SOUTH AFR IC AN JOU R N AL OF

SPORTS MEDICINE
SPORTGENEESKUNDE

J O U R N A L  O F  T H E  S. A .  S P O R T S  M E D I C I N E  A S S O C I A T I O N  
T Y D S K R I F  V A N  D I E  S. A.  S P O R T G E N E E S K U N D E - V E R E N I G I N G

VOLUM E 6 NUMBER 4 AUG/SEPT 1991

CONTENTS

Editorial Comment
Drugs in sport - Erythropoietin .................... 3

Overview
A philosophy for the treatment of ACL 
instability ......................................................... 4

Physiology
The achilles tendon: A pilot study to investigate 
the relationship between calf size and strength 
and achilles tendon thickness ........................  11

Physiology Notes
Notes on the physiology of muscle 
contraction .................................................... 18

Nutrition
Methods that can be used for the determining 
of food intake.................................................... 22

Physiotherapy
The physiotherapy assessment and treatment of 
a tennis elbow.................................................... 25

News
SASMA News .............................................
Industry News .............................................

27
28

National Advisory Board

Editor in Chief:
Clive Noble 
Associate Editors:
P rof TD Noakes 
Dawie van Velden 
Advisory Board:
Traumatology:
Etienne Hugo 
Physiotherapy:
Joyce Morton 
Nutrition:
Mieke Faber 
Biokinetics:
Martin Schwellnuss 
Epidemiology:
Derek Yach 
Radiology:
John Straughan 
Physical Education:
Hannes Botha 
Internal Medicine:
Francois R etief

International Advisory Board

Lyle J  Micheli
Associate Clinical Professor o f
Orthopaedic Surgery
Boston, USA
Chester R Kyle
Research Director, Sports
Equipment Research Associates
California, USA
P rof H C Wildor Hollmann
President des Deutschen
Sportarrtebundes
Koln, West Germany
Howard J  Green
Professor, Department o f
Kinesiology
Ontario, Canada
George A Brooks
Professor, Department o f  Physical
Education
California, USA
Neil F Gordon
Director, Exercise Physiology
Texas, USA
Edmund R Burke
Associate Professor, Biology
Department, University o f
Colorado
Colorado, USA
Graham N  Smith
P hysiologist
Glasgow, Scotland

Photographs counesty o f the Image Bank

JO U R N A L  O F  T H E  S O U T H  A FR IC A N  
SPO RTS M E D IC IN E  A SSOCIA TION  
269 W E S T  A V E N U E  
H E N N O P S M E R E  
V E R W O E R D B U R G , 0157

T he Jo u rn al o f  the SA  S p o rts M edicine A ssociation is p u b lish ed  by M e d p h arm  P ublications, 3rd 
F lo o r N oodhulpliga C e n tre , 204B  H F  V erw oerd D riv e, R a n d b u rg  2 1 9 4 . PO  Box 1004, C ram er- 
view  2060. T el: (011) 7 8 7 -4 9 8 1 /9 . T he v iew s expressed in th is pub licatio n  a re  those o f  the author* 
and not necessarily those o f  the p ublishers.

P r in t e d  b y  T h e  N a t a l  W i t n e s s  P r in t i n g  a n d  P u b lis h i n g  C o m p a n y  ( P t y )  L i d

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EDITORIAL

D R U G S  IN  S P O R T  - E R Y T H R O P O IE T IN

It is not to have taken part but to win at all 
costs has become the dictum in sport through­
out the world.

Unfortunately, to achieve this wining goal, 
both fair means and foul have been used.

Fair means excellent training methods, 
proper diet, proper rest, good psychological 
motivation, etc. Foul in most situations 
means drugs. In order to keep competition 
fair, drug testing to prevent athletes from 
using substances which may be helpful, has 
becom e the order o f the day. Unfortunately 
the last o f  banned substances has become as 
long as your arm.

This has made it both difficult for the 
athlete as well as his doctor. Well known 
cough mixtures for exam ple are banned sub­
stances. It is therefore im portant for the 
"clean" sportsman to go to a doctor who is 
knowledgable about these banned substances.

The main problem however, is the sports­
man who is taking drugs to enhance per­
formance. There is a war going on between 
the crooked athletes and the administrating 
doctors.

W hereas most substances are detectable 
in the urine within a variable time following 
intake, there are some drugs which because 
they are natural to the body are impossible to 
detect as such except that their levels may be 
abnorm al. Testosterone is one o f these sub­
stances which acts as an anabolic steroid. The 
anabolic steroids are especially used in strength 
athletics where anaerobic activity is required. 
They also play a role in endurance athletics.

In endurance athletes the aim is to get as 
much oxygen as possible to the involved 
muscles. This essentially means an increase 
in red blood cells to carry more oxygen to the 
rest o f the body.

Physiologically this can be done by attitude 
training, where low oxygen levels in the 
atm osphere stimulate the production o f red 
blood cells.

Blood doping is a technique which has 
recently been used. H ere the athlete trans­
fuses him self with his own blood stored some 
tim e earlier. This is o f course "foul play".

M ore recently (1986) synthetic erythro­
poietin has been formulated and used by 
athletes. Erythropoietin is a substance nor­
mally produced by the kidneys which is 
responsible for the formulation o f red blood 
cells.

It is called EPO  and is able to raise the 
haematocrit significantly. It clearly increases 
the oxygen carrying capacity o f the blood. 
The problem is it is undetectable in the patient 
and thus escapes routing detection.

The major problem however, is that it 
causes an increase in blood viscosity which in 
turn may cause vascular sludging and pos­
sible vascular occlusion.

It has been shown to cause an 8% im prove­
ment in maximal aerobic capacity, better 
than the 5% achieved by blood doping. Its 
effect is also immediate and lasts for 120 days 
(blood doping 10-15 days).

There is a possibility that EPO  has been 
the reason for the deaths o f 18 cyclists from 
Holland and Belgium since 1987.

It is a frightening thought that with 
increased availability, the death rate may 
increase in endurance athletes.

EPO has a very positive role in medicine. 
It does wonders for the anaem ia o f renal 
failure and can cause a significant haemato­
crit rise in these patients. These people are 
not in danger o f sludging, however, which is 
the real danger with athletes.

It is produced in California under the trade 
name EPOGEN and is banned by the Inter­
national Olympic Committee. It has been 
used in Europe for the last few years and is 
apparently available on the black market in 
the USA. It is undetectable and even so only 
stays in the body for about 24 hours. It has 
been called "Go Juice" by those who use it.

The tragedy is that despite negative pub­
licity athletes will still use it in the hope o f 
winning.

It looks like we have another problem on 
our hands!

D r Clive Noble MBBChB, FCS (SA) 
Editor-in-Chief

---------------------------------------------------  3
SPORTSGENEESKUNDE VOL. 6 NO. 4

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OVERVIEW

A PHILOSOPHY FOR THE TREATMENT 
OF ACL INSTABILITY

PJ Erasmus, Parow

NATURAL HISTORY O F ACL 
DEFICIENT KNEE

McDaniel (CORR 172 - 1983, pg 158-163) 
evaluated 49 patients, on the average 14 years, 
after the rupture o f the ACL and found the 
following:

Weakness 55%
Giving way 73%

8% once a month or more 
30%  once a year or more 

Meniscectomy 6 8 %  had one or both removed 
Osteoarthritis 10%  frank

3 0 %  joint space narrowing

Found that the patient at risk was the:

Heavy weight
varus deformity - bony

lateral ligament instability
meniscectomy 
weak hamstrings

M ary Lynch (CORR 172 - 1983 pg 148-154) 
found that jo in t stability in all planes and, 
particularly in nearly full extension, is an inte­
gral function o f the intact meniscus. When the 
integrity o f the meniscus is compromised by 
associated ligament instability or partial or total 
removal, these functions are altered. U lti­
mately, failure o f the meniscus leads to pro­
gressive joint degeneration.

261 patients with ACL tears were evaluated. 
There was a 98% chance o f a meniscal tear in 
untreated ACL tears within one year o f injury. 
The incidence was decreased to 48 % by primary 
reconstruction. Bilateral meniscectomies in­
creased the anterior instability 18 times. After 
partial or total meniscectomy there was a 22% 
greater incidence o f Fairbank's changes than in

the control group and 2 times greater incidence 
than in the mensical sutured group. There was 
no better joint surface preservation with partial 
than with total meniscectomy.

Recent work by Freddi Fu e ta l (57th Meeting 
AAOS) suggests the following:

• Total meniscectomy results in a 235% 
increase in contact stresses.

• Contact stresses after partial menis­
cectomy increase to the proportion o f the 
meniscus removed.

• Removal o f the posterior horn leads to 
stresses o f nearly the same degree as of 
total meniscectomy especially with the 
knee in flexion.

MECHANISM  OF DEGENERATION IN 
ACL DEFICIENT KNEE

Dejour (FJOS Vol 1 No 2 - 1987, pg 85-97) 
evaluated 214 patients with ACL deficient 
knees, on average 13 years after their original 
injury and suggests the following mechanism 
for degeneration secondary to a ACL insuffi­
ciency.

Found that with a deficient ACL there is at 
least 6 mm anterior displacement o f the tibia on 
the femur in the one legged stance and that this 
leads to an increased load on especially the 
posterior aspect o f the medial tibial plateau. 
After a medial meniscectomy the anterior 
displacement o f the tibia increases to at least 
12 mm which results in an even bigger load on 
the posterior aspect o f the tibia. In addition, the 
absence o f the medial meniscus increases the 
load o f the whole medial compartment by at 
least 30%.

4 ---------------------------------------------
SPORTS MEDICINE VOL. 6 NO. 4

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OVERVIEW

Recurrent antero lateral sub­
luxation (pivot shift) leads to me- 
niscal tears and stress fractures o f 
the articular surface o f the femoral 
condyles and is often the reason for 
the sportsman seeking medical 
advice as it interferes with his 
sporting ability and leads to a 
symptomatic painful knee.

Dejour however, believes that it 
is rather the chronic anterior dis­
placement (Lachman), which is 
increased by the loss o f the medial 
meniscus, than the antero lateral 
subluxation (pivot shift) which 
causes medial compartment os­
teoarthritis. This means that if the 
antero lateral subluxation (pivot 
shift) is eliminated without elim i­
nating the anterior displacement 
(Lachman) the patient will be able 
to go back to sport but the progres­
sive medial compartment osteo­
arthritis will not be halted.

The overload on the posterior 
aspect o f the medial plateau results 
in a distinct radiological medial 
compartment osteo arthritis con­
sisting of:

• osteophytes in the inter condy­
lar notch;

• osteophytes on the posterior 
aspect o f the medial tibial pla­
teau;

• narrowing o f the medial joint 
lips;

• posterior subluxation o f the 
medial femoral condyle seen on 
a lateral standing view.

In treating the ACL deficient knee 
our aim should be:

1. saving the menisci;
2. eliminating the anterior dis­

placement;
3. eliminating the antero lateral 

subluxation.

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GIVE THEM A  SPORTING
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OVERVIEW

T H E  P A T IE N T  A T R IS K

Considering what has already been said about 
the natural history o f the ACL deficient knee 
and the mechanism o f medial compartment 
osteo arthritis it seems that the following 
patients are especially at risk and should be 
treated surgically:

• young active sportsmen;

• heavily build patients;

• already established meniscal injury;

• varus deformity - this deformity can either 
be o f bony origin or can be secondary to 
lateral ligamentous laxity.

