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Jerrold Petrofsky, Lee Berk, Gurinder Bains, Iman Akef Khowailed, Haneul Lee, Michael Laymon
Clinical Journal of Sport Medicine, Volume 27, No. 4, July 2017
Delayed-onset muscle soreness (DOMS) is a relatively common phenomenon experienced by people who are new to exercise, or essentially anyone who exceeds their normal workout intensity. DOMS can range from mild irritation to severe pain that can form a significant barrier inhibiting performance, or exercise participation altogether. Furthermore, previous research has shown that DOMS is greater in intensity and duration in older individuals and individuals with diabetes, which is a particularly important patient population within family medicine. This cross-sectional repeated measure design study was performed to assess the impact on DOMS of heat applied for 8 hours immediately or 24 hours after exercise.
60 subjects aged 20-40 who were physically inactive for 6 weeks and had BMI’s less than 40 were divided randomly into 3 groups (control, ThermaCare heat wraps applied immediately after exercise, and ThermaCare heat wraps applied 24 hours after exercise). To provoke DOMS, the subjects completed squats in 3, 5-minute bouts with 3 minutes of rest in-between each bout. Visual analog pain scales, blood myoglobin, muscle strength, range of motion, and stiffness of the quads were the main outcome measures of the study.
The results revealed a significant reduction in soreness in the group that had the heap wraps applied immediately after exercise (P<0.01). This was corroborated by blood myoglobin, algometer and muscle stiffness data. In addition, there was some benefit to applying the heat 24 hours after exercise when compared to control.
In summary, low-level continuous heat wraps left for 8 hours after heavy exercise can reduce the effects of DOMS (assessed by both subjective and objective measures). Although cold therapy is commonly used after heavy exercise to reduce soreness, heat seems to have the added benefit of increasing flexibility of tissue and tissue blood flow. The authors note that for the purposes of reducing joint swelling, it is still probably better to use cold therapy.
Sean Mindra MD, CCFP
PGY3 – Sport and Exercise Medicine, University of Ottawa
Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine
We have all heard of compartment syndrome. This is a medical emergency where increased pressures within a compartment can lead to rapid ischemia, muscle damage, and even potential amputation after a trauma or injury.
How many of us have heard of chronic exertional compartment syndrome (CECS)?
CECS is a cause of chronic exertional leg pain. Most often seen in young runners and elite athletes, it is a relatively unknown and underdiagnosed condition. Its incidence and pathophysiology are not well understood. One theory suggests a noncompliant fascia that cannot accommodate the expansion of muscle volume during exercise, causing increased intracompartmental pressures.
Suspect CECS with athletes who present with chronic anterior/lateral leg pain that worsens with prolonged use and resolves shortly upon cessation of activity. Most cases will occur in the anterior or lateral compartments. Classically, these athletes will be able to tell you that a specific time, distance, or intensity will bring on the symptoms, characterized as burning, aching, cramping, or pressure. It usually resolves fairly shortly if they stop the activity unless they continue to push through the symptoms for longer durations. It is fairly common to be bilateral. They may have some numbness/tingling in the dermatomal distribution of the nerve that runs through the compartment and weakness of those muscle groups.
Physical exam is often normal at rest. Some people will have visible painless fascial herniations. On physical exam immediately after exercise, there may be pain on palpation of the muscles involved, pain with passive stretching of the muscles, and the compartments may be quite firm. No imaging is necessary but will commonly be done to rule out other diagnoses such as a stress fracture. The diagnosis of CECS can be made clinically but given its non-specific nature, it can be confirmed using immediate post-exercise intracompartmental pressure testing. If confirmed, a surgeon may be consulted for an ELECTIVE fasciotomy.
The differential diagnosis includes medial tibial stress syndrome (shin splints), stress fractures, fascial defects, nerve entrapment syndromes, popliteal artery entrapment syndrome, and vascular or neurogenic claudication.
It is important to note that shin splints present with pain on the medial border of the tibia. Shin splints are NEVER lateral! A high level of suspicion is required for the diagnosis of ant/lat CECS as all imaging will be reported as normal.
