Sports-specific adaptations and differentiation of the athlete's heart

Although the sports-specific adaptations and differentiation of an athlete's heart (AH) were first described 100 years ago, the condition is still an area of active debate. In clinical practice, there is often an obvious lack of basic knowledge concerning the prerequisites and well established extent of the structural and functional characteristics of an AH. Some misunderstandings arise from the somewhat misleading term 'athlete's heart' because not every athlete, even if he or she is training and competing at a very high level, develops an enlarged heart. Such a condition can only be expected after years of quantitative and qualitative demanding aerobic endurance training. Although the correlation with competitive performance of endurance events is rather low in trained athletes, the relationship between heart dimensions and ergometric performance represents an important criterion for differentiation between physiological and pathological cardiac enlargement. The assessment of measures exceeding the usual clinical limits, especially concerning volume-dependent echocardiographic parameters, also requires consideration of the strong influence of anthropometric data. The existence of a concentric left ventricular hypertrophy (LVH) in strength-trained athletes is still a topic of debate in the literature, but is rejected by most recent well-conducted trials. In our review. only bodybuilders using anabolic steroids exhibited a distinctly higher hypertrophic index compared with all other groups of endurance or strength athletes. Current unsolved issues in clinical sports medicine concern the early detection of myocardial complications in athletes exercising during infectious diseases, and the eligibility for competitive sport in cases of borderline LVH.     

The Scandinavian athlete's heart; echocardiographic characteristics of male professional football players

This investigation explores the cardiac four‐chamber remodeling response to training in male players in Norwegian professional football league, and ethnicity as determinants in the development of athlete's heart. Standard 2D echocardiographic examination and analysis of all four cavities were performed in 504 football players of Caucasian origin, 49 of African origin, and 47 matched Caucasian controls (<3 h training /week). All results were indexed to body surface area (BSA). Most athletes exhibited BSA‐indexed values within normal ranges. Left ventricle (LV) mass was equally enlarged in both groups of athletes, but LV relative wall thickness and right ventricular (RV) relative wall thickness were increased in Africans compared with Caucasian athletes (0.37 ± 0.06 vs 0.33 ± 0.06 and 0.25 ± 0.06 vs 0.22 ± 0.04, respectively). Both LV and RV were smaller in Africans than in Caucasian athletes (67.8 ± 12.0 ml/m² vs 73.6 ± 13.2 ml/m² and 12.8 ± 2.1 vs 13.7 ± 2.4 cm²/m², respectively, both P < 0.05), while left and right atria increased similarly. This first large‐scale echocardiographic survey of elite football players in a Scandinavian league suggests use of BSA‐indexed upper normal limits for both LV and RV in athletes. African athletes had significantly more concentric remodeled LV and RV than the Caucasian athletes.     

Female athlete's heart: Systolic and diastolic function related to circulatory dimensions

There are relatively few studies on female athletes examining cardiac size and function and how these measures relate to maximal oxygen uptake (VO_2max). When determining sports eligibility, it is important to know what physiological adaptations and characteristics may be expected in female athletes, taking body and cardiac size into account. The purposes of this study were (a) to compare right and left heart dimensions and function in female endurance athletes (ATH) and in non‐athletic female controls of similar age (CON); and (b) to explore how these measures related to VO_2max. Forty‐six ATH and 48 CON underwent a maximal bicycle exercise test and an echocardiographic examination at rest, including standard and color tissue Doppler investigation. All heart dimensions indexed for body size were larger in ATH (all P < 0.01). The diastolic mitral E/A ratio was 27% higher in ATH (P < 0.001) while systolic left and right atrio‐ventricular longitudinal displacement was 7% (P = 0.002) and 15% (P < 0.001) larger in ATH, respectively. Half (50.3%) of the variability in VO_2max could be explained by left ventricular end‐diastolic volume. Our results could be useful in evaluating female endurance athletes with suspected cardiac disease and contribute to understanding differences between female athletes and non‐athletes.     

The young athlete's knee: recent advances

The understanding and treatment of the young athlete's knee has improved and continues to do so as arthroscopy and good long-term follow-up studies guide the process. In the management of epiphyseal fractures about the knee the presence of associated ligament injury and the high likelihood of a growth plate injury is now well documented. In the management of ligament injuries and internal derangements, arthroscopy has profoundly changed diagnosis and treatment. Pathology can be precisely identified and the appropriate treatment initiated to preserve an athletic career and possibly prevent degenerative arthritis in adulthood. Lastly, patellofemoral pain continues to be a difficult problem to treat, but a more scientific approach is evolving. This has been facilitated by a better understanding of the varied etiologies for anterior knee pain, and a trend away from classifying all such conditions as chondromalacia.     