WHAT SHOULD BE RECONSTRUCTED?

It is clear that both the pivot shift and the 
Lachman signs should be eliminated by surgery 
if we wish to obtain a longterm satisfactory 
result.

Jakob (JBJS Vol 69B No 1 - 1987, pg 294- 
299) suggests grading the pivot shift, and this 
can be used as a guide to which surgical proce­
dure should be perform ed. (See Table 1).

I would not suggest a specific procedure for 
repairing this instability but I am just mention­
ing a few o f the more common procedures.

Lateral Extra Articular

Ilio tibial bank (M clntosh/Lem aire/A ndrew s/ 
Muller) can be used or possibly biceps tendon.

Table 1

Grade 1: pivot shift + int rotation -
- neutral lateral extra
- ext rotation - 1 

lachman <  9 mm
articular repair

Grade 2: pivot shift + int rotation - lateral extra
+ neutral articular repair
- ext rotation plus central

lachman 10-15 mm repair

Grade 3: pivot shift + ant rotation - lateral extra
+ neutral articular repair
+ ext rotation - central repair

lachman >  15 mm medial extra 
articular repair

Table 2

Tissues Available Strength (N) Width(mm)

Anterior Cruciate Ligament 1 7 2 5 ± 2 6 9 N.A.
Bone-Patellar Tendon-Bone

Central 1/3 2 9 0 0 ± 2 6 0 1 3 ,8  ±  1 ,4
Medial 1/3 2 7 3 4 ± 2 9 8 1 4 ,9  ±  1,1

Semitendonosus 1 2 1 6 ± 50
Fascia Lata ( 15 mm) 
Fascia Lata (45 mm)

6 2 8
1 8 0 0

± 35 1 5 ,6  ±  0 ,8

Gracilis 8 3 8 ± 3 0
Quadriceps-patellar retina- 

culum-patellar tendon,
central 2 6 6 ± 7 4 1 6 ,3  ±  3 ,5

Meniscus less commonly used

T h e  fo llo w in g  are th e norm al loads in daily activities:

A ctivity M aximum Force (N) Activity M aximum Force (N)

Level walking 2 1 0 Ascending Ramp 107
Ascending stairs 6 7 Descending Ramp 4 8 5
Descending stairs 133 Jogging 6 3 0
Sitting and Rising 1 73 Jolting 7 0 0

6 -------------------------------
SPORTS MEDICINE VOL. 6 NO. 4

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OVER VIEW GIVE THEM A  SPORTING
CHANCE AGAIN ST PAIN

w l

M ust not use a technique that 
will in any way com prom ise the 
lateral stabilising structures as 
that will increase the load on the 
medial compartment.

Intra Articular

Autogenous

Table 2 indicates tissue available 
for autoge-nous grafts and with it 
their strength in Newtons are 
given. This is data from Noyes et 
al. It should be noted that they do 
not state what part o f the fascia lata 
was tested, the distal part o f the 
fascia lata is much stronger than 
the proximal part and it would be 
important to know which part they 
tested to make a reasonable 
assessment on the use o f fascia 
lata or otherwise.

It seems that only the patellar 
tendon (Jones/ Erikson/ Clancy) 
and the semitendonosus is o f ade­
quate strength. A wide strip o f ilio 
tibial band or fascia lata might be 
strong enough but as it com pro­
mises the lateral stabilising struc­
tures, it should probably only be 
used in rare cases.

It should be noted that auto 
grafts are free grafts which under­
go necrosis, vascular invasion and 
cellular proliferation. There i s bone 
to bone healing in cases where 
bone-patellar tendon-bonegrafts 
are used.

Homogenous (Allografts)

At the moment there is a great 
interest in this tissue, and the fol­
lowing is a basic summary o f the 
present situation.

The following tissue can be 
used:

• bone/patellar tendon/bone
• fascia lata
• achilles tendon

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OVERVIEW

• bone/anterior cruciate/bone

Stringent donor criteria is necessary to avoid 
disease transmission such as Aids, Hepatitis, 
etc.

G rafts can be harvested clean which then 
need sterilisation by either:

• ethylene oxide which tends to cause a 
synovitis in the joint; or

• irradiation, which causes a decrease in the 
strength.

When fresh frozen and then irradiated (2Mrad) 
there is a 25% loss o f strength. When freeze- 
dried and irradiated there is a 75% loss o f 
strength.

G rafts can also be harvested sterile which 
do not need any further treatment.

Preservation can either be done by deep 
freezing (below -70° C) or by freeze-drying.

No rejection o f allografts has been reported 
and they seem to heal and incorporate in the 
same way as autografts.

It seems that if it is possible to obtain tissue 
that has met with stringent donor criteria and 
has been harvested sterily and deep freezed, it 
might be the tissue o f choice to use. On the other 
hand if the tissue available has been gassed, 
irradiated or freeze-dried it seems to be o f 
inferior quality and should not be used.

Heterogenous/Prosthetic materials

The problems with prosthetic ligaments as well 
as augmentation devices can be summarised as 
follows:

• weak ingrowth o f biological tissue in areas 
o f fixation;

• release o f worn particles leading to tissue 
reaction both intra articularly and in areas o f 
fixation; and

• fatigue and failure with long-term use.

As a result o f these mentioned problems the 
present indication for prosthetic ligaments are 
only in salvage surgery.

As regards augmentation devices there is no 
conclusive proof that they in fact give superior 
results to autogenous grafts used without any 
augmentation and cases have been described 
where debris from these devices has resulted in 
intra as well as extra articular tissue reactions.

The following few articles make interesting 
reading:

1. Poly propoline LAD - Roth AJSM  16, 3, pg 
301-305, 1985.

2. Poli ethyline - Edwald CORR 115, pg 213- 
219, 1976.

3. Carbon fibre - Parsons CORR 196, pg 71-76, 
1985.

4. Prosthetic Synovitis - Kaufman J  Rheun 12, 
pg 1066-1074, 1985.

5. Arthritis in artificial ligaments - Kline AJSM  
17: 717, 1989.

Medial Extra Articular

Reefing postero medial capsule (Houston) or an 
advancement semi membranosus tendon (Tril- 
lat), this seems to be preferable as it is not 
influenced by the isometric points, which are 
very difficult to determ ine on the medial side.

OPERATIVE REQUISITES

Having decided who should be treated and what 
should be repaired there are certain technical 
requirements which must be met for a success­
ful reconstruction.

Proper graft selection

Strength
The graft should be at least as strong or stronger 
than the ACL. From the work o f Noyes it seems 
that o f  the autogenous tissue it is only the 
patellar tendon, a doubled semitendonosus and 
a wide strip o f fascia lata that can be used for 
ACL reconstruction.

Joint acceptability
This is especially important when using pros­
thetic ligaments o r homogenous, heterogenous 
grafts. Cases o f reactive synovitis to these types

8 -------------------------------
SPORTS MEDICINE VOL. 6 NO. 4

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OVERVIEW G IVE THEM A  SPORTING
CHANCE AGAIN ST PAIN

o f ligaments have been described 
and it is possible that, in the future, 
we will see more o f this problem. 
Longterm survival 
It is important that the recon­
structed ligament should have a 
reasonable functional survival 
period.

Isometric placement

Definition o f  isometry 
A graft is isometric if it is so posi­
tioned that is maintains constant 
length and tension throughout 
passive knee motion.

Intra Articular
(Odenstein JB JS  67A, pg 257-262, 1985)

Femur. 15 mm ( ± 3 )  anterior from 
over the top.
Tibia: 23 mm ( +  4) posterior from 
the menisco capsular junction 
Angle: with the knee flexed 90° the 
angle between the femoral shaft 
and ACL is 28 ( ±  4).

It seems from the most recent work 
o f Henning and M uller that the 
anterior edge o f the ACL repre­
sents the isometric points. An­
terior from this on the tibia results 
in tightness in extension and pos­
terior in tightness in flexion.

A nterior from this in the femur 
results in tightness in flexion and 
posterior in tightness in extension.

Extra Articular
(Krackow A/SA/ 11, 5, pg 293-302, 1983) 

Lateral
Femur, best position is ju st proxi­
mal and posterior from the origin o f 
the lateral ligament on the lateral 
femoral condyle.

Tibia: best position specifically 
in combination with the mentioned 
femoral sight, is just anterior from 
G urdey's tubercle.

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OVERVIEW

Medial
To my knowledge no specific work has been 
done on the isometric points on the medial side 
of the tibia/fem ur. We however, know that they 
would lie on Burm ester's Curve and has been 
well described in M uller's book on the knee. 
{"The Knee Form, Function, Ligament Recon­
struction" - Springer Verlag 1983).

In practice this means that a graft should be so 
positioned that after placement, the knee should 
be able to move passively through a full range o f 
movement without undue laxity or tensioning 
developing in the graft. The best way to attain 
this is to test the isometry o f the proposed point 
o f implantation o f the graft before finally fixing 
it and then once it has been fixed to again check 
for tensioning and full range o f movement.

Fixation

Fixation should be o f such a nature that imme­
diate guarded post operative mobilisation is 
possible. It seems that fixation to a bony point 
is preferable to ligamentous fixation. The ideal 
is a bone to bone fixation as is achieved with 
patellar tendon grafts. Non absorbable materi­
als should be used and there should be no undue 
compression o f the ligamentous parts o f the 
graft as this will lead to pressure necrosis and 
rupture o f the graft.

At present it seems that the best way of 
fixating bone-tendon-bone grafts is by the so- 
called interference screw method as has origi­
nally been described by Lambert, or by interface 
fixation where the bony part o f the graft is bigger 
than the hole in which it is fixated. In tendon 
grafts it seems that the best fixation is obtained 
by using unabsorbable sutures and a so-called 
"whip" stitch. This can be tied either through 
bone holes or over a screw or staple.

Tensioning

Correct tensioning is im portant to prevent lax 
grafts which will lead to instability or tight 
grafts which will either rupture or lead to a 
permanent jo in t contracture. A tensiometer is 
o f use but even more practical is to put the joint 
through a full range of motion after the graft has

been fixed and at the same time to test the 
stability.

Minimal Iatrogenic joint damage

The more surgical damage done to the joint 
and the ligamentous structures the more post 
operative swelling, scarring and osteo arthritis 
will result. Using the arthroscope, meticulous 
tissue plane dissection, meticulous tissue re­
apposition and hemosthasis all contribute to 
lessening the surgical damage.

POST OPERATIVE REQUISITES

Early mobilization decreases disuse effect, 
lessens capsular con tractu res, m aintains 
articular cartilage nutrition and allows early 
controlled forces on the graft which has a 
positive effect on collagen healing. It is clear 
that wherever possible, one should strive to 
start mobilising the joint as soon as possible. In 
studies O 'B rien, Wong and Friedrich came to 
the following conclusion: "Immediate full ac­
tive motion, quadriceps and hamstring exer­
cises may produce insignificant and safe loads 
on an isometric ACL reconstruction". To 
achieve this one has to fulfil the already men­
tioned criteria of:

• proper graft selection;

• isometric placement;

• adequate internal fixation; and

• correct tensioning.

