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Every patient is an athlete: Hot Topics in Sports Medicine 2012

Carlin Senter M.D.Primary Care Sports Medicine

UCSF Internal Medicine and Orthopaedics

UCSF Essentials of Primary Care August 14, 2012

In 50 minutes you will know1. The return to play/work progression for

concussion treatment.2. 2 unique causes of fatigue in an athlete.3. 5 questions to ask every athlete with hip pain.4. How to write an exercise prescription.

Case #1• 40 y/o woman presents to your office for ER follow-up one

week after bike accident.• Went over handle bars traveling on city streets. • No loss of consciousness.• Taken by ambulance to ER.• Had trauma work-up including head CT (-).• Diagnosed with clavicle fracture, nonoperative tx by

orthopaedic surgeon, discharged home.• Has headache, fatigue, dizziness, light sensitivity. Trouble

staying focused at work, sleeping more than usual.• Normal neurologic exam.

Diagnosis: Concussion • H/o trauma• Headache• Fatigue• Dizziness• Light sensitivity• Trouble staying focused at work• Sleeping more than usual.

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How would you treat the concussion?

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1. Order urgent MRI brain to rule out subtle post traumatic bleed, return to clinic after MRI.

2. Rest from work and biking, return to clinic 1 week.

3. Return to work but rest from biking, return to clinic in a month.

4. Return to work and biking (assuming cleared by orthopaedic surgeon for clavicle fracture).

Concussion definition• Blow to head, neck, body � force to head• Rapid onset of neurologic impairment• Symptoms usually short-lived and resolve

spontaneously but in some cases can be prolonged• Symptoms represent functional or metabolic change

in CNS, not structural injury• Graded set of clinical syndromes that may or may

not include loss of consciousness• Symptom resolution is sequential• Standard neuroimaging is normal

3rd International Conference on Concussion in Sport (2008). Clin J Sport Med May 2009.

Physical

Cognitive

Emotional

Sleep

Concussion symptoms

http://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf. Accessed Nov. 9, 2008.

Concussion clinic evaluation• History keys

– Mechanism of injury– Symptoms initially and currently– If sports

• Did they play through the symptoms? • Did they have a second hit (might make sxs last longer)

– Loss of consciousness (if many minutes then would expect transport and head CT)

– PMH – associated with prolonged symptoms• ADHD, learning d/o• Depression, anxiety• Concussion

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• Worsening headache• Seizure• Increasing

drowsiness• Focal neuro deficit• Repeated vomiting• Slurred speech

• Does not recognize people/places

• Increasing confusion/irritability

• Weakness/numbness arms or legs

• Neck pain• Loss of consciousness

>30 secondshttp://www.cdc.gov/ncipc/tbi/Facts_for_Physicians_booklet.pdf. Accessed Nov. 9, 2008.

SCAT2

3rd International Conference on Concussion in Sport (2008). Clin J Sport Med 2009.

Concussion treatment• Cognitive rest• Physical rest• Medication

– Avoid aspirin and ibuprofen

– Tylenol OK• Avoid alcohol• Avoid driving

Symptom resolution after sport concussion

• Majority 7-10 days • High school athletes shown to take longer to recover based on

neuropsychologic testing compared to college athletes (Field et al, J Pediatr, 2003.)

• Prolonged symptoms: > 4 weeks. Consider neurology or neuropsychology consult.

3rd International Conference on Concussion in Sport (2008). Clin J Sport Med May 2009.

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Return to work/play• Asymptomatic• Normal neurologic exam (SCAT2)

– Cognitive– Balance

• Computerized neuropsychologic testing

Guskiewitcz in SCAT2 Clin J Sports Med. July 2010.

Step-wise activity progression

Light aerobic activity

Sport specific activity

Non-contact training

Full contact practice

Game play

2nd International Conference on Concussion in Sport (2004). 2005 Br J Sport Med 39:196.

Asymptomatic

Clinician clearance

Clinician clearance

Case #2• 19 y/o female collegiate cross country runner

home for spring break comes to clinic• Complains of increasing fatigue, decreased

appetite, trouble recovering from work-outs, worsening performance in meets, difficulty concentrating in class.

• No abnormalities in GI hx or gyn hx• Exam: Height 5’3”, weight 125#. Tearful when

discussing symptoms, but physical exam otherwise normal.

