Cardiac tissue Doppler imaging in sports medicine

The differentiation of training-induced cardiac adaptations from pathological conditions is a key issue in sports cardiology. As morphological features do not allow for a clear delineation of early stages of relevant pathologies, the echocardiographic evaluation of left ventricular function is the technique of first choice in this regard.Tissue Doppler imaging (TDI) is a relatively recent method for the assessment of cardiac function that provides direct, local measurements of myocardial velocities throughout the cardiac cycle. Although it has shown a superior sensitivity in the detection of ventricular dysfunction in clinical and experimental studies, its application in sports medicine is still rare. Besides technical factors, this may be due to a lack in consensus on the characteristics of ventricular function in relevant conditions.For more than two decades there has been an ongoing debate on the existence of a supernormal left ventricular function in athlete's heart. While results from traditional echocardiography are conflicting, TDI studies established an improved diastolic function in endurance-trained athletes with athlete's heart compared with controls.The influence of anabolic steroids on cardiac function also has been investigated by standard echocardiographic techniques with inconsistent results. The only TDI study dealing with this topic demonstrated a significantly impaired diastolic function in bodybuilders with long-term abuse of anabolic steroids compared with strength-trained athletes without abuse of anabolic steroids and controls, respectively.Hypertrophic cardiomyopathy is the most frequent cause of sudden death in young athletes. However, in its early stages, it is difficult to distinguish from athlete's heart. By means of TDI, ventricular dysfunction in hypertrophic cardiomyopathy can be disclosed even before the development of left ventricular hypertrophy. Also, a differentiation of left ventricular hypertrophy due to hypertrophic cardiomyopathy or systemic hypertension is possible by TDI.Besides the evaluation of different forms of left ventricular hypertrophy, the diagnosis of myocarditis is also of particular importance in athletes. Today, it still requires myocardial biopsy. The analysis of focal disturbances in myocardial velocities might be a promising non-invasive method; however, systematic validation studies are lacking.An important future issue for the implementation of TDI into routine examination will be the standardisation of procedures and the establishment of significant reference values for the above-mentioned conditions. Innovative TDI parameters also merit further investigation.     

Three-phase radionuclide bone imaging in sports medicine

Three-phase radionuclide bone (TPB) imaging was performed on 238 patients with sports-related injuries. A wide variety of lesions was encountered, but the most frequent lesions seen were stress fractures of the lower part of the leg at the junction of the middle and distal thirds of the posterior tibial cortex (42 of 79 lesions). There were no differences in the type, location, or distribution of lesions between males and females or between competitive and noncompetitive athletes. In 110 cases, bone stress lesions were often diagnosed when radiographs were normal, whereas subacute or chronic soft-tissue abnormalities had few specific scintigraphic features. TPB imaging provides significant early diagnostic information about bone stress lesions. Normal examination results (53 cases) exclude underlying osseous pathologic conditions.     

MR imaging of lymphomas: impact on therapy

Seventy-six patients with either Hodgkin disease or non-Hodgkin lymphoma underwent magnetic resonance (MR) imaging as part of their evaluation. In this report the unique and common MR findings of these neoplasms are reviewed in each of the major anatomic sites. Further, the impact of these findings on therapy decisions and follow-up is emphasized.     

The unique ethics of sports medicine

The ethical code by which physicians traditionally conduct themselves is based on the relationship between the physician and the patient: both work toward the goal of improving or maintaining health. Constraints on this relationship may be behaviors of patient choice (tobacco use, excessive alcohol use, sedentary behavior, and so on). The athlete-physician relationship is ethically different. Influences such as the physician's employer, the athlete's desire to play with pain and injury, and the economic consequences of playing or not complicate medical decisions. This perspective suggests something different and even unique about the ethics of the sports medicine practitioner. This article explores the differences fostering the ethical tight ropes that sports physicians walk in their sports medicine practices.     

Acupuncture in sports medicine

Conclusions Acupuncture is a minimally invasive, relatively safe medical procedure that appears to have complex effects on the central and peripheral nervous system, immune system, and pain perception. Although acupuncture should not supplant the role of conventional therapies such as rehabilitation to treat these conditions, it is a useful adjunct to treat pain, which can inhibit muscular contraction, interfering with rehabilitation and athletic performance. It is also useful for treatment of chronic conditions that fail to respond to more conventional therapies. Although recent studies are of higher quality, problems remain in the design and interpretation of acupuncture research. Larger, better-controlled studies are needed to determine the effectiveness of acupuncture compared with more conventional treatments.     

Ethics in sports medicine

Physicians have struggled with the medical ramifications of athletic competition since ancient Greece, where rational medicine and organized athletics originated. Historically, the relationship between sport and medicine was adversarial because of conflicts between health and sport. However, modern sports medicine has emerged with the goal of improving performance and preventing injury, and the concept of the "team physician" has become an integral part of athletic culture. With this distinction come unique ethical challenges because the customary ethical norms for most forms of clinical practice, such as confidentiality and patient autonomy, cannot be translated easily into sports medicine. The particular areas of medical ethics that present unique challenges in sports medicine are informed consent, third parties, advertising, confidentiality, drug use, and innovative technology. Unfortunately, there is no widely accepted code of sports medicine ethics that adequately addresses these issues.     