While uncomfortable, there is no evidence to suggest that the pain from CECS indicates any muscle damage or has long-lasting implications. Modified activity is a reasonable treatment option. People may choose to avoid continuous running and opt to bike, swim, skate or play shorter shifts. Hopefully, this brief introduction sheds some light on the subject.
Jim Niu MD, CCFP
Sport and Exercise Medicine Fellow, University of Ottawa
Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med
Kien V. Trinh, Dion Diep, Hannah Robson
Clinical Journal of Sport Medicine, Volume 28, No. 4, July 2018
Currently, many sporting organizations including the International Olympic Committee (IOC) prohibit the use of any substance that has an ergogenic (performance enhancing) effect, poses a risk to the use of the user’s health and safety, or violates the spirit of sport. The legalization of marijuana in Canada is tentatively set for October 2018, which may increase the use and normalization of the drug. Thus, it is vital that primary care physicians remain up to date regarding the rules and regulations surrounding marijuana use, as well as its effects on users. Much of the literature points to marijuana being more of an ergolytic drug, where it impairs rather than improves one’s physical performance, stamina, or recovery. Despite patient beliefs that that marijuana use can improve their performance, it’s ergogenic potential remains poorly understood. The purpose of this study was to determine the effects of marijuana on athletic performance.
This systematic review included any primary study of any design of any clinically or laboratory-relevant outcomes on athletic performance. Studies included both male and female participants of any athletic background, between the ages of 18 and 65 with no other comorbid conditions. All studies used marijuana cigarettes for the intervention group and all studies utilized a control group (participants that were not given marijuana cigarettes). Vital signs, pulmonary measures, physical work capacity, grip strength, and exercise duration were chosen to be relevant outcomes. After identifying and screening 929 citation postings, only 3 trials met the inclusion criteria.
The effects of marijuana on heart rate, blood pressure and exercise duration remains unclear. Low-quality evidence exists for marijuana having an ergogenic on effect on exercise by inducing bronchodilation and increasing FEV1 after exercise compared to inactive controls. There was no significant difference in grip strength between treatment, sham and inactive control groups. Additionally, there is low-quality evidence that suggests marijuana use is associated with decreased physical work capacity compared with sham and inactive control groups.
There are several limitations to this study. Firstly, there were only 3 trials (one observational, one crossover, and one crossover randomized control trial) that met the inclusion criteria. When comparing these 3 trials, clear heterogeneity is noted between study type, intervention, and outcomes. Thus, no meta-analyses were performed. Furthermore, despite various available forms of consumption (e.g. edible, vaporization, tinctures, oils), all studies only assessed smoked marijuana as their treatment. There is a clear paucity of current research on marijuana and its effects on athletic performance. The banning of substances in competition is a highly debated and ever-changing field. With its legalization in Canada looming, further research is warranted on marijuana and its effect on athletic performance to help investigate and justify current and future doping policy.
Sean Mindra, MD, CCFP
PGY3 – Sport and Exercise Medicine, University of Ottawa
Advisor: Dr. Taryn Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine
Groin pain in both the recreational and elite athlete can be challenging to evaluate and treat, especially in the primary care setting. This systematic review was done to uncover the most prevalent surgical aetiologies, characterize the susceptible patient profiles, and discuss treatment. This review involved 73 studies (4655 patients) from North America, Asia, Europe and Australia. The age range was from 13-48 yo, with the average age being 27.4 years old.
The objective of this article is to discuss the top 5 aetiologies of hip/groin pain (> 80% of presentations) in the young active population to aid in the diagnosis by primary care physicians with subsequent referral to orthopaedic surgery.
There is equal distribution between intra-articular and extra-articular causes of groin pain.
The most common ethology is Femoral Acetabular impingement, FAI – (32%). 58% are males and the most common sports associated with FAI are ice hockey and soccer. The incidence of a labral tear associated with FAI is 35%. Tests used to diagnosis include palpation and FADIR testing (ant. impingement test). MRI is the most common imaging used to diagnose groin pain (40%). Intra-Articular causes (FAI and labrum) are almost exclusively treated with laparoscopic chondrolabral debridement and repair. Labral tears are the 5th most common cause of groin pain with a prevalence of 5% in this population. It is most commonly seen in hockey, soccer, rowing and tae kwon do. MRI arthrogram and/or 3T MRI should be used to aid in this diagnosis.
