Imaging of muscle injury in the elite athlete

Injuries to muscle in the elite athlete are common and may be responsible for prolonged periods of loss of competitive activity. The implications for the athlete and his/her coach and team may be catastrophic if the injury occurs at a critical time in the athlete's diary. Imaging now plays a crucial role in diagnosis, prognostication and management of athletes with muscle injuries. This article discusses the methods available to clinicians and radiologists that are used to assess skeletal muscle injury. The spectrum of muscle injuries sustained in the elite athlete population is both discussed and illustrated.     

Bilateral simultaneous rupture of the infrapatellar tendon in a recreational athlete. A case report

Bilateral rupture of the infrapatellar tendons is a rare event in an otherwise healthy athletic individual. The event is usually quite severe and diagnosis can be readily made on a clinical examination. In the case presented here, predisposing factors consisted of an underlying patella alta and a long history of repetitive trauma to the knee. Prompt diagnosis and surgical repair will lead to a good functional result.     

Achilles tendon rupture in an elite athlete following multiple injection therapies

Achilles tendinopathy is common, and its management continues to be challenging, especially in elite athletes. Despite a wide range of novel management options, none guarantees a rapid return to high level sporting activity. Eccentric exercise has been shown to reduce symptoms and normalise imaging abnormalities, but time constraints on professional athletes often make this an unrewarding isolated management strategy. Eccentric exercises concurrent with ongoing training may not be as successful as eccentric training alone, reducing one's confidence in this modality for the “in-season” tendinopathy in the elite athlete. When a professional athlete is faced with a tendinopathy recalcitrant to eccentric exercise, manual therapy and orthotics, a more invasive approach is often attempted to expedite a return to unencumbered training. Numerous injection therapies are described, ranging from homeopathic products to glucocorticosteroids. The robustness of the literature surrounding these techniques is variable, but when an athlete is desperate to return to full training, clinicians working with elite athletes are often tempted to utilise more empirical management options. We present a patient who illustrates the potential dangers of injection therapy in the elite athlete, in particular sequential injection therapy involving vascular sclerosants, which to our knowledge has not previously been described. Written consent for the presentation of this case was obtained from the athlete concerned.     

Exercise-induced bronchospasm in the elite athlete

The term exercise-induced bronchospasm (EIB) describes the acute transient airway narrowing that occurs during and most often after exercise in 10 to 50% of elite athletes, depending upon the sport examined. Although multiple factors are unquestionably involved in the EIB response, airway drying caused by a high exercise-ventilation rate is primary in most cases. The severity of this reaction reflects the allergic predisposition of the athlete, the water content of the inspired air, the type and concentration of air pollutants inspired, and the intensity (or ventilation rate) of the exercise. The highest prevalence of EIB is seen in winter-sport populations, where athletes are chronically exposed to cold dry air and/or environmental pollutants found in indoor ice arenas. When airway surface liquid lost during the natural warming and humidification process of respiration is not replenished at a rate equal to the loss, the ensuing osmolarity change stimulates the release of inflammatory mediators and results in bronchospasm; this cascade of events is exacerbated by airway inflammation and airway remodelling. The acute EIB response is characterised by airway smooth muscle contraction, membrane swelling, and/or mucus plug formation. Evidence suggests that histamine, leukotrienes and prostanoids are likely mediators for this response. Although the presence of symptoms and a basic physical examination are marginally effective, objective measures of lung function should be used for accurate and reliable diagnosis of EIB. Diagnosis should include baseline spirometry, followed by an appropriate bronchial provocation test. To date, the best test to confirm EIB may simply be standard pulmonary function testing before and after high-intensity dry air exercise. A 10% post-challenge fall in forced expiratory volume in 1 second is used as diagnostic criteria. The goal of medical intervention is to limit EIB exacerbation and allow the athlete to train and compete symptom free. This is attempted through daily controller medications such as inhaled corticosteroids or by the prophylactic use of medications before exercise. In many cases, EIB is difficult to control. These and other data suggest that EIB in the elite athlete is in contrast with classic asthma.     

Effort thrombosis in the elite throwing athlete

BACKGROUND: Upper extremity vascular injuries are uncommon in the elite throwing athlete. However, the extreme stresses that are placed on the upper extremity of elite baseball players, especially pitchers, puts them at risk for such injuries. One such injury is upper extremity venous thrombosis or "effort thrombosis." PURPOSE: We wanted to review the common initial clinical symptoms and physical examination findings of effort thrombosis in elite baseball players and to review the associated clinical conditions such as hypercoagulable states and pulmonary embolism. STUDY DESIGN: Retrospective review of a series of cases. METHODS: A retrospective review of the medical records of a Major League Baseball organization and a Division I college was performed for the period 1987 to 1997. RESULTS: We located four cases of effort thrombosis involving elite baseball players. Contrast venography was used to confirm the diagnosis in all cases. All patients were successfully treated with transluminal catheter-directed urokinase thrombolysis followed by first rib resection and systemic anticoagulant therapy for up to 3 months. All four players returned to play at or above their previous level of competition with no long-term chronic sequelae. CONCLUSIONS: Prompt clinical recognition, diagnosis, and treatment of effort thrombosis in the elite baseball player provides the player with an excellent prognosis for return to the previous level of play.     