Causes of fatigue in a runner1. Cardiac

– Coronary artery dz– Hypertrophic

cardiomyopathy2. Endocrine

– Hyperthyroid– Hypothyroid– Diabetes

3. Hematologic– Iron deficiency– Iron deficiency anemia

4. Malignancy5. Infection6. Depression, stress7. Pregnancy8. Nutritional

– Disordered eating– Drugs, alcohol– Celiac dz

9. Overtraining syndrome

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Labs/Studies• White blood cell count and differential normal• Hematocrit 36.2 (normal) • Thyroid stimulating hormone: normal• Fasting blood sugar: normal• Pregnancy test negative• EKG normal

What do you do now?

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1. Screen for depression2. Screen for eating disorder3. Order serum iron and ferritin4. Order stress echocardiogram5. Diagnose overtraining and

recommend rest6. 1 and 27. 1, 2, and 3

Work-up, continued• Depression screen (PHQ-9) = 5 (normal < 5)• Eating disorder screen

– No restrictive eating– No binge/purge behavior– No h/o dieting

• Ferritin 9 (low)• Iron 111 (normal)

Importance of iron in athletes: VO2The Fick principleVO2 = cardiac output • (arterial O2 – venous O2)

• Increasing hemoglobin � increased arterial O2 �increased VO2

• Decreasing hemoglobin (anemia) � decreased arterial O2� decreased VO2

Oxygenconsumption

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Spectrum of iron deficiency

Normal Irondeficient

Anemic

FerritinHemoglobin

Iron deficiency is common in athletes• Iron deficiency anemia

– Athletes same incidence as general population– 2.9% women, 0.2% men

• Iron deficiency without anemia (low ferritin)– 37% female athletes and 23% female non-athletes

have ferritin <20 (Rodenberg, 2007)– 10% male athletes (Hinton 2007)– Recreational athletes: 29% female, 4% male subjects

with ferritin <16 (Sinclair 2005)– 35% female, 15% of male elite basketball players with

ferritin <20 (Dubnov 2004)

Why are athletes iron-deficient?• Low dietary intake

– Vegetarians: eat more nonheme than heme iron• Decreased iron absorption

– Celiac sprue– Chronic diarrhea– Gastrectomy

• Increased iron loss– Blood loss

• Menstruation if younger woman• GI malignancy if older adult• Runners may have increased GI bleeding in stomach + large intestine (Pfitzinger 2008)

– Sweat– Urine– Hemolysis: foot strike � RBC breakdown

• Increased iron utilization– Pregnancy

Iron deficiency anemia impairs performance

• Low hemoglobin + low ferritin = iron deficiency anemia

• Decreased VO2max• Decreased transport of oxygen to tissues

Normal Iron deficient Anemic

FerritinHemoglobin

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Treating iron deficiency anemia improves performance

• Higher hemoglobin• Increases work capacity• Decreases heart rate

with exercise• Decreases lactate

concentration• Extreme example: blood

doping

http://www.bicycle.net/2009/tyler-hamilton-calls-it-over-after-drug-test-positive-and-depression

Does iron deficiency without anemia impair performance?

Does treating this improve performance?

Controversial

Normal Iron deficient Anemic

FerritinHemoglobin

Does iron deficiency without anemia impair performance?

• 48 non-anemic collegiate rowers at beginning of season– 24 normal, 24 “depleted” (Ferritin < 20 µg/L.)– Compared to normals, depleted group demonstrated

• 10min less training/day• 0.3L/min lower VO2 peak• Higher lactate during 4K time trial

Does treating iron deficiency without anemia improve performance?

• Garza Clin J Sports Med,1997 meta analysis– Increasing ferritin levels does not lead to improvements in endurance

performance– In athlete with low ferritin and low-normal hemoglobin, “relative anemia”

may be present and iron supplementation may help improve performance by increasing hemoglobin

• Hinton et al. J Appl Physiol, 2000.– RCT with 42 untrained women with avg ferritin 9 and Hgb 13– Iron supplementation x 6wks– Iron group: ferritin incr 10 to 14.5, no change Hgb, decreased time to

complete time trial, increased O2 consumption, no change VO2max• Friedmann et al. Med Sci Sports Exerc, 2001

– RCT 40 elite athletes with ferritin < 20 and avg Hgb 13.6– Iron supplement x 12 wks– Iron group: ferritin incr 16 to 40, no change Hgb, increased VO2max, oxygen

consumption, time to exhaustion

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Effects of iron deficiency without anemia: controversial

• Low ferritin indicates relative anemia in some athletes. Improved performance is based on improved hemoglobin with supplementation leading to increased oxygen carrying capacity leading to increased VO2.

OR• Low ferritin indicates decreased store of iron in tissue

leading to decreased function of mitochondrial iron complexes which may or may not affect VO2max but compromises endurance capacity in athletes.