REHABILITATION PROGRAM M E

It is essential to have a carefully planned post 
operative rehabilitation programme. It should 
be started immediately post operatively and be 
continued over an approxim ate 9 month period. 
There should be good liaison between the 
surgeon, physiotherapist and biokinetist. □

10 ---------------------------------------------
SPORTS MEDICINE VOL. 6 NO. 4

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PHYSIOLOGY

THE ACHILLES TENDON: A PILOT 
STUDY TO INVESTIGATE THE 

RELATIONSHIP BETWEEN CALF SIZE 
AND STRENGTH AND ACHILLES 

TENDON THICKNESS

J Mitchell, J Bowles, N Green and D Wolff

A B STR A C T

In order to establish normal data for calf size and strength and Achilles 
tendon thickness, 19 young, healthy and physically active males, aged between
18 and 25 years, and with a mean body mass o f 75,2 +  6,1 kg and a mean 
height o f 1,81 ±  0,04 m, were selected as subjects for this study. C alf size 
was found to be 36,9 ± 2 , 0  cms (mean ±  standard deviation), and calf strength 
43 ±  14 kg for 10RM and 67 ±  20 kg for 1RM. Achilles tendon thickness was 
2,53 ±  0,30 cms (mean ±  standard deviation) at the calcaneal insertion, 1,87 ±  
0,21 cms at 4 cms above the calcaneus and 2,79 ±  0,33 cms at the musculo­
tendinous junction. The Achilles tendon thickness at the calcaneal insertion was 
significantly sm aller than at the musculo-tendinous junction (t =  2,58; p <  0,01) 
and greater than at 4 cms above the calcaneus (t =  5,42; p  <  0,001). T here was a 
significant correlation between calf size and strength (r =  0,66), but no significant 
correlation between calf size and Achilles tendon thickness, o r between calf 
strength and Achilles tendon thickness. It is suggested that a large, strong calf and 
a thin Achilles tendon may be predisposing factors for Achilles tendon rupture.

Jeanette M itchell

Department o f  Physiotherapy 
University o f  the Witwatersrand 
M edical School 
7 York Road 
Parktown
Johannesburg 2193

IN T R O D U C T IO N

There has been an increase in 
the incidence o f rupture o f the 
Achilles tendon in recent years, 
which may be associated with 
the increasing emphasis on 
sport.1,2 It has been reported 
that 83,3 % o f cases o f Achilles 
tendon rupture1 occur at the 
intermediate part o f the tendon 
(three to five centim etres1 or 
two to six centimetres3 above 
the calcaneus), which suggests 
that this part o f the tendon is

the narrowest and therefore the 
weakest part. Furtherm ore, it 
seems likely that if  an individ­
ual has a large calf or a strong 
calf, and a thin Achilles ten­
don, rupture at the narrowest 
part o f the tendon could occur.

No normal values for calf 
size and strength and for 
Achilles tendon thickness are 
reported in the current litera­
ture. Therefore, this study was 
designed to establish some nor­
mal data and to determine 
w hether there is a relationship

----------------------------------------  11
SPORTSGENEESKUNDE VOL. 6 NO. 4

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•  Relieves pain

•  Reduces inflammati

•  Restores mobility

PAN a m ;
R M *  tU  o c s t o{j traum *

L E N N O N ^ ^ L l M n i

Quality medicine you can afford to t

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[S3] RANAMOR° -75 Iryection. Each 3rrrf am poule contains 75mg Dictofenac Sodtum with 4% 

v /v  benzyl alcohol as preservative. Reg. No. 75 m g/3m l Ampoules W/3.1/52R
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PHYSIOLOGY

between size and strength o f 
the c alf and Achilles tendon 
thickness.

M ATERIALS AND 
METHODS

Sample

Questionnaires were distributed 
to second-year male medical 
students at the University o f the 
W itwatersrand to select ap­
propriate subjects. From this 
population, 50 male students 
were found to be suitable in 
that they had no history o f  any 
ankle injuries, particularly 
Achilles tendon rupture or 
tendinitis, and were physically 
active. Nineteen o f these 
students consented to the 
measurement procedure. The 
final sample thus consisted o f
19 young, healthy, active males 
between the ages o f 18 and 25 
years, with an average height 
o f 1,81 ±  0,04 metres (N =  
17) and an average body mass 
o f  75,2 ± 6 , 1  kilograms (N =  
17).

M ETHODS OF 
M EASUREM ENT

C alf size

C alf circum ference was taken 
as a measure o f calf size. Each 
calf o f each subject was meas­
ured while the subject was 
seated, with the hip, knee and 
ankle joints at an angle o f ap­
proxim ately 90 degrees. The 
broadest circum ference o f the 
c alf was measured using a 
standard measuring tape, cali­
brated in centimetres.

C alf strength

Each calf was measured for

strength using a standard 
gymnasium straight-leg-calf- 
induced-heel-raising-resistance 
apparatus (calf-raising ma­
chine). M easurements were 
made on each subject in the 
standing position, with one leg 
then the other leg straight and 
weight-bearing, so that each 
calf was measured separately. 
A warm-up exercise o f 10 sub- 
maximal heel-raises followed 
by a one-m inute calf-stretch 
was given before the tests. A 
rest period o f two minutes was 
allowed between the tests. The 
testing procedure involved, 
firstly, the 10RM (ten repeti­
tion maximum o r the greatest 
weight that can be lifted ten 
times at a normal speed without 
fatigue o r discom fort) being 
measured for each calf. Sec­
ondly, the 1RM (one repetition 
maximum o r the greatest 
weight that can be lifted once at

a normal speed without dis­
com fort o r fatigue) was meas­
ured for each calf.

Achilles tendon thickness

The Achilles tendon thickness 
was measured at three points:

• at the insertion o f the ten­
don into the calcaneus 
(TA,);

• at a point four centimetres 
above the calcaneus (TA2);

• at the musculo-tendinous 
junction (TA3).

V ernier callipers, calibrated in 
millimetres, were used, and the 
subject was seated with the 
hip, knee and ankle joints at an 
angle o f approxim ately 90 
degrees, the feet supported on a 
stool.

Table 1: M ean values of variables 
(mean ± standard deviation: N =  19)

Variables Left leg Right leg Both legs P

CS 3 6 ,8  ±
2 ,0  cms

3 6 ,9  ± 
2 ,0  cms

3 6 ,9  ± 
2 ,0  cms

NS

10RM 43 ± 14 kg 43 ±  14 kg 43 ±  14 kg NS

1RM 67 ±  20 kg 67 ±  2 0  kg 67 ±  2 0  kg NS

TA, 2 ,5 4  ±  
0 ,3 0  cms

2 ,5 3  ± 
0 ,3 3  cms

2 ,5 3  ± 
0 ,3 0  cms

NS

TA? 1,87 ± 
0 ,2 7  cms

1,88 ± 
0 ,1 8  cms

1,87 ± 
0,21 cms

NS

TA , 2 ,8 0  ± 
0,31 cms

2 ,7 8  ± 
0 ,3 8  cms

2 ,7 9  ± 
0 ,3 3  cms

NS

CS = Calf size
NS = Non-significant
RM = Repetition maximum (calf strength)
TA, = Achilles tendon thickness at calcaneal insertion
TA j = Achilles tendon thickness at point 4cm above calcaneus
TA a = Achilles tendon thickness at musculo-tendinous junction

---------------------------------------------------- 13
SPORTSGENEESKUNDE VOL. 6 NO. 4

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PHYSIOLOGY

Table 2: Tests for significance 
(t - tests; N = 19)

Variables t P

10RM/1RM 4 ,0 9 < 0 ,0 0 1

CS/TA, 7 0 ,4 0 < 0 ,0 0 1

c s / t a 2 6 9 ,6 9 < 0 ,0 0 1

CSyTA3 6 8 ,0 0 < 0 ,0 0 1

t a ,/t a 2 5 ,42 < 0 ,0 0 1

t a , / t a 3 2 ,5 8 < 0 ,0 0 1

t a 2/ t a 3 5 ,7 0 < 0 ,0 0 1

CS = Calf size 
NS = Non-significant 
RM = Repetition maximum 

(calf strength)
TA, =  Achilles tendon thick­

ness at calcaneal inser­
tion

TA 2 =  Achilles tendon thick­
ness at point 4cm above 
calcaneus 

TA3 = Achilles tendon thick­
ness at musculo- 
tendinousjunction

All measurements were made 
by the same researchers, to 
eliminate any inter-rater vari­
ance.

RESULTS

Difference between legs

On statistical analysis o f the 
data, it was found that there 
was no significant difference 
between the left and the right 
legs for any o f the m easure­
ments (Table 1).

C alf size and strength and 
Achilles tendon thickness

Table 1 shows the mean values 
for calf size and strength (10RM 
and 1RM) and for the Achilles 
tendon thickness at the three 
points o f measurement (the 
calcaneal insertion; 4 cms

Table 3: Tests for correlation (Pearson’ s correlation (r); N =  19)

Variables r r2 P

CS/10RM 0 ,6 6 0 ,4 4 < 0 ,0 1
CS/1RM 0 ,6 6 0 ,4 4 < 0 ,0 1
CS/TA, 0 ,3 0 0 ,0 9 NS
c s / t a 2 0 ,3 0 0 ,0 9 NS
c s /t a 3 0 ,3 7 0 ,1 4 NS
1ORM/TA, 0 ,1 4 0 ,0 2 NS
1ORM/TA 0 ,2 4 0 ,0 6 NS
10RM /TA3 -0,2 3 0 ,0 5 NS
1RM/TA, 0,21 0 ,0 4 NS
1 r m / t a 2 0 ,3 0 0 ,0 9 NS
1 r m /t a 3 -0,17 0 ,0 3 NS
TA 1/TA 2 0 ,1 6 0 ,0 3 NS
TA 1/TA 3 0 ,5 5 0 ,3 0 < 0 ,0 5
T A 2/T A 3 0 ,1 6 0,03 NS
Body Mass 0 ,7 6 0 ,5 8 < 0 ,0 0 1
Body Mass/1 ORM 0 ,7 9 0 ,6 2 < 0 ,0 0 1
Body Mass/1 RM 0 ,6 6 0 ,4 4 < 0 ,0 1

CS =
NS =
RM =
TA, =
T A 2 =
T A , =

Calf size 
Non-significant
Repetition maximum (calf strength)
Achilles tendon thickness at calcaneal insertion 
Achilles tendon thickness at point 4 cm above calcaneus 
Achilles tendon thickness at musculo-tendinous junction

above the calcaneus, and the 
musculo-tendinous junction), 
for the left leg, the right leg and 
both legs.

As expected, the 1RM calf 
strength was significantly 
greater than the 10RM strength 
(Table 2). Table 2 shows too 
that the thickness o f the Achil­
les tendon varies significantly 
along its length. At the cal­
caneal insertion, the Achilles 
tendon is thicker than at its in­
termediate part and thinner 
than at the musculo-tendinous 
junction. At the musculo­
tendinous junction, the Achil­
les tendon is thicker than at its 
intermediate part (Table 1).

