equal the respiratory quotient (RQ) o f the exercising muscles, with a mean value for these subjects o f 0,97 -F /-0,06, indicating that the metabolic substrate is essentially glyco­ gen. Beyond the AT, respira­ tory C 0 2 output rises at a faster a rate above as compared to below the AT, reflecting the rate o f H C 0 3 - buffering of lactic acid. Projecting the straight line o f VC02 versus VQ2 below the AT into the region beyond the AT provides an es­ timate o f the VC02 due to con­ tinuing aerobic metabolism. The difference between the actual VC02 and the aerobically produced VC02 (excess VC02) describes the rate o f C 0 2 gen­ erated from H C 0 3 - buffering o f lactic acid. The integrated excess C 0 2, corrected for any hyperventilation, provides a measure o f the quantity of H C 0 3 - depletion and thus lac­ tate accumulation. Since our measurements are non-steady state, a dynamic simulation model o f total lactate accumu­ lation and arterial lactate con­ centration, based on excess C 0 2 output and compartmental blood flows and volumes, was developed and found to predict experimental results o f lactate concentration increase. Thus, the excess C 0 2 output can be a useful measure o f lactate accu­ mulation and, with the devel­ oped model, serve to describe ------------------------------------------ 21 SPORTGENEESKUNDE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) A T T R A C T the rise in arterial lactate con­ centration during a progres­ sively increasing work rate test. Key Words: C 0 2 production - Excess C 0 2 - Lactate accumu­ lation - Lactate concentration model - Lactate threshold - Muscle "RQ". Clin J Sport M ed 1991; 1(1): 27-34. Clinical Evaluation o f Shoul­ der Instability Richard J Hawkins, MD, and Nicholas GH Mohtadi, MD, Department of Orthopaedic Surgery, University of Eastern Ontario and University Hospi­ tal, London, Ontario, Canada; and University of Calgary Sport Medicine Centre, Calgary, A l­ berta. The shoulder is the most un­ stable joint in the body. Pa­ tients with shoulder instability may present in a variety o f ways, ranging from subtle com­ plaints o f pain including the "dead arm syndrome", to those with subjective instability, ap­ prehension, or even those who can voluntarily demonstrate a dislocation. Instability can be classified according to the on­ set (traumatic, atraumatic, over­ use), the direction (anterior, posterior, multidirectional), the timing or frequency (acute or recurrent), the degree o f insta­ bility (subluxation or disloca­ tion), and whether it occurs voluntarily or not. The physi­ cal examination should be di­ rected toward ruling out other problems and determining whether generalized ligamen­ tous laxity is present. Specifi­ cally, the stability assessment includes apprehension tests, the relocation test, or Fowler's sign and an estimation o f gle­ nohumeral translation. The use o f a local anaesthetic injection into the subacromial space can be very helpful in guiding the physical examination. An ac­ curate diagnosis o f shoulder in­ stability can usually be made on a clinical basis by utilizing the information outlined in this report. Key Words: Appre­ hension tests - Glenohumeral translation - Relocation tests. Clin J Sports M ed 1991; 1(1): 59-64. Isokinetic evaluation of quad­ r ic e p s a n d h a m str in g symmetry following anterior cruciate ligament reconstruc­ tion. Harter RA, Osternig LR, Stan- difer LW. A rch Phys Med Rehabil 1990; 71: 465-8. Isokinetic muscle parameters are commonly measured after anterior cruciate ligament (ACL) reconstruction to deter­ mine the dynamic status o f the knee as well as monitor prog­ ress in rehabilitation. In this study, the symmetry o f the quad­ riceps and hamstrings muscu­ lature in postsurgical and con­ tralateral normal limbs o f sub­ jects who had undergone one o f two types o f ACL reconstruc­ tion was evaluated. In addition, subjects were evaluated for differences on selected isoki­ netic parameters between types o f surgery and lengths o f postoperative periods. Forty six subjects aged 18 to 49 years (mean, 2 3.7 years) postsurgi­ cal and normal contralateral limbs were divided into groups according to type of autogenous intraarticular ACL substitute and length o f postoperative period. From the results o f paired tests and analyses o f variance it was evident that significant asymmetries be­ tween limbs for all measures o f quadriceps and hamstrings musculature strength and en­ durance existed (p < 0.001) ir­ respective o f the type o f recon­ struction technique. Average surgical knee deficits in ham­ strings endurance were sig­ nificantly less for the long-term (41 to 101 months) follow-up group (1.9%) than for the in­ termediate (24 to 40 months) group (12.1% ). It would seem that extended periods o f time are required to approximate hamstrings endurance symme­ try after ACL reconstruction. In these subjects, assymmetries between postsurgical and con­ tralateral normal limbs may re­ flect either incomplete reha­ bilitation or an inability to regain full isokinetic strength and endurance following ACL reconstruction. Have you subscribed to Sports Medicine? See page 24 for more details. 