Hodgkin's Lymphoma in an elite endurance athlete

Cancer is a life-threatening condition. We describe the case of a 22-yr-old world-class endurance athlete who presented with mild local lymphadenopathy but without any systemic complaints or impaired performance. He was subsequently diagnosed with stage III A (S) Hodgkin's lymphoma. A complete physiological workup before the diagnosis revealed high aerobic capacity. Immediately after six courses of escalated BEACOPP chemotherapy in an identical test setting, aerobic capacity was markedly reduced (-42%), mainly because of a decrease in total hemoglobin mass (-37%), despite maintaining a certain amount of endurance training. Other potentially performance-limiting systems such as heart, lung, or aerobic metabolism did not show any signs of impairment. Two months after chemotherapy, the athlete had recovered his hemoglobin mass, and his aerobic performance was almost back to pretherapy levels. This case illustrates that advanced malignancies can be present in elite athletes without affecting performance, and that aerobic capacity can be regained within a short time after systemic chemotherapy.     

Self-reported symptoms and exercise-induced asthma in the elite athlete

PURPOSE: The purpose of this study was to compare self-reported symptoms for exercise-induced asthma (EIA) to postexercise challenge pulmonary function test results in elite athletes. METHODS: Elite athletes (N = 158; 83 men and 75 women; age: 22 +/- 4.4 yr) performed pre- and post-exercise spirometry and were grouped according to postexercise pulmonary function decrements (PFT-positive, PFT-borderline, and PFT-normal for EIA). Before the sport/environment specific exercise challenge, subjects completed an EIA symptoms-specific questionnaire. RESULTS: Resting FEV1 values were above predicted values (114--121%) and not different between groups. Twenty-six percent of the study population demonstrated >10% postexercise drop in FEV1 and 29% reported two or more symptoms. However, the proportion of PFT-positive and PFT-normal athletes reporting two or more symptoms was not different (39% vs. 41%). Postrace cough was the most reported symptom, reported significantly more frequently for PFT-positive athletes (P < 0.05). Sensitivity/specificity analysis demonstrated a lack of effectiveness of self-reported symptoms to identify PFT-positive or exclude PFT-normal athletes. Postexercise lower limit reference ranges (MN-2SDs) were determined from normal athletes for FEV1, FEF25--75% and PEF to be -7%, -12.5%, and -18%, respectively. CONCLUSION: Although questionnaires provide reasonable estimates of EIA prevalence among elite cold-weather athletes, the use of self-reported symptoms for EIA diagnosis in this population will likely yield high frequencies of both false positive and false negative results. Diagnosis should include spirometry using an exercise/environment specific challenge in combination with the athlete's history of asthma symptoms.     

Tear of the acetabular labrum in an elite athlete

The case is reported of a professional footballer with a tear of the acetabular labrum. The clinical findings, treatment, and rehabilitation are described as well as a discussion of the difficulties of diagnosis.     

Fibroma of tendon sheath of the infrapatellar fat pad

We report on a 13-year-old boy who was found to have a fibroma of the tendon sheath associated with the patellar tendon and within Hoffa’s fat pad of the knee. This benign tumor has never been described in this location previously. The MRI characteristics are correlated with the histologic findings. Received: 20 November 1998 Revision requested: 17 December 1998 Revision received: 16 February 1999 Accepted: 19 February 1999     

The prevalence of spondylolysis in the Spanish elite athlete

The diagnosis of spondylolysis is a major cause of concern for patients and their families, especially when the patients are young athletes with promising futures in their sports. In this study, 3152 case histories of high-level athletes were evaluated to determine which sports had a higher prevalence of spondylolysis. The overall percentage of spondylolysis among athletes in this study (8.02%) was not very much higher than that among the general population, which varies between 3% and 7%. However, when each sport was considered separately we found much higher values for some sports, with the highest percentages occurring in throwing sports (26.67%), artistic gymnastics (16.96%), and rowing (16.88%). The analysis of the biomechanical movements involved in the sports with greater prevalence of spondylolysis has led us to include the element of torsion against resistance as another possible causative factor for spondylolysis that should be added to the already known causative mechanisms, lumbar hyperextension and rotation. We have divided the sports into three risk groups according to the prevalence of spondylolysis shown and the characteristics of the sample, and we recommend systematic radiological examination of the lumbar spine in athletes considered to be at greater risk of developing spondylolysis.     

Imaging of cartilage in the athlete

Since the development of radiography, we have been able to visualize the osseous alterations related to arthritis. These include productive changes, such as osteophyte formation, sclerosis, and buttressing, as well as erosive changes and subchondral cyst formation. However, because cartilage is radiolucent, it is not directly visible by either radiography or computed tomography. With careful attention to technique, both hyaline and fibrocartilage can be visualized by magnetic resonance imaging.     