Correlations between calf 
size, strength and Achilles 
tendon thickness

Table 3 shows that there is a 
good correlation between the 
size and strength o f the calf for 
both the 10RM and the 1RM. 
However, Table 3 shows too 
that there is no significant cor­
relation between calf size and 
Achilles tendon thickness at the 
calcaneal insertion, at the mus­
culo-tendinous junction and at 
the point 4 cms above the cal­
caneus. There is also no sig­
nificant correlation between 
calf strength and the Achilles 
tendon thickness at the calca­
neal insertion; at the musculo­
tendinous junction, or at the 
intermediate part o f the Achil­
les tendon (Table 3). Table 3 
shows too that although there 
is a significant correlation 
between the Achilles tendon 
thicknesses at the calcaneus 
and the musculo-tendinous 
junction, there is no such 
correlation between either o f 
these measurements and that at 
the interme-diate part o f the

14 --------------------------------------------
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PHYSIOLOGY

tendon. A significant correla­
tion exists between body mass 
and calf size and strength 
(Table 3), but no such correla­
tion was shown between height 
and these variables.

DISCUSSION

It is reasonable to suppose that 
the Achilles tendon thickness is 
related to calf size and strength, 
and that these variables are re­
lated to an individual's height 
and body mass. Furtherm ore, 
physiological hypertrophy o f 
the calf muscles in proportion 
to physiological needs should 
produce an increase in the 
strength o f the calf muscles 
and hypertrophy o f their ten­
don.

The data from this study 
confirm that the first o f these 
suppositions is correct. C alf 
size and strength are signifi­
cantly correlated and are corre­
lated, in turn, with body mass. 
However, no significant cor­
relation was found between 
calf size or strength and height. 
This correlation with body 
mass is weak, however, with 
changes in body mass explain­
ing only approximately 50% o f 
the change in calf size and 
strength. T h erefo re, other 
factors such as non-physio- 
logical exercise, for example, 
must contribute to the variance 
in calf size and strength.

M ore im portantly, the data 
from this study show that calf 
size and strength are not 
asso-ciated with changes in 
A chilles tendon thickness. 
M oreover, the thickness o f the 
Achilles tendon varies along 
its length, with the intermedi­
ate part being the thinnest. 
These results show that it is 
possible for an individual to

develop a large, strong calf 
w ith o u t d e v e lo p in g  an 
appropriately thick Achilles 
tendon. This combination o f a 
strong calf and a thin Achilles 
tendon could result, therefore, 
in a rupture o f the Achilles 
tendon, at its thinnest, inter­
mediate part, especially if the 
tendon is placed under ab­
normal tension.

CONCLUSIONS

This study has shown that 
height and body mass do not 
explain all the changes in calf 
size and strength. Similarly, a 
significant relationship be­
tween calf size and strength 
and Achilles tendon thickness 
does not exist in the normal, 
healthy, physically active 
young male. Furtherm ore, the 
thickness o f  the A chilles 
tendon varies. Therefore, the 
presence o f a thin Achilles 
tendon and a strong calf muscle 
may be considered as a predic­
tive factor o f Achilles tendon 
rupture, and such trauma is 
most likely to occur at the thin­
nest, intermediate part o f the 
tendon.

ACKNOW LEDGEMENTS

This study was approved by the 
Committee for Research on 
Human Subjects (Protocol No. 
12/2/90).

R E F E R E N C E S

1. J o z s a L , K v istM , B alintB J, Reffy A, 
Jarvinen M , Letho M and B arzo M. 
T h e role o f the recreational sport 
activity in A chilles tendon rupture. 
A m er J  Sports M e d , 1989; 17(3): 
338-342.

2. N o b leC . T h e P fizer m anual o f sports 
injuries. Vol 1. 1989. P fizer L abora­
tories (Pty) L td, Sandton.

3. T he Lancet. L ancet, 1989; 1: 1427- 
1428. n

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W .F.I. H/34/128

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--------------------------------------------------- - 15
SPORTSGENEESKUNDE VOL. 6 NO. 4

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F H Y S E O L O G Y  N O T E S

NOTES ON THE PHYSIOLOGY OF 
MUSCLE CONTRACTION

M Frescura

Muscle can be categorised into 
three types: skeletal (some­
tim es known as striated 
muscle on account o f its 
striated appearance under the 
light microscope), cardiac and 
smooth. In this series o f  
articles, we will be addressing 
the fundamental question o f 
how a muscle contracts with 
reference to skeletal muscle 
only. We shall commence with 
an outline o f some o f the gross 
mechanical properties o f this 
type o f muscle and then, in 
order to understand the 
physiological basis o f  muscle 
contraction we shall progress 
to a description o f events at the 
cellular level.

Skeletal muscle makes up 
the great mass o f  somatic 
musculature. Characteristically, 
it contracts and fatigues 
rapidly, does not normally 
contract without nervous 
stimulation and is generally 
under voluntary control. When 
an individual chooses to flex a

M  Frescura 

M RC
P O  Box 70 
TYGERBURG 7505

muscle, an electrical signal is 
transmitted from the brain to 
the muscle via the nervous 
system. The membrane sur­
rounding individual muscle 
cells has electrical properties 
such that a potential difference 
exists across this membrane o f 
magnitude about -90 mV at 
rest. The potential difference 
is maintained by a characteris­
tic distribution o f  ions. When 
the electrical signal or nerve 
impulse arrives at the muscle 
membrane, there is a transitory 
reversal o f potential which is 
the cue for the mechanical 
event o f muscle contraction. 
Although the mechanical event 
does not normally occur with­
out the preceding electrical 
event, the two are physiologi­
cally distinguished. The man­
ner in which mechanical con­
traction is coupled to electrical 
stimulation is a very involved 
subject, best dealt with as a 
separate issue. For the mo­
ment, let's consider some o f 
the mechanical properties o f 
muscle that have been investi­
gated by physiologists.

CONTRACTION

Physiologists know that if  a 
sufficiently strong single elec­
trical shock is administered to a

muscle, the muscle responds 
with a quick sharp contraction 
or twitch (Figure 1A). If elec­
trical stimulation is admini­
stered in the form o f two 
shocks in succession, two 
twitches occur. However, if  
the time interval between 
twitches is gradually shor­
tened, the twitches begin to 
fuse or summate (Figure IB). 
The summated response from 
two shocks delivered in quick 
succession gives rise to a 
smooth contraction o f larger 
and longer duration than that o f 
a single twitch (Figure 1C). 
Going a step further, if a series 
o f shocks o f  sufficiently high 
frequency is delivered, the 
muscle will maintain its con­
traction which is technically 
known as a tetanus (Figure 
1D-F). A lower frequency o f 
stimulation allows the indi­
vidual twitches to be distin­
guished (Figure ID). N ow  in 
the human body, muscles nor­
mally contract tetanically, i.e. 
are stimulated by a train o f 
electric shocks (impulses) 
from the nervous system 
delivered at a frequency o f 
about 15 to 30 shocks per sec­
ond. The contraction lasts just 
as long as the train o f electrical 
impulses are fired and that 
depends on you. By a volun­
tary decision in the brain to

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PHYSIOLOGY NOTES

Figure 1: Representation o f tracings obtained from  stim ulating a skeletal muscle. Tim e scale of electrical
stimuli show n  along horizontal axis. Intensity of

Figure 1 A: A tw itch  response from a single stimulus.

Figure 1C: As for B but w ith a shorter interval 
between stimuli showing fusion of response (summa­
tion).

Figure 1E: As for D but w ith shorter intervals 
between stimuli showing a sustained contraction.

muscle contraction show n along vertical axis.

Figure 1B: The response from tw o  stimuli in succes­
sion.

Figure 1 D: Response from a train of electrical stimuli.

Figure 1F: As for E but with a shorter interval 
between stimuli leading to a smooth tetanus.

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PHYSIOLOGY NOTES

Figure 2: Diagrams to illustrate m otor units w ithin each of tw o  muscles.

Figure 2A: Each motor unit consists of a motor 
neuron and tw o  muscle fibres.

Figure 2B: Each motor unit consists of a motor 
neuron and five muscle fibres. In reality, the number 
of fibres associated with each motor unit would be 
larger but is reduced in the diagram for simplicity.

stop the muscle contracting, 
the train o f electrical impulses 
is "switched o f f .

FATIGUE

What happens if the train o f 
electrical shocks inducing a 
contraction persists? A tetanic 
contraction cannot go on in­
definitely and if  stimulation 
continues for long periods, the 
muscular response declines 
and eventually disappears 
altogether. The muscle be­
comes fatigued.

There are several factors 
that bring this about, one o f 
which is exhaustion o f energy 
reserves within the muscle. 
This leads to a build up o f 
lactic acid which is toxic to the 
muscle tissue. Fortunately, 
w e experience this in terms o f 
pain in our muscles after pro­
longed muscle exercise and so 
our brain tells us to "stop" 
contracting the muscle, i.e.

"switch o f f  the train o f  electri­
cal impulses.

CONTROL O F TOTAL 
M USCLE TENSION AND 
FATIGUE

The greater the frequency o f 
stimulation the greater the 
intensity o f the mechanical 
response until a frequency is 
reached beyond which the 
response no longer increases 
(Figure IF). This is the grea­
test tension the muscle can 
develop. The total tension a 
muscle can develop depends 
upon two factors:

• the amount o f  tension 
developed by each con­
tracting fibre in a muscle; 
and

• the number o f muscle fibres 
stimulated in the contract­
ing muscle at any given 
time.

The first o f  these factors de­
pends on the frequency with 
which each fibre is stimulated, 
leading to summation and 
tetanus. It also depends on 
some aspects o f the struc­
ture and dimensions o f  the 
components o f a muscle fibre 
which we will consider at a 
later date.

The second o f  these factors 
can also vary in two ways 
depending on the number o f 
motor neurons activated and 
the number o f muscle fibres 
associated with each o f them. 
Look at Figure 2A and B. A 
single motor neuron stimulates 
a specific number o f muscle 
fibres. This arrangement, 
namely, a motor neuron and 
the fibres it innervates, is called 
a motor unit which may be 
small or large depending on 
the number o f fibres associated 
with the neuron (two and five 
respectively in Figures 1A and 
IB). A muscle is composed o f 
many such units. As the num-

20 ----------------------------------
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PHYSHOLOGY NOTES

ber o f  motor units receiving 
electrical stimulation goes up, 
so does the intensity o f the 
contraction. In addition, the 
number o f muscle fibres asso­
ciated with a single motor 
unit varies considerably in dif­
ferent types o f muscle. In 
muscles such as those o f the 
hand and eye, which are able to 
produce very delicate move­
ments, the size o f the individ­
ual motor units is small (in an 
eye muscle, one motor neuron 
innervates about ten muscles 
fibres only). By contrast, in the 
more coarsely controlled 
muscles o f the back and legs, 
each motor unit contains hun­
dreds o f  muscle fibres (a single 
motor unit in the large 
gastrocnemius calf muscle

contains closer to one thou­
sand seven hundred muscle 
fibres). If a muscle fibre is 
composed o f  small motor 
units, the total tension produced 
by the muscle can be increased 
in small steps by the recruit­
ment o f additional motor units, 
whereas if  the motor units are 
large, a greater jump in 
tension occurs as each addi­
tional motor unit is recruited. 
Muscles with small motor 
units then, allow finer control 
o f muscle tension. And the 
total tension a muscle deve­
lops can vary according to the 
number o f fibres associated 
with each motor unit.