22 ___________________ SPORTS MEDICINE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) ANABOLIC STEROIDS MASA TAKES STAND AGAINST DISPENSING OF ANABOLIC STEROIDS MASA has come out strongly against the dispensing o f ana­ bolic steroids, warning the profession it considers making these drugs available to the public for non-medical reasons in a serious light. At present the biggest di­ lemma faced by doctors is that there is little indisputable evi­ dence concerning the effect o f high dosage or extended usage o f anabolic steroids on athletes' health, as research with high dosages o f these substances is not permissible. However, the South African Sports Medicine Association (SASMA), a special interest group o f M ASA, is o f the opin­ ion - based on a comprehensive literature survey and a careful analysis o f the claims concern­ ing the psysiological, physical and psychological effects and adverse effects o f anabolic- androgenic steroids - that their potential medical use is limited and can be replaced with safer and more effective drugs. SASMA believes that the medical supervision o f sports­ men should primarily be di­ rected to clinical diagnosis and treatment o f patients to restore normal health and function rather than to scientific meth­ ods or to enhancement o f per­ formance. The Association has formu­ lated a Position Statement on the use and abuse o f anabolic steroids, which has been adopted by MASA as official policy on the issue and includes the following recommendations: • Serious and continuing ef­ forts should be made to educate athletes, coaches, trainers, physicians, par­ ents, physical educators and the general public re­ garding the limited bene­ fits and potential risks o f steroid use as documented by scientific research. • All sports governing bod­ ies (including the body building association) must uniformly reject the use o f anabolic-androgenic ster­ oids on the basis o f ethics and the ideals o f fair play o f competition and because their use gives possible competitive advantages harmful to the user. • A national drug testing programme should be in­ stituted by all sport gov­ erning bodies to be a deter­ rent to steroid usage and testing should equally encompass all levels o f sportsmen. For this reason an accredited laboratory should be appointed to conduct the testing and the testing procedures should be standarised throughout the country. • Consideration should be given to re-evaluating the medical use and indication for the anabolic-andro­ genic steroids, by the Medicines Control Coun­ cil in view o f rescheduling or even banning these drugs for medical or non-medical reasons. There is currently no method for predicting which individu­ als are more likely to develop adverse effects, some o f which are potentially hazardous. • Doctors should not be al­ lowed to prescribe these drugs in non-pharmaco- logical doses to obviously healthy athletes with the sole intention o f increasing in an artifical and unfair manner their performance in competition. • Pharmacists, veterinarians, pharmacological companies and other suppliers should be strongly discouraged and prohibited to supply any sportsman or sports club with anabolic steroids with­ out a valid prescription. Should instances come to light where athletes were illegally supplied with these potentially harmful drugs, the necessary disciplinary steps should be taken. • Doping control in South Africa for all national sport­ ing bodies should be co­ ordinated and standardised by an independent body with medical, scientific and sport representation to comply with international standards and the rules o f the International Olympic Committee Medical Com­ mission. □ ------------------------------------------ 23 SPORTSGENEESKUNDE VOL. 6 NO. 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) AffirikaaEse Spoirtgeinieeslkminide '̂V eff ©Mgmg A S p e c ia lis l g r o u p o f th e M A S A ( in c o r p o r a t e d a s s o c ia t io n not fo r g a in ) 'n S p e s ia l e g r o e p v a n d ie M V S A ( i n g e ly f d e v e r e n ig in g so n d e r w in s b e ja g ) PO Box 13206 CLUBVIEW 0014 M ay 1991 Dear Doctor, The characteristic that distinguishes a professional from an educated person is the professional person’s desire and responsibility to stay abreast of the developments of his or her field of expertise. The halflife of our professional knowledge is about 3 years, and for this reason it is vitally.important to continuously refresh and supplement our knowledge. Sports Medicine, the official mouthpiece of the SA Sports Medicine Association, has over the years become a treasured source of knowledge for the health care professional in the sports medicine arena. The journal features not only original research papers and articles by leading specialists in sports medicine, but also current news and relevant abstracts. The publishing of Sports Medicine has been taken over by Medpharm Publications. The journal will be published quarterly namely, February, May, August and November. Due to the present rate of inflation SASMA are no longer able to distribute Sports Medicine free of charge and have reluctantly introduced a subscription fee of R20.00 per annum (Members of SASMA will continue to receive the publication free of charge). In addition to managing costs, this will enable the editorial board maintain a high quality editorial content and render a more effective service to you, the health care professional. Your subscription to Sports Medicine is an investment in your future and the future of the health care profession. We count on your continued support. Regards, CLIVE NOBLE EDITOR SPORTS MEDICINE Name: .. Address: Code: ................................................................. Tel: ................................................................. Enclosed please find my cheque/postal order payable to SASMA for: ® R30 for FULL MEMBERSHIP* to SASMA (This includes receiving Sports Medicine free of charge) ® R25 for ASSOCIATE MEMBERSHIP** to SASMA (This includes receiving Sports Medicine free of charge) • R25 for STUDENT MEMBERSHIP*** to SASMA (This includes receiving Sports Medicine free of charge • R20 + GST (R22,60) for subscription to Sports Medicine NOTE * Full membership: Medical practitioner who is a member of MASA ** Associate membership: Members of supplementary Health Service professions, registered with the SAMDC and who are members of their own professional associations *** Student Membership: Medical students who are in their clinical years R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. )