Iron supplementation for elite athletes• Iron deficiency with anemia

– Treat with iron supplementation as you would with non-athlete

– Goal = normal hemoglobin (> 12g/dL for women)– Improves athletic performance, increases VO2max

• Iron deficiency without anemia– No defined protocol– Studies use different cut-offs to define low ferritin in

athletes• Australian Institute of Sport

– Ferritin ≤ 20 µg/L = iron deficiency without anemia– Goal Ferritin 30 µg/L

Case #3• 18 y/o freshman cross-

country runner• “heart beat stays fast”• “hard to stop sweating”• “tired all the time”• Times worse than when in

high school

Differential diagnosis• Cardiac

– Arrhythmia• Metabolic

– Hyperthyroid– Anemia– Diabetes– Malnutrition/eating

disorder

• Pulmonary– Exertional

bronchoconstriction• Malignancy• Infection• Depression• Pregnancy• Overtraining syndrome

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Work-up• Physical exam: VS normal, exam normal• CBC with differential: normal• Fasting BG: normal• TSH: normal• Pregnancy: negative• Iron studies and ferritin: normal• EKG: normal• Depression screen: mildly positive• Eating disorder screen: negative• Cardiopulmonary exercise test with echo: no exertional

bronchoconstriction, no arrhythmia, no structural heart disease

What is the diagnosis?

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1. Parasite2. Depression3. Overtraining syndrome4. Arrhythmia5. Lupus 6. Occult malignancy

Overtraining syndrome• Increased perceived

exertion• Decreased performance• Decreased energy and

mood• Symptoms must last > 2

weeks• No diagnostic test• Diagnosis of exclusion

Overtraining syndrome model

Time

Fitness level

Overreaching

Supercompensation

Overtrained

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Consequences of overtraining syndrome

• Overuse injuries• Recurrent illnesses• Missed events• Depression• Premature retirement

http://personalrs.blogspot.com/2008/12/tipos-e-sintomas-do-

overtraining.html

Overtraining syndrome treatment• Rest x 2-3 weeks

– Decrease training volume by 50%

• If symptoms continue – More rest– Track symptoms– Track mood scores– Sports psychology– Nutrition http://www.genucare.com/archives/496.html

Case #4• 20 y/o collegiate cross

country athlete• Presents to clinic with right

groin pain• Started a few weeks ago,

getting worse gradually• Still able to run but pain

gets worse the more she runs, hard to lift her leg due to pain

Differential diagnosisgroin pain in runner

• Intraarticular hip problem– Impingement– Labral tear– Femoral neck stress

fracture • Extraarticular hip

problem– Hip flexor strain– Sports hernia

• GI/gyn problemsFalvey EC et al, BJSM. 2007.

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Hip impingement Hip labral tear

http://www.aafp.org/afp/1999/1015/p1687.html

5 questions for every athlete with hip pain

1. Training: increased mileage?2. Nutrition: Calories in versus calories out?

History of eating d/o? Dietary restrictions?3. History of stress fractures?4. Family history of osteoporosis?5. Menstrual history?

Our patient• Increased mileage from 30 to 60 miles/week in last month

without increased caloric intake• No dietary restrictions or h/o eating d/o• (+) h/o tibial stress fracture in high school• No family history osteoporosis• Menses regular until college but none since freshman year

(18 months) • Exam

– Walking with right-sided limp– Tender right inguinal region– Pain with passive ROM: flexion, internal, and external rotation

of hip– Neurologically intact lower extremities but pain with active hip

flexion

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Hip passive range of motion

Flexionnormal 120°

External rotationnormal 40-60°

Internal rotationnormal 30-40°

http://www.youtube.com/watch?v=5LNYdJIrWYo

What’s your leading diagnosis?

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1. Hip flexor strain2. Hip impingement or hip labral tear3. GI/gyn problems4. Sports hernia5. Femoral neck stress fracture

High index of suspicion to prevent bad outcome Female athlete triad

Healthy energy status

Healthy menstrual

cycles

Healthy bones

Low energy availability with or without eating d/o

Osteoporosis Amenorrhea

Low bone density

Suboptimal energy availability

Irregular menses

OPTIMAL HEALTH

PATHOLOGY

Nattiv A et al, ACSM Position Stand, 2007.

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Female athlete triad treatment• Best treatment = prevention

– Screen for risk factors– Finding 1 risk factor should prompt eval for others

• Increase energy availability – Increase dietary intake– Decrease exercise– Has been shown to restore menses– Has been shown to increase bone density

• Estrogen: does not improve BMD as much as if menses are restored with increased energy availability

• Multidisciplinary approach: primary care doctor, nutritionist, psychologist, eating d/o specialist, athletic trainer

Nattiv A et al, ACSM Position Stand, 2007.