An interesting way o f over­
coming the fatigue that might 
result from prolonged continu­

ous activity in some muscles is 
for motor neurons to fire 
synchronously. Thus, some 
motor units may be active while 
other motor units are momen­
tarily inactive or, if you like, 
resting. In muscles which are 
active for long periods o f  time, 
e.g . postural muscles which 
support the weight o f the body, 
this synchronous activity helps 
prevent fatigue while main­
taining an almost constant 
tension.

In the next article we shall 
look at the ultrastructure and 
explore some o f the events 
involved in muscle contraction 
at the level o f an individual 
muscle fibre. □

I C A T I O N  F O RA P P
R E S E A R C H  GRANT

To p ro m o te  k n o w le d g e  a b o u t th e  role o f sugar in 
h e a lth  a n d  nutrition, th e  South A fric a n  Sugar 
A ssociation looks to  th e  s cie n tific c o m m u n ity  for 
re lia b le  a n d  u p -to -d a te  in fo rm atio n. As p a rt o f this 
process, it supports scie n tific rese arch p ro je cts 
d e s ig n e d  to  c la rify  issues w h ic h  arise in this p u b lic  
terrain. The Sugar A ssociation a c ts  o n  th e  
re c o m m e n d a tio n s  o f a  Research A dvisor a n d  Advisory 
Panel.

Priorirties for rese arch fu n d in g  b y  th e  A ssociation are;

1. Physical w ork, exercise or sport in relatio n to  diet.
2. O be sity a n d  th e  c o m p a ra tiv e  role o f d iffe re n t 

d ie ta ry  fa c to rs  a n d  forms o f exercise.
3. Causes o f d e n ta l caries a n d  p e rio d o n ta l disease.
4. Diet in re la tio n  to  d ia b e te s  mellitus.
5. H yp erlipidae m ias in relatio n to  diet.
6. G ly c a tio n  o f proteins.

Proposals in a n y  o n e  o f the se priorirty fields will b e  
giv e n  c o n sid e ra tio n . The research grants a re  a w a rd e d  
o n  a  2 ye a rly basis. C o n tin u a tio n  o f th e  g ra n t for th e  
s e c o n d  y e a r o f study is d e p e n d e n t o n  progress m a d e , 
as assessed b y  th e  Advisory Panel from  a  re p o rt 
su b m itte d  fo r this purpose.

INSTRUCTIONS FOR PROPOSAL PREPARATIONS:
In o rd e r to  a llo w  fo r a  p ro p e r e v a lu a tio n  o f proposals 
b y  reviewers, th e  fo llo w in g  items should b e  in c lu d e d :
1. O n e  p a g e  a b s tra c t o f th e  p ro p o sa l p ro je c t 

(200-w ord m a xim u m )
2. Short d e scrip tio n  o f b a c k g ro u n d  fo r p ro p o s e d  

p ro je c t research,
3. S o c c in c t s ta te m e n t o f p ro je c t ob je ctives,
4. Short d e scrip tio n  o f m e th o d s  to  b e  used in pursuing 

ob je ctive s.
5. C le a ra n c e  fo r th e  research fro m  a n  A n im a l or 

H um an Review  C o m m itte e  if a p p lic a b le .
6. C u rriculum  v ita e  a n d  list o f full-len gth p u b lic a tio n s  

o v e r th e  last six years.
7. D e ta ile d  b u d g e t (to  in c lu d e  th e  p ro p o s e d  b u d g e t 

for th e  first a n d  s e c o n d  years o f study).

NOTE: No funds a re  p ro v id e d  fo r m a jo r e q u ip m e n t (unit 
c o s t g re a te r th a n  R2 000) o r tra v e l costs.
The d e a d lin e  fo r proposals to  b e  s u b m itte d  is 
15 N o v e m b e r 1991. A p p lic a tio n  form s a re  a v a ila b le  
from  a n d , w h e n  c o m p le te d , should b e  re tu rn e d  to:
The Nutritionist .The South A fric a n  Sugar A ssociation,
PO Box 374, DURBAN 4000. Tel: (031) 305 6161.

N e ithe r la te  a p p lic a tio n s  nor a p p lic a tio n s  re c e iv e d  b y 
fa csim ile  will b e  a c c e p te d .

SUGAR ASSOCIATION
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SPORTSGENEESKUNDE VOL. 6  NO. 4

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N U T R I T I O N

METHODS THAT CAN BE USED FOR 
THE DETERMINING OF FOOD INTAKE

Mieke Faber

There are at present various 
methods for the measurement 
o f the dietary intake o f indi­
viduals and groups. There is 
no best method for all study 
purposes. Each method has 
advantages and disadvantages. 
In general, methods can be 
divided into 2 basic categories. 
One category records data at 
the time o f eating. The second 
category collects data about 
the diet in the immediate, re­
cent or distant past.1

The selection o f  the method 
for a dietary survey depends 
on:

• objectives o f  the study, 
e.g. the degree o f accuracy 
needed and the type o f data 
needed.

• the study population, e.g. 
the sample size, the co­
operation and ability o f 
the subjects and the con­
straints on time.

• the expertise available, 
e.g. the skill o f the inter­
viewer.

Mieke Faber

Research Institute f o r  
Nutritional D iseases 
M edical Research Council 
Tygerberg

• The resources available, 
e.g. finances.2

The likely response rate and 
the accuracy o f the method is 
also important.3 Generally, 
the more accurate the method, 
the greater the cost, the greater 
the degree o f respondent co­
operation that is required and 
the lower the response rate.3

DIETARY RECORDS OF 
PRESENT FOOD INTAKE

In this method, the respondent 
keeps a record o f all food and 
drink consumed. The portion 
sizes are either weighed, 
measured or estimated.4 For 
this method the respondents 
must be literate, physically able 
to write, and motivated to keep 
a detailed diary.5 The advan­
tage o f  this method is that it 
does not rely on memory. It 
can also provide detailed food 
and food pattern information. 
It must however, be kept in 
mind that there is a decline in 
the accuracy in recording after 
a few consecutive days. An­
other disadvantage is that the 
fact that he must record every­
thing that he consumes might 
intentionally or unintentionally 
influence and alter the respon­
dent's dietary intake.6 For 
example, a respondent might 
choose to order a sandwich at 
lunch instead o f choosing a

dozen or so items from a salad 
bar, because the former would 
be easier to record.7 The 
seven-day dietary record is 
impractical for epidemiologic 
studies since it demands a high 
degree o f  cooperation on the 
part o f  the subjects.4

The dietary record can 
either be a weighed record or 
an estimated record. When 
keeping a weighed record, the 
respondents weigh and record 
the food immediately before 
eating and after the meal the 
leftovers are weighed. This is 
thought to be the most accurate 
method. It requires a higher 
degree o f cooperation from the 
respondents than some other 
methods and this is likely to 
affect the response.1 With 
an estimated record the food 
eaten is recorded in household 
measures such as spoons and 
cups. It is simpler and less de­
manding for the respondents 
than the weighing method. 
There is less interference with 
usual dietary practices if  the 
food need not to be weighed. 
Estimated records are poten­
tially well suited for collecting 
cross-section al d a ta ,1 e s ­
pecially if  it is kept in mind that 
the weighed method and the 
estimated method gave similar 
assessments o f mean protein 
and energy intake.5

In order to classify the nu­
trients into the top or bottom

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NUJTMmON

thirds at 80 per cent reliability 
it was indicated that for sugar 
and carbohydrates 2 to 3 days 
o f record keeping are long 
enough, whereas for dietary 
cholesterol and P/S ratio much 
longer surveys o f 2 to 3 weeks 
are needed. For most o f the 
other nutrients a week's sur­
vey appears to be enough.8 It 
would appear that the period 
for measuring habitual intake 
should be 7 days.9 In order to 
monitor lipid and energy in­
take, 7 consecutive days o f 
food recording were consid­
ered the minimum requirement 
for a 95% confidence lim it.10 
Dietary intake indicated that a 
one week record was as rep­
resentative as any other week 
during a 28-day study.11 It can 
be questioned whether a period 
longer than seven days should 
be used since it was found that 
the validity o f  the 7-day dietary 
record declined during the last 
few days o f the record period. 
Moreover, respondents keep­
ing records for longer periods 
tend to be more motivated and 
better educated than those 
who drop out.12 Thus, i f  the 
recording period is too long, 
the final sample may not be 
representative o f  the group it is 
intended to reflect.

RECALL OF INTAKE IN 
THE PAST

24-hour recall

The respondent is asked to re­
call his intake in the last 24 
hours or for the preceding day. 
Food quantities are usually 
assessed by the use o f house­
hold measures, food models or 
photographs. The interviewer 
should be trained in the art o f 
questioning.1 The main dis-

It should always be 
kept in mind that each 
method has its short­
comings. The method 
most suitable f o r  the 
purpose o f the study 

should be used.

advantages o f this method is 
its reliance on memory,3 and 
the fact that due to day to 
day variation it can only be 
used for groups.1 When using 
the 24-hour recall method, 
some respondents overesti­
mate their usual intake and 
some underestimate it.5 This 
method may also be subject to 
the "flat slope" syndrome. This 
means that it may overesti­
mate the intakes o f those re­
spondents with a low intake 
and underestimate the intakes 
o f  those with a high intake.12 
This could be o f particular con­
cern in athletes, as different 
groups o f athletes may have 
either habitually low or high 
levels o f food intake.7 The 24- 
hour recall has been directly 
validated by comparing re­
called intakes with intakes that 
were previously observed and 
unobtrusively recorded by the 
investigators. Mean intakes 
estimated from these two 
methods were similar for the 
group as a whole, indicating 
that the 24-hour recall is valid 
for assessing intakes o f  
groups.12 The 24-hour recall is 
less costly and less demanding 
on the subject. The main 
advantages o f this method is 
that it is quick and simple to 
perform and it places a minimal

burden on the respondent 
leading to a high response 
rate.1 It can yield good infor­
mation about the average 
dietary intake o f a large popu­
lation, but it is unsatisfactory 
on the individual level.213 
However, it can be used to 
determine the nutrient intake 
o f  an individual provided that 
multiple recalls, spaced over a 
considerable time period, are 
obtained. The average o f the 
multiple days may give a good 
indication o f the individuals in­
take.6 In as early as 1952 
Young et a l has stated that 
when an estimate o f  the mean 
intake o f  large groups (n >  50) 
is desired and when some 
errors o f  10 per cent can be 
tolerated, the shorter 24-hour 
recall method can be used in the 
place o f  the more time-con­
suming seven day record. This 
would mean a saving in time, 
both in collection o f data and its 
calculation and analysis. Less 
participants time and co ­
operation is needed, resulting 
in the possibility o f a more 
r ep resen ta tiv e p op ulation 
sample.14

The 24-hour recall can be 
administered by interview or 
per telephone. When the 24- 
hour recall was administered 
per telephone, it was found that 
this method produced accep­
table estimates o f  the means 
and distributions o f  nutrient 
intakes among groups o f indi­
viduals. The telephonic 24- 
hour recall can markedly re­
duce the cost, time, logistical 
and personnel constraints 
associated with nutrition sur­
v ey s.15