Physiological cyclic variation of the myocardial integrated backscatter signal in athlete's heart

BACKGROUND: Left ventricular hypertrophy which realizes in athlete's heart could create some problems of acoustic reflection related to the increase of myocytic and not-myocytic elements of the heart. The aim of the present study was to analyze the ultrasonic backscatter myocardial indexes both as peak end-diastolic signal intensity and as its cardiac-cyclic variation in athlete's heart, compared to healthy sedentary controls. METHODS: Two groups of ten subjects each, all males of mean age (31.6+/-3.5), and of comparable weight and height were analyzed: group (A) comprised ten cyclists of good professional level and group (C) included ten healthy subjects acting as controls. A 2D-color Doppler echocardiography with a digital echograph Agilent Technologies (AT) Sonos 5500 was carried out on all subjects in the study for the conventional analysis of the left ventricular mass and function. The ultrasonic myocardial integrated backscatter signal (IBS) was analyzed with an "Acoustic Densitometry" module implemented on an AT echograph. The signal was also sampled with a R.O.I. placed at interventricular septum and at posterior left ventricular wall level. The systo-diastolic variation of the backscatter was also considered as Cyclic Variation Index (CVIibs). RESULTS: The left ventricular mass was significantly higher in athletes in comparison with controls (LVMbs: A: 154.5+/-18.7; C: 101.4+/-12.4; p<0.001). The end diastolic IBS signal did not show significant statistical differences between the two groups. The CVIibs both at septum (A: 30.5+/-5.3; C: 27.2+/-7.3; p<0.002) and posterior wall level (A: 43.7+/-9.1; C: 40.7+/-9.1; p<0.001) though was comparable in both groups. CONCLUSION: The conclusions reached in the present study confirmed the physiology of the left ventricular hypertrophy of the athlete's heart evaluated with an ultrasonic integrated backscatter tissue characterization, in particular through the cyclic variation of integrated backscatter myocardial signal. This finding is probably the expression of a preserved intramural myocardial function in the athlete's heart despite the increase of left ventricular mass induced by physical training.     

Physical examination of the athlete's elbow

Elbow injury is encountered less frequently than are other joint conditions. The bony architecture, muscle, ligament, and nerve anatomy are complex, and the forces leading to injury in the athlete's elbow are unique. Appreciating the pathomechanics leading to injury and a detailed knowledge of elbow anatomy are the foundation for conducting a directed history and physical examination that achieves an accurate diagnosis. Recent advances in physical examination have improved our ability to accurately diagnose and treat athletic elbow disorders. This article reviews general and focused physical examination maneuvers of the elbow in a systematic anatomic fashion.     

Physical examination of the overhead athlete's shoulder

Overhead athletes seek the services of an orthopedic surgeon because of pain and/or dysfunction. It is important to address the cause of the symptoms more so than the source of the patient's pain, so that treatment will eliminate the problem rather than merely ameliorate symptoms temporarily. In order to accomplish a thorough assessment of shoulder function, the examiner must expand his/her view from isolated assessment of the glenohumeral joint range of motion, stability, assessment of rotator cuff strength, palpation and provocative maneuvers, and add assessment of the shoulder in the context of the kinetic chain. The examination of the thrower's shoulder, coupled with a thorough history, will usually provide a solid functional diagnosis and provide a good idea as to the presence of structural damage. As a result, the value of rehabilitation and the benefit of surgical intervention are made more predictable.     

Magnetic resonance imaging of athlete's heart: myocardial mass, left ventricular function, and cross-sectional area of the coronary arteries

To evaluate left ventricular myocardial mass and function as well as ostial coronary artery cross-sectional area in endurance athletes, an athlete group of 12 highly trained rowers and a control group of 12 sedentary healthy subjects underwent MR examination. An ECG-gated breath-hold cine gradient-echo sequence was used to calculate myocardial mass, end-diastolic and end-systolic volumes, stroke volume, and cardiac output, all related to body surface area, as well as ejection fraction. A 3D fat-saturated ECG- and respiratory-triggered navigator echo sequence was used to evaluate coronary arteries: left main (LM), left anterior descending (LAD), left circumflex (LCx), and right coronary artery (RCA). Cross-sectional area was calculated and divided for body surface area. Myocardial mass was found significantly larger in athlete group than in control group (p = 0.0078), the same being for end-diastolic volume (p = 0.0078), stroke volume (p = 0.0055), LM (p = 0.0066) and LAD (p = 0.0129). No significant difference was found for all the remaining parameters. Significant correlation with myocardial mass was found for LM (p < 0.001) and LAD (p = 0.0340), not for LCx and RCA. Magnetic resonance imaging is a useful tool in evaluating the myocardial hypertrophy and function of athlete's heart. Magnetic resonance angiography is a valuable noninvasive method to visualize the correlated cross-sectional area increase of the left coronary artery system. Received: 25 March 1999; Revised: 31 August 1999; Accepted: 1 September 1999     

Arthroscopic evaluation of the injured athlete's knee

In summary, arthroscopic evaluation of the athlete's knee joint provides a highly accurate means of diagnosing intra-articular lesions. It provides valuable information regarding treatment and prognosis. In addition, if arthroscopic surgical treatment is possible, even greater benefits in regard to more rapid return to full athletic activity will be possible.     