The second most common cause of groin pain is athletic pubalgia (sports hernia). Athletic pubalgia (24%) is followed by Adductor related pathology (12%) and inguinal related pathology (10%). All three of these conditions are seen almost exclusively in men (>98%). There was no correlation of the athletic level of the athlete. Soccer is the most common cause of all three of above pathologies, followed by football and hockey. According to this review, the most common (>70%) surgical intervention for athletic pubalgia is open or arthroscopic repair with mesh reinforcement. 70% of adductor related pathology is treated with complete adductor tenotomy and 1% with reattachment. Inguinal hernia related pathology is evenly split between open and laparoscopic repair.
“Overall it is recommended that a consistent physical exam and imaging approach should be determined to diagnosis athletic groin pain, which should consist of, but not limited to, gross palpation, FADIR, FABER, MRI and plain radiograph.”
Of note, in patients where both intra and extra-articular pathology is present, superior outcomes are seen when both are surgically addressed at the same time.
Darren de SA, Per Holmich, Mark Phillips, Sebastian Heaven, Nicole Simunovic. British Journal of Sport Medicine, Oct 3, 2016
Article: The old knee in the young athlete: knowns and unknowns in the return-to-play conversation (Ardern CL, Khan KM, British journal of Sports Medicine November 19, 2015, 10.1136/bjsports-2015-095481.)
Written by: Geneviève Rochette Gratton , MD, CCFP, Fellow in Sport & Exercise Medicine at University of Ottawa
Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine
In Sport Medicine, we found ourselves frequently having to discuss pros and cons of returning to a certain sport after an injury with our athletes. The article recently published by the British journal of Sport Medicine reviews all the aspect that should be included in a return-to-play conversation. As an example, the authors use a young female athlete who recently sustained an ACL rupture playing amateur football.
In order to help the athlete make an informed decision, it is our job as physician to give our patients accurate information, and guide them in making the right decision.
What we know:
- Regardless of treatment choice (surgical vs non-surgical), the athlete is able to achieve remarkable physical function (meeting impairment-based and activity-based measures)
- Likeliness to return to pre-injury level of sport is doubled in 25 years old and younger compared to older athletes. Young athletes have an increased risk (up to 6 times) of re-rupture or new ACL tear when returning to pivoting sports.
- Following an ACL injury, most (up to 90%) will develop symptoms of patellofemoral osteoarthritis or post-traumatic tibiofemoral within 10 to 15 years.
What we don’t know:
- Is the risk of subsequent osteoarthritis increased with return to pivoting sport? Especially knowing that a new insult could accelerate and increase knee osteoarthritic changes.
- Does retirement for pivoting sport reduce the risk of osteoarthritis?
- What is the impact of early retirement or changing sport on the quality of life of the athlete?
In this article, a few recommendations are made in regards to what should be discussed with the athletes to help them make the most informed decision:
- The athletes are in charge of their return-to-play decision. In order to help them, motivational interviewing has proven efficient to help ease the conversation regarding changing, modifying or stopping their sport as well as helping them understand the risk of going back to pivoting sports.
- It is important to share the decision making with the athlete by explaining the pros and cons of the different treatment options, and to help them understand what is reasonable. In combination with motivational interviewing, this can empower the athlete in making an informed decision.
- The context of the athlete needs to be taking into consideration when talking about risks. Salaries, endorsement, athletic identity, level of sport, pressure from piers (coaches, families, teammates…) are some of the factors that should be included.
It is important to remember that being an athlete in a competitive sport does not equal being healthy. As clinician, we should be aware that an athlete perception of treatment success can differ from ours, and we should not let our own biases lead the conversation regarding return-to-play. We should aim toward a shared decision-making approach, also helping the athlete differentiate performing from being healthy in order for him to make the best return-to-play decision.