According to Gam et al. 
(1978) if a cut-off point is used 
to ascertain the percentage o f 
subjects at nutritional risk, a

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M JTM mON

higher proportion o f individu­
als will be classified as being at 
risk using a 1-day nutrient 
intake as compared to seven 
days. Although 1-day dietary 
intake methods may be used 
with confidence in determining 
the mean intake o f a large 
enough sample, 1-day dietary 
intake methods are inappro­
priate in ranking individuals, 
or in estimating the proportion 
o f individuals at nutritional 
risk.16

Diet history

This method assesses the 
usual intake over a period o f 
time such as the past year. As 
opposed to the food frequency 
method, portion sizes o f  all 
the foods are given and this 
method determines the whole 
diet and not only a few nutri­
ents.6 The diet history method 
yields higher values than the 
seven day record413 as well as 
the 24-hour recall.13 This 
method gives information on 
the diet over a long period o f 
time. The main disadvantage 
is that it relies on the respon­
dents memory. It also concen­
trates on regular patterns so 
that irregularities are easily 
underestimated.1 It also re­
quires that subjects be aware 
o f their food intake and have 
well defined eating patterns.7

Food frequency 
questionnaires

In this method, the respondent 
is presented with a list o f foods 
and asked how often he eats 
them.6 For estimating usual 
food intake o f a group, the 
frequency method appears to 
be highly successful. This 
method is however, not recom­

mended to estimate the precise 
nutrient intake o f individuals.17 
This method is cheap and 
simple.1

Analyzing the collected 
data

After the food intake has been 
determined, it must be con­
verted into nutrient intake. 
Although this can be done by 
hand, this is a very cumber­
some method. Nowadays, 
nutrient analysis is usually 
done by computer. For this 
purpose, various computer 
programmes are available, 
either for the PC or for the 
mainframe. Before the food 
can be analysed, all food con­
sumed must be converted to 
grammes. There is a South 
African manual available that 
assists with the conversion o f 
food items from household 
measures to grammes.18 After 
the food items are converted to 
grammes, it is analysed by 
computer in order to obtain the 
different nutrients.

In summary it can be said 
that when doing a dietary 
study, it should always be kept 
in mind that each method has 
its shortcomings. The method 
most suitable for the purpose 
o f the study should be used.

REFERENCES

1. Cameron ME and van StaverenW A. 
M anual on methodology fo r  fo o d  
consumption studies, 1988. Oxford 
University Press: Oxford.

2. Karkeck JM . Improving the use o f 
dietary survey methodology. J  Am 
Diet Assoc, 1987; 87: 869-871.

3. Fehily A M . Epidemiology for nutri­
tionist: 4 survey methods. Hum 
Nutr: A ppl Nutr, 1983; 37A: 419- 
425.

4. Block G. A review o f validation o f 
dietary assessment methods. Am J 
Epidmiol, 1982; 115: 492-505.

5. Todd KS, Hudes M and Calloway

DH. Food intake measurement: 
problems and approaches. Am J 
Clin Nutr, 1983; 37: 139-146.

6. Block G. Human dietary assess­
ment: methods and issues. Prev 
Med, 1989; 18: 653-660.

7. Barr SI. Women, nutrition and exer­
cise: a review o f  athletes ’ intake and 
a discussion o f energy balance in 
active wom en. Prog Food Nutr Sci, 
1987; 11: 307-361.

8. M arr JW  and Heady JA. Within- 
and between-person variation in 
dietary surveys: number o f days 
needed to classify individuals. Hum 
Nutr: A ppl Nutr, 1986; 40A: 347- 
364.

9. Acheson KJ, Campbell IT, Edholm 
OG, M iller DS and Stock MJ. The 
measurement o f food and energy 
intake in man - an elevation o f some 
techniques. Am J  Clin Nutr, 1980; 
33: 1147-1154.

10. Jackson B, Dujovne CA, DeCoursey
S, Beyer P, Brown EF and Has- 
sanein K. Methods to assess relative 
reliability o f diet records: minimum 
records for monitoring lipid and caloric 
intake. J  Am Diet Assoc, 1986; 86 : 
1531-1535.

11. St Jeor ST, Guthrie HA and Jones 
MB. Variability in nutrient intake in 
a 28-day period. A m  J  D iet Assoc, 
1983; 83: 155-162.

12. Gersovitz M, Madden JP an d  Wright 
HS. Validity o f the 24-hour recall 
and seven-day record for group 
comparisons. Am J  Diet Assoc, 1978; 
73: 48-55.

13. Karvetti R and Knuts L. Validity o f 
the 24-hour dietary recall. J  Am Diet 
Assoc, 1985; 85: 1437-1442.

14. Young CM , Hagan GC, Tucker RE 
and Foster W D. A comparison o f 
dietary study methods. Dietary his­
tory vs seven-day record vs 24-hour 
recall. J  Am Diet Assoc, 1952; 28: 
218-221.

15. Posner BM, Borman CL, Morgan 
JL , Borden WS and Ohls JC. The 
validity o f  a telephone-administered 
24-hour dietary recall methodology. 
Am J  Clin Nutr, 1982; 36: 546-553.

16. Gam S M , Larking FA and Cole PE. 
T he real problem with 1-day diet 
records. Am J  Clin Nutr, 1978; 31: 
1114-1116.

17. Mullen BJ, Krantzler N J, Grivetti 
LE, Schutz H and Meiselman HL. 
Validity o f a food frequency ques­
tionnaire for the determination o f 
individual food intake. Am J  Clin 
Nutr, 1984; 39: 136-143.

18. Langenhoven M L, Conradie PJ, 
Gouws E , Wolmarans P and van Eck 
M. NR1ND Food Quantities Man­
ual, 1986. South African Medical 
Research Council, Parow. □

24 ----------------------------------
SPORTS MEDICINE VOL. 6  NO. 4

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PHYSIOTHERAPY

THE PHYSIOTHERAPY ASSESSMENT 
AND TREATMENT OF A TENNIS 

ELBOW

Joyce Morton

With Wimbledon only 
recently over, it seems 
an appropriate time to 
discuss the physiotherapy 
ap-proach to a lesion o f 
the extensors carpi 
radialis longus and 
brevis.

A tennis player will usually 
give a history o f a typical over­
use injury. As with all teno- 
periosteal lesions, the older 
the player, the more prone he is 
to injury. The injury is caused 
by faulty stroke technique, too 
heavy a racquet or too tightly 
strung a racquet, or an incor­
rect size o f the racquet grip. 
The result is that the extensor 
muscles o f the forearm are 
loaded with a weight which is 
too heavy for them, they are 
unable to cope with the stress 
and micro-trauma takes place. 
As the player continues to play 
tennis, any attempted healing 
by the body breaks down and 
more micro-trauma takes 
place. Eventually the pain is so 
severe that the player is often 
no longer able to grip his 
racquet, let along play a shot.

On examination, the diag­
nosis is confirmed by keeping 
the elbow extended and ex­
tending the wrist against re­

sistance. Pain is felt at the 
elbow, but may refer along the 
back o f the forearm as far as 
the wrist and dorsum o f the 
hand, or the pain may even 
refer up the arm.

There are three sites which 
can be the cause o f the pain at 
the elbow, the most common 
being the tenoperiosteal origin 
on the lateral epicondyle. It is 
this lesion which often responds 
to a steroid injection and also 
often responds to physiother­
apy techniques. At least in this 
case it is comforting to know 
that if  one avenue o f treatment 
fails, there is another avenue to 
follow. The physiotherapist 
treats the injury as follows:

After palpating for the pain­
ful area she massages the site 
with deep transverse frictions 
using her thumb. This tech­
nique divized by the late Dr 
James Cyriax is without doubt 
one o f the most successful 
techniques that we use for soft 
tissue injuries. To begin with, 
the patient will find the 
massage exquisitely . painful 
but as the minutes go by the 
area becomes numb. Dr 
Cyriax advocates that this 
massage is continued for 15 
minutes. It is extremely tiring 
work for the physiotherapist 
and I must add that her thumb 
too becomes numb!

S om e p h ysioth erap ists 
follow this by placing the arm 
in internal rotation, the fore­
arm in pronation, the elbow in 
a few degrees o f flexion and the 
wrist in full flexion. Keeping 
the wrist fully flexed, the 
physiotherapist snaps the 
elbow into full extension. This 
technique is called a Mills 
manipulation.

As only a small section o f 
the tenoperiostial junction is 
affected, the aim o f the physio­
therapy treatment is to pull 
apart the two surfaces joined 
by the painful scar so that the 
rest o f the tendon may take the 
strain instead. After a time 
new fibrous tissue is laid down 
which is not under tension. The 
new scar is malleable and pain 
free when the patient uses his 
extensors. Even Mr GD Mait­
land, whose teachings most 
South African physiotherapist 
follow, agrees that this is the 
only way to treat a tennis elbow 
if  it is a true tennis elbow. If 
however there is an elbow joint 
component and this usually 
occurs i f  the injury has been 
chronic, then the joint is treated 
using the techniques that Mr 
Maitland advocates and the 
tenoperiosteal junction is trea­
ted using the techniques ad­
vocated by Dr Cyriax.

The other two sites are

---------------------------------------- 25
SPORTSGENEESKUNDE VOL. 6  NO. 4

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PHYSIOTHERAPY

either at the body o f the tendon 
over the head o f the radius or at 
the origin o f the extensor carpi 
radialis longus at the supra­
condylar ridge. These two 
sites respond to m assage 
swiftly.

The bellies o f the extensor 
muscles may also be injured at 
the level o f the neck o f the 
radius. The area is palpated 
by squeezing the bellies be­
tween finger and thumb, not by 
pressing the bellies against 
the radius as this is normally 
tender and would give a false 
diagnosis. M assage does not 
really help with this injury

but a steroid injection does.
The mistake that a player 

now makes is that because it is 
now symptom free he rushes 
back to tennis. The muscle has 
been injured, thus it is weak­
ened. As with all muscle in­
juries, one does not return 
to sport until the muscle is 
strengthened. A program m e o f 
graded exercises is given 
starting with isometric trai­
ning. As there is no movement 
o f the jo in t only the muscle is 
being loaded. The exercise is 
done at each 20 degrees star­
ting from full flexion o f the 
elbow to full extension. Each 
contraction is held for 10 sec­
onds. Pain is the guiding factor 
as one does not want to start 
the whole cycle again by cau­
sing m icro-traum a. The 
patient progresses to lifting a 
very light load. A m uscle's 
strength is built up if that 
muscle is exercised until it is 
tired. Research in the last 18 
months has shown that it is the 
eccentric movement which is 
the key to strengthening. This 
means that the weight must be

lowered against gravity whilst 
using the extensors. If the 
player sits with his wrist 
extended over the edge o f a 
table, he can extend and flex 
his wrist whilst holding the 
weight. He will then be doing 
both concentric and eccentric 
strengthening. The load is 
increased guided by the fact 
that there is no pain.

Stretching o f  the muscles 
once they are warm, must not 
be forgotten. The muscles run 
over two joints, therefore to 
stretch them, the elbow is 
extended, the wrist flexed and 
the forearm pronated. The 
stretch is held for 30 seconds 
and then during a further 30 
seconds slightly more stretch 
is achieved due to the inverse 
stretch reflex.