Case #5• 55 y/o woman presents for routine annual exam. No

complaints but shocked that she gained 10# since she saw you last year. Takes no medications.

• BP 140/80, HR 80, Height: 5’3”, weight 170# (BMI 30)• Labs:

– HgA1c 6.3%– Fasting glucose 104– Total cholesterol 192, TG 119, HDL 50, LDL 118

What treatment would most benefit this patient now and in the long run? Strong evidence that physical activity

associated with lower risk of• Coronary artery

disease• Stroke• High blood pressure• High cholesterol

• Type 2 diabetes• Colon cancer• Breast cancer• Falls

US Dept Health and Human Services. Physical Activity Guidelines Advisory Committee Report, 2008: http://www.health.gov/paguidelines/guidelines/chapter2.aspx. Accessed 11/6/2011.

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The exercise prescription: What’s the right dose of activity?

Credit: Piotr Redlinski for The New York Times

Physical activity recommendations: 4 types of activities

Physical activity recommendations: components of each activity

•Frequency

• Intensity

•Time

•Type

Estimating exercise intensityLow Moderate Vigorous

Heart rate <50% max 50-70% max >70% maxTalk test Can talk and

singCan talk but not sing

Can only say a few wordsbefore pause for breath

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Exercise prescription:Combine activity with components

•Frequency

• Intensity

•Time

•Type

CV fitness recommendationsFrequency Intensity Time Type5x/week Moderate 30 minutes Major muscle

groupsOR

Frequency Intensity Time Type3x/week Vigorous 20 minutes Major muscle

groups

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Balance recommendations

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Frequency Intensity Time Type2-3d/week Unknown 20 minutes Heel-toe walk,

stand on 1 foot, Tai Chi

Strength recommendations

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Frequency Intensity Time Type2-3d/week Novice: 40-50%

Experienced: 80%Unknown All major

muscle groups

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Flexibility recommendations

ACSM Position Stand on Prescribing Exercise, Med Sci Sports Ex, 2011.

Frequency Intensity Time Type2-3d/week Stretch to

feeling of tightness

Hold 10-30seconds

All major muscle-tendon units

Action plan: Exercise is Medicine1. Identify potential health benefits of exercise.2. Is the patient healthy enough to begin

exercise?3. Assess patient’s stage of change.

1. Precontemplation2. Contemplation3. Preparation4. Action and maintenance

4. Write the exercise prescription.http://exerciseismedicine.org/documents/HCPActionGuide.pdf. Accessed 11/6/11.

What makes a successful exercise program?

• Program characteristics – Moderate intensity– Supervised activity by

experienced leader– Group support

• Individually tailored program– Goal-setting– Reinforcement: social

support for behavioral change

– Problem-solving

http://en.wikipedia.org/wiki/File:07-06_WtrAerob1a.jpg

Pedometers• Popular and effective for promoting physical activity• 10,000 steps/day was old recommendation• Update for 2011:

– Pedometers don’t measure speed– May need <10,000 steps/day for sig health benefit– 100 steps/minute is rough estimate of moderate intensity

exercise– Recommend using steps/minute and the number of

minutes/session

ACSM Position Stand on Prescribing Exercise, Medicine & Science in Sports & Exercise, 2011.

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Choose an activity that fits your style. Case• 55 y/o woman presents for routine annual exam. No

complaints but shocked that she gained 10# since she saw you last year. Takes no medications.

• BP 140/80, HR 80, Height: 5’3”, weight 170# (BMI 30)• Labs:

– HgA1c 6.3%– FPG 104– Total cholesterol 192, TG 119, HDL 50, LDL 118

Write the exercise prescription

•Frequency

• Intensity

•Time

•Type

Stationary bike5/10 intensity10 minutes each time3 times a week

Carlin Senter, MD

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Exercise prescription resources

http://bleacherreport.com/articles/1189176-bay-to-breakers-2012-changes-the-race-must-make

“All parts of the body if used in moderation and exercised in labors to which each is

accustomed, become thereby healthy and well developed, and age slowly; but if

unused and left idle, they become liable to disease, defective in growth, and age

quickly.”Hippocrates

Thank you!

Carlin Senter, M.D.Primary Care Sports Medicine

UCSF Internal Medicine and Orthopaedics http://www.cdc.gov/physicalactivity/everyone/guidelines/index.html Accessed October 23, 2011.

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http://go4life.niapublications.org/ Accessed October 23, 2011.http://go4life.niapublications.org/try-these-exercises#strength-exercises Accessed October 23, 2011.

http://win.niddk.nih.gov/publications/walking.htm Accessed October 23, 2011.