Infection and the elite athlete: a review

Light to moderate exercise has been associated with an increase in immune function and reduced risk of infectious diseases. Conversely, heavy exercise has been implicated in suppression of many immune parameters and a concomitant increased risk of infectious diseases. Infections can result in lost training time and negatively affect the performance of the elite athlete. Exercising during an infection can also increase the risk of secondary complications, such as viral myocarditis and post-viral fatigue syndrome. In addition to immunosuppression, other factors responsible for increased infection rates among athletes are close bodily contact with other people during training and competition, and environmental factors during the pursuit of sporting activities that increase exposure to pathogens. Although there is a generally higher risk of infection among athletes compared to the general population, some sports are associated with a particularly high risk for certain infections. These are skin infections in rugby and wrestling, infections of the foot in long-distance runners, and ear infections in those involved in water sports. Upper respiratory tract infections are the most frequently reported disability among all athletes and are the cause of more lost training days than all other infections put together. Transmission of blood-borne pathogens, although very uncommon in the athletic setting, are the cause of the most serious infections an athlete may develop. When considering the negative impact of infections on performance, it seems prudent that athletes use interventions to decrease the immunosuppressive effects of heavy exercise, and to minimize exposure to pathogens as far as practically possible. Management of the infected athlete is especially important if there is to be a speedy return to full training, and if the incidence of a relapse or secondary complications are to be minimized.     

Osteoporotic fracture in an elite male Kenyan athlete

An elite Kenyan runner presented with a tibial fracture sustained during an international cross-country race. There was no clear history of symptoms suggestive of preceding overload and no radiological features of stress fracture. He was found to have sustained an osteoporotic, insufficiency fracture. There are no previous case reports of an osteoporotic fracture in a male athlete. Possible aetiologies and directions for future investigation are presented.     

Acute os styloideum injury in an elite athlete

The os styloideum, an accessory carpal bone, may suffer injury during traumatic wrist flexion. The case described corresponds to an acute os styloideum injury in an elite athlete; a diagnosis made using high-resolution computed tomography and magnetic resonance imaging permitted not only the identification of the anomaly and associated abnormalities but also ruled out more significant injury to the extensor carpi radialis brevis.     

Fibroma of tendon sheath of the infrapatellar fat pad in the knee

A 69-year-old patient with unexplained pain of the right knee reported no prior trauma. A soft tissue tumor was identified using magnetic resonance imaging (MRI). The tumor showed low signal intensity on T1-weighted images, high signal intensity on T2, and peripheral enhancement on gadolinium-enhanced MRI. Perioperative observation revealed that the tumor was partly adhesive to the anterior knee joint capsule, but not to the patellar tendon.     

MtDNA haplogroups and elite Korean athlete status

Mitochondrial DNA (mtDNA) variation has recently been suggested to have an association with athletic performance or physical endurance. Since mtDNA is haploid and lacks recombination, specific mutations in the mtDNA genome associated with human exercise tolerance or intolerance arise and remain in particular genetic backgrounds referred to as haplogroups. To assess the possible contribution of mtDNA haplogroup-specific variants to differences in elite athletic performance, we performed a population-based study of 152 Korean elite athletes [77 sprint/power athletes (SPA) and 75 endurance/middle-power athletes (EMA)] and 265 non-athletic controls (CON). The overall haplogroup distribution of EMA differed significantly from CON (p<0.01), but that of SPA did not. The EMA have an excess of haplogroups M* (OR 4.38, 95% CI 1.63-11.79, p=0.003) and N9 (OR 2.32, 95% CI 0.92-5.81, p=0.042), but a dearth of haplogroup B (OR 0.26, 95% CI 0.09-0.75, p=0.003) compared with the CON. Thus, our data imply that specific mtDNA lineages may provide a significant effect on elite Korean endurance status, although functional studies with larger sample sizes are necessary to further substantiate these findings.     

Bilateral infrapatellar tendon rupture in a patient with jumper's knee

This is the fourth case report of bilateral infrapatellar tendon rupture as a result of indirect trauma in a patient without systemic disease. This is the only report we have found of jumper's knee leading to simultaneous infrapatellar tendon ruptures.     

Imaging of stress fractures in the athlete

Osseous stress fractures and stress reactions represent the effect of abnormal repetitive stress on normal bone. An accurate and thorough clinical history and sequential radiographs often suffice 40 make the diagnosis especially when the fracture occurs in one of the common locations, such as the tibia, metatarsals, or calcaneus. In cases that are atypical in location or clinical presentation the authors rely more on MR imaging, radionuclide bone scanning, and occasionally CT. MR imaging detects early changes of osseous stress injury and allows precise definition of anatomy and extent of injury, and is the preferred modality for evaluating the continuum of osseous manifestations of stress injury. MR imaging is useful in evaluating shin splints, early osseous stress injuries, and overt stress fracture. In the elite athlete prompt diagnosis and early rehabilitation are the goals.