When the player returns to 
his game, it is advisable that 
he wears a tennis elbow brace 
o r a heat retainer. Heat retain­
ers are becoming more and 
more popular in this country as 
they not only keep the area 
very warm but also act as a 
proprioceptive stimulus. □

First analgesia is produced by deep 
massage.

M ill's manipulation may succeed at the epicondyle should injection fa il, but the procedure is valueless unless the 
patient's wrist is fix e d  in fu lle st flexion throughout.

2 6  -----------------------------------------------
SPORTS MEDICINE VOL. 6 NO. 4

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NEWS

SASMA NEWS/SASGV NUUS

Een van die hoofdoelstellings 
v an  d ie  S u id - A f r ik a a n s e  
Sportgeneeskunde Vereniging 
is om wetenskaplike navorsing 
op die gebied van sport­
geneeskunde aan te moedig en 
te publiseer tot voordeel van 
ons lede en ander persone wat 
gemoeid is met die versorging 
en afrigting van sportlui. Ten 
einde ons in staat te stel om 
hierdie oogm erk te bereik, is 
daar op die vorige uitvoerende 
komiteevergadering van die 
SASGV besluit om die stan- 
daard van ons tydskrif nog 
verder te verhoog ten einde 
meer plaaslike en oorsese 
navorsers aan te moedig om in 
die joem aal te publiseer.

Die eerste stap in hierdie 
rigting is reeds geneem met 
die aanstelling van die inter- 
nasionale adviserende raad 
wat saamgestel is uit verskeie 
sportwetenskaplikes wereld- 
wyd wat ingewillig het om 
jaarliks 'n  bydrae te maak deur 
artikels aan te bied vir pub- 
likasie, asook om artikels te 
beoordeel vir publikasie. Die 
feit dat ons tydskrif goedge- 
keur is vir subsidie aan univer- 
s ite ite  v ir  g e p u b lis e e r d e  
navorsingsartikels is 'n  be- 
langrike motivering vir plaas­
like navorsers wat verbonde is 
aan tersiere navorsings- en 
onderrig-instellings.

W e have also decided to 
increase the num ber o f pages in 
our journal, to accommodate 
more lengthy articles. In the 
past the ever increasing esca­
lating cost o f printing and paper

was a major constraint in 
achieving this ideal. W e hope 
to overcome this hurdle by 
increasing our A ssociation's 
membership as well as sub­
scribers to our journal. The 
Association is in great debt to 
all publishers and advertisers 
that have made our journal 
financially viable over the past 
few years. In turn, we believe 
that the increased readership 
o f the journal will be to the 
benefit o f the advertisers 
and sport in South Africa.

By attracting articles from 
abroad, the journal will also 
become an international forum 
for scientists to disseminate 
research findings m ore widely. 
South Africa has a major role to 
play in establishing sound 
principles in the medical care 
o f our athletes, both in South 
Africa as well as the whole 
African continent. A reputable 
journal in this context will be 
instrumental in achieving our 
goal. O ur journal is already 
distributed to the international 
advisory board, and hopefully 
we will attract subscribers 
from overseas. South Africa 
ranks high in the world in the 
field o f medicine, and sports 
medicine is no exception. In­
deed, we have something to 
say! Education in Sports 
M edicine and research in the 
sports sciences are already 
firmly established in our coun­
try, and there are indications 
that m ore universities in 
South Africa will establish 
Sports M edicine educational

program m es in the near future.
M et die verhoging van die 

wetenskaplike standaard van 
ons jo em aal, beoog ons nie om 
ons joem aal se aantreklike 
voorkom s te verloor nie. Dit is 
ons voom em e om 'n gesonde 
balans te handhaaf tussen 
hoogs wetenskaplike en teg- 
nologiese artikels en meer 
inform ele oorsigartikels wat 
verstaanbaar is vir 'n groot 
sektor van ons nie-mediese 
leserspubliek. Dus sal ek 
voortgaan om die joem aal in 
volkleur te publiseer. Die 
gewilde kort kolomme insake 
fisioterapie, voeding en far- 
m akologie, gaan uitgebrei 
word om ook 'n gereelde 
sportfisiologie bydrae in te 
sluit. H ierdie waardevolle 
bydraes vervul 'n groot leemte 
in ons opvoedkundige pro­
gram m e wat wetenskaplike 
feite op verstaanbare wyse 
oordra aan al ons lesers. Dit 
word geskryf deur kundiges in 
die onderskeie velde, en ons is 
hulle baie dank verskuldig vir 
hierdie groot opoffering wat 
hulle maak om ten spyte van 'n 
baie druk professionele pro­
gram nog 'n bydrae te maak tot 
die Suid-Afrikaanse Sport­
geneeskunde Tydskrif.

The Editorial Board o f the 
South African Sports M edicine 
Journal invites our readers and 
scientists in all related medical 
fields to submit articles to the 
E d ito r, D r C live N oble, 
M edpharm  Publications, PO 
Box 1004, Cramerview 2060, 
or the Associate Editors: P ro f

--------------------------------------------------- 27
SPORTSGENEESKUNDE VOL. 6 NO. 4

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NEWS

BEST SPORTS MEDICINE GRADUATE

Post-graduate students of the n ew  sports medicine course at the 
University of Cape T o w n

TD Noakes, Sports Science 
Centre, University o f Cape 
Town, Medical School, Obser­
vatory 7925, o r D r DP van 
Velden, Department o f Family 
M edicine, PO Box 19063, 
Tygerburg 7505.

We envisage that the South 
African Sports M edicine As­
sociation will have to play an 
increasingly important role in 
p reparing o u r athletes to 
participate internationally. We 
also have to prepare prim ary 
care physicians to act as team 
doctors for travelling South 
African teams to important 
international sporting contests. 
Sports M edicine has become 
so specialized, that the days 
are limited for individual 
doctors to care for athletes 
w ith o u t a d e q u a te  s p o rts  
medical training. O ur athletes 
deserve to be cared for by 
competent physicians with 
specialized knowledge in their 
specific sport. Doctors also 
need to be trained in all aspects 
o f doping control, and must be 
adequately equipped to advise 
athletes on the use and abuse 
o f medicines in sport. Informed 
doctors will stimulate the trust 
o f the athletes to reveal their 
confidential medical problems 
without the fear that the doctor 
will break confidentiality by 
disclosing information without 
their prior consent.

It is in the interest o f all 
athletes to have access to the 
best possible medical care, and 
not to be exploited by scien­
tists, doctors o r coaches. 
Through our journal we wish to 
keep our sportsmen informed 
on the new developm ents in the 
Sports M edicine field to help 
them in a scientific way to 
m aintain their com petitive 
edge. □  --------------------------

The sports arena is becoming 
more and more sophisticated 
and with this, unfortunately, 
sports injuries are on the in­
crease. To keep abreast o f 
these developments, the Uni­
versity o f Cape Town has in­
troduced a new post graduate 
course in sports medicine for 
medical practitioners.

Extending over two years, 
the new course includes 
regular lectures, workshops, 
clinical case discussions and 
sports medicine clinics. A 
comprehensive research pro­
ject must also be completed.

The top student who will 
graduate with the new ly 
d e v e lo p e d  p o s t- g r a d u a te  
Sports M edicine degree from 
the University o f Cape Town, 
will win a prestigious medal 
and accompanying cash prize 
as a result o f an annual 
sponsorship that has been

announced by Boots Pharm a­
ceuticals.

This announcement was 
made at the recent Sports 
M edicine Congress at Sun City 
with the aim o f promoting 
continuing medical education. 
"We believe Sports Medicine 
is a growing science and o f im ­
portance in South Africa due to 
the varied types o f sports 
injuries that people encoun­
ter," the product manager o f 
Froben said.

The accompanying cash 
prize is granted to the top 
student to present him /her 
findings at an overseas con­
gress with the aim o f gaining 
better exposure and knowledge 
o f current developments.

The first students will 
g r a d u a te  w ith  a BSc 
(M ed)(Hons) Sports Medicine 
Degree at the end o f 1991. 
---------------  □ ------------------

28 — ■ ■ ■ ■
SPORTS MEDICINE VOL. 6 NO. 4

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NUUS

FEMALE ATHLETES - 
HEALTH RISKS

M ale and female athletes 
generally develop sim ilar 
training related injuries but 
despite the equality o f the 
sexes, women are more prone 
to horm one and diet-related 
complications.

In her paper on problems o f 
high p e rfo rm a n c e  fem ale 
athletes presented at the IV 
South African Sports M edicine 
Association Congress in Sun 
City in April, guest speaker 
Professor M oira O 'B rien o f 
Dublin, said that a detailed 
record o f the athlete's men­
strual cycle was vital to pre­
vent the onset o f musculoskel­

etal problems.
These problems are more 

common in female athletes 
who are amenorrheic. Skeletal 
problems are also associated 
commonly with late menarche, 
particularly in single sided 
sports such as tennis and top 
level swimming.

P ro f O 'Brien who is the 
Director o f the Human Per­
formance Laboratory at Trinity 
College, said amenorrhoea 
should be investigated as 
osteoporosis could occur due to 
deficient oestrogen production, 
even in 20 year old female 
athletes. "If the low levels o f 
oestrogen are untreated, it will 
increase the risk o f fractures 
and osteoporosis at the meno­
pause", she said.

P ro f O 'Brien suggests that 
female athletes who develop 
recurrent shin splints o r stress 
fra c tu re s sh o u ld  h av e a 
biomechanical assessment as 
well as a full horm one profile, 
a dietary analysis, and bone 
mineral density assessed.

She pointed out that while 
moderate exercise protected 
women against osteoporosis, 
excessive exercise might cause 
the condition. Amenorrheic 
athletes who are hypoestrogenic 
develop reduced bone mass. 
P ro f O 'Brien said the mean 
bone density in amenorrheic 
runners aged 25, was compa­
rable to that o f women aged 50. 
"If not treated, they are guar­
anteed stress fractures at the 
menopause", she warned.

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---------------------------------------------------- 29
SPORTSGENEESKUNDE VOL. 6 NO. 4R

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NEWS

Osteoporosis is associated 
with the age o f  onset o f train­
ing, intensity and volume o f 
training, duration o f participa­
tion in training, the type o f 
sport, diet and stress.

In his paper on osteoporosis 
in exercise, Witwatersrand 
orthopaedic registrar Dr Robert 
van der Plank, warned that 
exercise induced amenorrhoea 
could be fatal.

"A woman who exercises to 
this level loses all the protec­
tive effects o f her own oestro- 
gens and she loses bone at the 
same rate as a woman who has 
been oopharectomised", Dr 
van der Plank said. Where 
other injuries are concerned, 
injuries to the ligaments o f  the 
ankle and knee joints are most 
common in female athletes. 
The most frequent injuries in 
high performance athletes can 
be attributed to overuse, doing 
too much too quickly, accord­
ing to Prof O ’Brien.

Dietary problems occur 
more frequently in female

Widespread ignorance about 
sport drug rules amongst doc­
tors, pharmacists and athletes 
alike was highlighted at a major 
sports medicine congress and a 
number o f legal implications 
for doctors who did not play by 
the rules were identified.