Ultrasound in sports medicine

The accuracy of sonography in evaluating various conditions of the musculoskeletal system has been demonstrated and its utility as a primary diagnostic imaging modality in the musculoskeletal system in the United States has been increasing in frequency. Sonography is universally tolerated across a broad patient population, including pediatric and pregnant patients and those in whom traditional magnetic resonance (MR) imaging is not an option, due either to absolute or relative contraindications. Sonographic examinations are relatively quick compared with an MR or computed tomographic study, and delays in scheduling are therefore minimal, an advantage for those patients who have traveled a long distance or who are in a considerable amount of discomfort at the time of their visit to the orthopedic surgeon. With portable ultrasound units, examinations can be performed on the playing field, immediately at the time of the acute injury, for rapid diagnosis. Lastly, ultrasound can be used to guide for therapeutic procedures at the same time the diagnostic exam is performed.     

Reticulocytes in sports medicine

Reticulocytes are the transitional cells from erythroblasts to mature erythrocytes. Reticulocytes are present in blood for a period of 1-4 days and can be recognized by staining with supravital dyes, such as new methylene blue, or fluorescent markers, which couple residual nucleic acid molecules, a hallmark of the immature forms of erythrocytes. Although reticulocytes could be counted through a microscope (there is a standard of International Committee for Standardisation in Haematology for manual counting), this method is reported to be time consuming, inaccurate and imprecise. The integration of the reticulocyte count in automated haematology systems allowed the widespread use of these parameters, although the lack of calibration material and different markers, technologies and software used in automated systems could engender discrepancies among data obtained from different analytical systems.The importance of reticulocytes in sports medicine derives from their sensitivity, the highest among haematology parameters, in identifying the bone marrow stimulation, especially when recombinant human erythropoietin is fraudulently used. Automated systems are also able to supply information on volume, density and the haemoglobin content of reticulocytes.Some of the related parameters are also used in algorithms for identifying abnormal stimulation of bone marrow as reticulocytes haematocrit. The pre-analytical variability of reticulocytes (transportation, storage, biological variability) should be taken into account in sports medicine also. Reticulocytes remain stable for almost 24 hours at 4 degrees C from blood drawing, they are affected by transportation, and biological variability is not high in general. It could be remarked, however, that the intra-individual variability is high when compared with other haematological parameters such as haemoglobin and haematocrit. The intervals of data reported in athletes are very similar to reference intervals characterizing the general population.The reticulocyte count shows some modifications after training and during the competition season. The variability induced by exercise cannot be overlooked since the so-called haematological passport, a personal athlete's document in which haemoglobin and other parameters are registered, may be introduced by sports federations. Exposure to naturally high altitude and 'living high-training low' programmes determined contentious results on reticulocytes. Simulated high altitude induced by intermittent hypobaric hypoxia does not modify reticulocytes, despite an increase in erythropoietin serum concentration. The variability among athletes competing in different sport disciplines is apparently limited. The knowledge of the behaviour of reticulocytes in training and competitions is crucial for defining their role in an antidoping control context. It is important for sport physicians and clinical pathologists to know the reticulocyte variability in the general population and in athletes, the pre-analytical warnings, the different methodologies for counting reticulocytes and the derived parameters automatically available, and, finally, the possible influence of training, competitions, type of sport and altitude.     

Ultrasound in sports medicine

Musculoskeletal sonography has been shown to be effective for many applications related to sports medicine. Some advantages of sonography over MR imaging include portability, accessibility, high resolution, and relative lower cost. More importantly, dynamic imaging under sonography visualization allows diagnoses that cannot be made with routine MR imaging. Additionally, direct imaging correlation with patient symptoms provides important information to the referring clinicians. The disadvantages of sonography include operator dependence and long learning curve. This can be minimized, however, with proper training and standardized technique. Musculoskeletal sonography has proved itself as one of several imaging methods invaluable to the diagnosis of sport medicine-related abnormalities.     

Misdiagnosis in sports medicine

With the increase in participation sports comes an increased prevalence of sports injuries. Injuries of the shoulder and knee present the sports medicine practitioner with the challenge of obtaining a proper diagnosis and providing appropriate treatment. Commonly misdiagnosed injuries to the shoulder and knee include anterior cruciate ligament injuries, patella subluxation/dislocation, and labral injuries. This article provides insight into obtaining a detailed history, performing a focused physical examination, and understanding the pathoanatomy of the affected joints in order to help avoid misdiagnosis of these complex injuries. These skills can aid practitioners to better meet the needs of the high school, college, professional, and recreational athlete.