Spiral imaging: a critical appraisal

In view of recent applications in cardiovascular and functional brain imaging, this work revisits the basic performance characteristics of spiral imaging in direct comparison to echo-planar imaging (EPI) and conventional rapid gradient-echo imaging. Using both computer simulations and experiments on phantoms and human subjects at 2.9 T, the study emphasizes single-shot applications and addresses the design of a suitable trajectory, the choice of a gridding algorithm, and the sensitivity to experimental inadequacies. As a general result, the combination of a spiral trajectory with regridding of the k-space data poses no principle obstacle for high-quality imaging. On the other hand, experimental difficulties such as gradient deviations, resonance offset contributions, and concomitant field effects cause more pronounced and even less acceptable image artifacts than usually obtained for EPI. Moreover, when ignoring parallel imaging strategies that are also applicable to EPI, improvements of image quality via reduced acquisition periods are only achievable by interleaved multishot spirals because partial Fourier sampling and rectangular fields of view (FOVs) cannot be exploited for non-Cartesian trajectories. Taken together, while spiral imaging may find its niche applications, most high-speed imaging needs are more easily served by EPI.     

Effects of creatine use on the athlete's kidney

With regard to athletes attempting to improve their performance, at the present time creatine monohydrate is clearly the most widely used dietary supplement or ergogenic aid. Loading doses as high as 20 g/d are typical among athletes. The majority (> 90%) of the creatine ingested is removed from the plasma by the kidney and excreted in the urine. Despite relatively few isolated reports of renal dysfunction in persons taking creatine, the studies completed to date suggest that in normal healthy individuals the kidneys are able to excrete creatine, and its end product creatinine, in a manner that does not adversely alter renal function. This situation would be predicted to be different in persons with impaired glomerular filtration or inherent renal disease. The question of whether long-term creatine supplementation (ie, months to years) has any deleterious affects on renal structure or function can not be answered at this time. The limited number of studies that have addressed the issue of the chronic use of creatine have not seen remarkable changes in renal function. However, physicians should be aware that the safety of long-term creatine supplementation, in regard to the effects on the kidneys, cannot be guaranteed. More information is needed on possible changes in blood pressure, protein/albumin excretion, and glomerular filtration in athletes who are habitual users of this compound.     

Screening the athlete's shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology

Chronic shoulder pain and dysfunction are common complaints among overhead athletes seeking care from physical medicine and rehabilitation. Impingement is a frequently described pathological condition in the overhead athlete. Impingement symptoms may be the result of rotator cuff pathology, shoulder instability, scapular dyskinesis or muscle dysfunction, biceps pathology, SLAP lesions and chronic stiffness of the posterior capsule. At present, numerous different shoulder tests have been described in literature and discussed with respect to their individual diagnostic accuracy. However, in view of the number of shoulder tests, it is often a challenge for the clinician to select the appropriate tests for diagnosing the underlying pathology. The purpose of this paper is to present and discuss a clinical algorithm which may be used in the early detection of the underlying causes of impingement symptoms. In this algorithm, a specific chronology and selection of diagnostic tests may offer the clinician a guideline in his physical examination of the athlete with shoulder pain.     

The skull and cervical spine radiographs of Tutankhamen: a critical appraisal

BACKGROUND AND PURPOSE: Tutankhamen, the last pharaoh of the XVIIIth dynasty, died unexpectedly at approximately age 18 years. A cause of death has never been established, but theories that the young king was murdered by a blow to the head have been proposed based on skull radiographs obtained by a team from the University of Liverpool in 1968. We recently had the opportunity to evaluate the skull and cervical spine radiographs of Tutankhamen. The purpose of this study was to report our critical appraisal of the radiographs of Tutankhamen regarding the findings alleged to indicate traumatic death. METHODS: Copies of lateral, anteroposterior, and submental vertex skull radiographs of Tutankhamen were reviewed with special attention to the claims of a depressed skull fracture, intracranial bone fragments, and calcified membrane of a posterior fossa subdural hematoma. A phantom skull was radiographed to reproduce the appearance of the floor of the posterior fossa in the lateral projection. RESULTS: The skull radiographs of Tutankhamen show only postmortem artifacts that are explainable by an understanding of the methods of mummy preservation used at the time of his death. Some findings also relate to trauma inflicted by an autopsy performed in 1925. The alleged calcified membrane of a posterior fossa subdural hematoma is easily reproduced with a skull phantom. CONCLUSION: Our critical review of the skull and cervical spine radiographs of Tutankhamen does not support proposed theories of a traumatic or homicidal death.