It became clear from a num­
ber o f  speakers at the IV South 
African Sports M edicine 
Association Congress in Sun 
City in April that doctors who 
prescribed drugs banned in

athletes, particularly in the 
so-called feminine sports such 
as gymnastics and synchroni­
sed swimming.

Professor O'Brien said eat­
ing disorders occurred in 20% 
o f athletes in sports where 
leanness was emphasised. In 
a recent English survey, 40% 
o f  synchronised swimmers 
were found to be below the 
recommended level o f  nutri­
ents. Female athletes are also 
more likely to be iron deficient.

Editor's Note
New on the market is 
the Lunar DPX, a highly 
efficient dual photon bone 
densitometer. It is one o f  the 
world's most advanced scan­
ners providing an accurate 
and precise measurement o f  
bone mass which leads to the 
detection o f  osteoporosis -  
both early and advanced 
stages.

For more information, please 
telephone Omnimed at (O il) 
833-6250.

sport could face legal action if 
the athlete is suspended from 
competing after positive dop­
ing tests.

In his talk on doctors, drugs 
and sport, Dr Joe Skowno, 
medical adviser to the Iron 
Man Triathlon in Johannes­
burg, said that doctors could 
play an important role in 
ruining a top sportsman's 
career.

"Thoughtless prescribing 
for a minor illness during

competitions may be the death 
knell o f an athlete's career," he 
said.

Dr Skowno warned that 
with the onset o f  international 
competition and the increasing 
number o f sportsmen turning 
professional, any medical blun­
der would not be taken lightly. 
Doctors who prescribe anabolic 
steroids to athletes can also be 
held liable for any serious 
medical side-effects as it is 
illegal to prescribe steroids to 
enhance performance.

Dr Skowno said one o f  the 
reasons for the widespread 
ignorance o f  sport drug rules 
was the lack o f an up to date and 
concise list o f banned or ac­
ceptable drugs in sport. Two 
commercial publications will 
be made available towards the 
end o f the year with guidelines 
on drug prescribing in sport.

B esid e s acqu irin g the 
necessary knowledge o f ac­
ceptable drugs in sport, Dr 
Skowno feels that the doctor 
should also play an active role 
in preventing the use o f ster­
oids and stimulants by athletes.

Dr Tim Noakes, who suc­
ceeds Dr Dawie van Velden as 
President o f  the Sports 
Medicine Association, said 
doctors, pharmacists and ath­
letes needed to know which 
drugs were acceptable in sport.

"In South Africa, 50% o f 
the athletes caught taking ban­
ned substances took the drugs 
out o f ignorance for incidental 
colds and flu. These drugs are 
often acquired over the counter 
and not prescribed by a doc­
tor," Prof Noakes said.

He also felt that doctors 
should discourage athletes 
from using drugs in sports, par­
ticularly since there was no 
proof that agents other than

DOPING IN SPORT - WIDESPREAD 
IGNORANCE AMONGST DOCTORS

30 ---------------------------------
SPORTS MEDICINE VOL. 6  NO. 4

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M J U S

steroids could enhance sport­
ing performance.

Prof Noakes singled out the 
lack o f a unified approach to 
the control o f drugs in sport in 
South Africa as one o f the key 
problems. He said it was cur­
rently up to the administrators 
o f the various sports to decide 
how vigorously they wanted to 
pursue the issue.

"The uncertainty o f  the fu­
ture structure o f sporting bod­
ies in the new South Africa 
makes it very difficult to draw 
up policies on testing for drugs. 
Many current structures will no 
longer exist and no one knows 
who should be talking to 
whom," Prof Noakes said.

Cost is another factor 
preventing blanket testing in 
South Africa. "Ideally tests for 
steroid abuse should be done 
throughout the year. This has 
proved to be effective in Brit­
ain, but has pushed up the cost 
o f testing," Prof NoaJces said.

SOUTHERN 
TRANSVAAL 
BRANCH OF SASMA 
UP AND RUNNING

Dr Joe Skowno was recently 
elected as the chairman o f the 
Southern Transvaal Branch o f 
the SASMA.

One o f the objectives o f the 
group will be to establish a 
roster o f  emergency sports 
care personnel in the Southern 
Transvaal. The branch plans 
to train doctors, physio­
therapists, etc., to deal with 
any emergency that might be 
encountered during a sporting 
activity. The idea is to supple­

ment existin g First Aid 
services currently available 
at m ost large sporting 
occasions, and not to replace 
them.

Any people interested in 
adding their names to the 
roster are please to contact 
Dr Skowno, PO Box 68958, 
Bryanston 2021.

NABUMETONE: 
PROVIDING 
EFFECTIVE, SAFE 
THERAPY FOR THE 
TREATMENT OF 
SPORTS INJURIES

Nabumetone is an effective, 
well tolerated treatment for 
sports injuries with comparable 
or better clinical trial results 
than it's major competitors.

Several studies have com­
pared the efficacy and toler­
ance o f nabumetone in this 
indication with those o f its 
major competitors. A com­
parative study with naproxen 
found that nabumetone-treated 
patients had a better resolu­
tion o f injury swelling, al­
though there was no signifi­
cant difference in overall out­
come between patient groups 
in this study. Another com­
parison between these two 
drugs found better results in 
the nabumetone group in terms 
o f anti-inflammatory action 
and pain relief. Comparative 
studies with ibuprofen have 
also found similar or better 
efficacy with nabumetone. 
Soluble aspirin has been found 
to be both less effective and 
less w ell tolerated than 
nabumetone in patients with

sports injuries.
In a double blind compara­

tive study, a 2 g initial loading 
dose o f nabumetone - followed 
by a 1 g at night for seven days 
- was compared with an 800 mg 
loading dose o f  ibuprofen - 
followed by a 400 mg four 
times daily dose for seven 
days.
~ One hundred and sixty 
seven patients were admitted 
to the study, o f  whom 85 
patients received nabumetone 
and 82 patients received 
ibuprofen. Twelve patients 
withdrew from the study, eight 
from the nabumetone group 
and four in the ibuprofen group. 
Patient withdrawals from the 
n ab u m eton e-treate group 
were due to lack o f efficacy 
(1 patients), non-compliance/ 
lost to follow-up (2 patients), 
and recovery prior to comple­
tion (5 patients). For the 
ibuprofen treated group, the 
withdrawals were due to lack 
o f  efficacy (1 patient), loss to 
follow-up (1 patient), and re­
covery prior to completion (2 
patients). All these patients 
were included in the efficacy 
analysis and the results at their 
last assessment were taken 
as the final assessment.

Both treatment groups 
showed a very highly statisti­
cally significant improvement 
( p >  0,001) for all parameters 
at both the interm ediate 
and final assessment points. 
There were no statistically 
significant differences be­
tween treatment groups for the 
change in pain, swelling or 
limitation o f function. Nabu­
metone however, was found 
to cause less adverse reaction 
(3,7%) vs ibuprofen (6,7%). 
The most common adverse 
rea ctio n s recorded w ere

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NEWS

gastrointestinal side effects - 
2,3%  for nabumetone and 
4,3%  for ibuprofen.

In a review o f 986 sports 
injury patients treated in 
seven centres o f the UK in both 
open and comparative studies 
it was concluded that nabume­
tone is an appropriate choice 
for the treatm ent o f sports 
injuries because it combines 
good clinical efficacy with a 
low incidence o f side effects 
e sp e c ially  g a stro in te stin a l 
reactions.

References available on request.

NEW AFRICA 
MERCY FLIGHT 
SERVICE

In response to the growing 
num ber o f South Africans 
travelling on business or 
holidaying in Africa, Europ 
Assistance has launched a 
new mercy flight service called 
Medstar.

"Last year we handled 411 
emergency repatriation cases 
from Africa, transporting sick 
and injured individuals by

charter Lear je t, and we expect 
the number o f cases to double 
in the next 18 months", says 
M unro Deysel, GM o f Europ 
Assistance.

Few South Africans, used to 
the First World medical facili­
ties here, are aware o f the lack 
o f medical care available to 
them while travelling in a Third 
W orld environment, o r con­
scious o f the risk they are ex­
posed to.

Almost all African countries 
suffer from a lack o f foreign 
exchange and medical skills. 
Qualified doctors are few and 
overworked, medicine is in 
short supply and medical 
equipment is often broken or 
unavailable. The threat o f 
contracting diseases like Aids 
is increased by the widespread 
re-use o f disposable needles.

"Our advice to fellow South 
Africans who become sick or 
injured while travelling in 
Africa, is to seek repatriation 
back to SA as soon as pos­
sible".

The new M edstar service is 
available on request and oper­
ates 24 hours a day from the 
Johannesburg based operations 
room manned by qualified ICU 
nurses and paramedics.

The service is backed by 27 
years o f specialised aviation 
experience, specialist SA doc­
tors on 24 hour standby, and 
over R2 million worth o f 
miniaturised hi-tech aviation 
medical equipment.

Europ Assistance is the 
la r g e s t tra v e l a s s is ta n c e  
organisation in the world, 
operating in 211 countries 
with full representation in 52 
African states.

The company can be con­
tacted on (O il) 838-6311. 
---------------  □ ■

[S3] V/3.1/62, V /3.1/238 
W .F.I. H/34/128

TILCOTIL®
Com ponents:
TENOXICAM 20 mg

Indications:

Sym p to m atic treatment of the 
follow ing painful inflam m atory and 
degenerative d iso rd ers of the 
m u scu loskeletal system : 
rheumatoid arthritis: osteoarthritis; 
a n kylo sin g sp o n d ylitis; extra- 
articular d iso rd e rs, e .g . tendinitis, 
b u rsitis, periarthritis, gouty 
arthritis (fo r tablets).

Dosage:

20 m g once daily at the sam e time 
each day. The parenteral form  is 
used for one or two d a ys. For 
treatment initiation in acute gouty 
arthritis 4 0 m g (2 tablets) once daily 
for two d ays followed by 20 mg 
once daily for a further five d ays is 
recom m ended.

Contra-indications:

Known h yp ersen sitivity to the drug. 
Patients in w hom  salicy la te s or 
other nonsteroidal anti­
inflam m atory d ru g s  (N S A ID s ) 
induce s ym p to m s of asthm a, 
rhinitis or urticaria. Patients who 
are suffering or have suffered from 
severe d ise a se s of the upper 
gastrointestinal tract, including 
ga stritis, g a stric  and duodenal 
ulcer. Before anaesthesia or 
su rg e ry , 'T IL C O T IL ' sh ou ld  not be 
given to patients at risk of kidney 
failure, or to patients with increased 
risk of bleeding.
Concurrent treatm ent with 
salicyla tes or other N S A ID s  should 
be avoided.
P re gn a n cy and lactation. 

Precautions:

Sim u lta n e o u s treatm ent with 
anticoagu lan ts and/or oral 
antidiabetics should be avoided 
u n le ss the patient can be clo se ly 
m onitored.
Renal function (B U N , creatinine, 
developm ent of oedem a, weight 
gain , e tc.) should be m onitored, 
when givin g a N S A ID  to the elderly 
or to patients with conditio ns that 
could increase their risk of 
developing renal failure.

Packs:

Tab lets 20 m g: 10 ’s, 3 0 ’s.
Vial pack containing 1 vial active 
su b stan ce  and 1 am poule water for 
injection.

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SPORTS MEDICINE VOL. 6  NO. 4

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