Exercise and heart disease.

Atherosclerotic coronary artery disease (CAD) is a leading cause of death in the United States. It accounts for myocardial infarction in approximately 1.5 million Americans annually and results in approximately 500,000 deaths yearly. Half of these deaths occur prior to patients being admitted to a hospital. A dramatic reduction in mortality related to atherosclerotic CAD has occurred in the last decade. This reduction has resulted from significant advances in both the medical and surgical management of this disease as well as from increased efforts to modify risk factors known to increase the likelihood of developing CAD. Modifiable risk factors include cigarette smoking, hypercholesterolemia, and hypertension. More recently, physical inactivity has been found to be a significant modifiable risk factor that can influence the development of CAD. This article reviews some of the observational data that support these conclusions, discusses the role of exercise in the prevention of CAD in select groups, and reviews some of the mechanisms by which exercise may modify the development of CAD.

The sprained ankle.

The sprained ankle is the most common musculoskeletal injury seen by physicians caring for active youngsters and adults. It accounts for approximately one fourth of all sports-related injuries and is commonly seen in athletes participating in basketball, soccer, or football. It has been shown that one third of West Point cadets suffer an ankle sprain during their 4 years at the military academy. While diagnosis and management of the sprained ankle is usually straightforward, several serious injuries can masquerade as an ankle sprain, and it is important for the clinician to recognize these to prevent long-term morbidity. In this article the basic anatomy of the ankle, mechanisms by which the ankle is injured, and the differential diagnosis of the acutely injured ankle are reviewed. Appropriate evaluation of the injured ankle and the criteria that should be utilized for determining the necessity of radiographs are discussed as well as management of the acutely sprained ankle and the role of prevention in reducing the risk of ankle injury.

Baseball and softball sliding injuries. Incidence, and the effect of technique in collegiate baseball and softball players.

We prospectively observed seven softball and three baseball Division I collegiate teams to study the incidence of sliding injuries, the types of injuries resulting from the sliding technique, and the amount of time lost from participation. Slides were categorized as either feet- or head-first on the basis of the leading part of the body during the slide. Slides were further stratified depending on whether a diveback technique was performed. We recorded 37 injuries in 3889 slides in 637 games and 7596 athlete game exposures. The overall incidence of sliding injuries was 9.51 per 1000 slides and 4.87 per 1000 game exposures. Softball players had a significantly higher incidence of sliding injuries (12.13 per 1000 slides) than did baseball players (6.01 per 1000 slides). In baseball, the injury rate was higher for feet-first slides (7.31 per 1000 slides) than for headfirst slides (3.53 per 1000 slides) or divebacks (5.75 per 1000 divebacks). In softball, injury rates were higher for head-first slides (19.46 per 1000 slides) than for feet-first slides (10.04 per 1000 slides) or divebacks (7.49 per 1000 divebacks). The majority of injuries sustained were minor, with only four (11%) injuries causing the athlete to miss more than 7 days of participation.

Preparticipation cardiovascular screening for US collegiate student-athletes.

CONTEXT: Sudden death in young competitive athletes due to unsuspected cardiovascular disease has heightened interest in preparticipation screening. OBJECTIVE: To assess screening practices for detecting potentially lethal cardiovascular diseases in college-aged student-athletes. DESIGN, SETTING, AND PARTICIPANTS: A total of 1110 National Collegiate Athletic Association member colleges and universities were surveyed between 1995 and 1997, with 879 (79%) responding to the questionnaire. MAIN OUTCOME MEASURES: Information on the administration and scope of the preparticipation screening process was obtained from the team physician or athletic director; preparticipation screening forms were evaluated for content and compared with 12 items recommended by the 1996 American Heart Association (AHA) consensus panel screening guidelines. RESULTS: Preparticipation screening was a requirement at 855 (97%) of 879 schools, was performed on campus at 713 schools (81 %), and was required annually by 446 schools (51 %). Team physicians were responsible for examinations at 603 (85%) of 713 schools with on-campus screening, although 135 of these schools (19%) also approved nurse practitioners and 244 schools (34%) allowed athletic trainers to perform examinations. Of the history and physical examination screening forms analyzed from 625 institutions, only 163 schools (26%) had forms that contained at least 9 of the recommended 12 AHA screening guidelines and were judged to be adequate, whereas 150 (24%) contained 4 or fewer of these parameters and were considered to be inadequate. Smaller Division III schools were more likely than larger Division I schools to have inadequate screening forms (30% vs 14%; P<.001). Relevant items that were omitted from more than 40% of the screening forms included history of exertional chest pain, dyspnea, or fatigue; familial heart disease or premature sudden death; and physical stigmata or family history of Marfan syndrome. CONCLUSION: The preparticipation screening process used by many US colleges and universities may have limited potential to detect (or raise the suspicion of) cardiovascular abnormalities capable of causing sudden death in competitive student-athletes.

Injuries in runners: a prospective study of alignment.

OBJECTIVE: To determine if measurable lower extremity alignment is a risk factor for overuse running injuries. DESIGN: Prospective cohort study. SETTING: Thirty-two week marathon training program. PATIENTS OR PARTICIPANTS: Three hundred fifty-five volunteers from the marathon training program began the study; 255 finished the study. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Past training and injury history was determined by questionnaire, and five lower extremity alignment measures were performed at the beginning of the training program: arch index (AI), heel valgus (HV), knee tubercle-sulcus angle (TSA), knee varus (KV), and leg-length difference (LLD). Overuse injuries, incurred by the runners and categorized by anatomic parts, were recorded during the training period. RESULTS: Ninety subjects experienced overuse injuries. Multivariate analyses with stepwise Poisson regression showed few consistent relationships between alignment and overuse injury rates. Higher AI was protective against overall injuries and knee injuries; higher HV was protective against knee and foot injuries; higher TSA was associated with shin injuries; higher KV was associated with shin injuries; and low LLD was associated with more overall injuries. CONCLUSIONS: Minor variations in lower extremity alignment do not appear conclusively to be major risk factors for overuse injuries in runners. Because of the study limitations and the likely multifactorial nature of running injuries, further study is suggested, perhaps in more novice runners.

Distal radial growth plate injury and positive ulnar variance in nonelite gymnasts.

To assess the prevalence of stress injury to the distal radial growth plate and of positive ulnar variance in a nonelite gymnast population, we administered a radiographic survey and questionnaire to 44 skeletally immature nonelite gymnasts (27 girls and 17 boys). The subjects trained an average of 11.9 hours per week. Radiographic findings consistent with stress injury of the distal radial physis were found in 25% (11 of 44) of participants. Ulnar variance was found to be more positive in the gymnasts when compared with age-predicted norms. An average side-to-side difference in ulnar variance of 0.9 mm was observed. Radiographic findings of stress injury to the growth plate and the amount of ulnar variance were not associated with age, sex, training intensity, wrist pain, height, or weight. There was also no significant relationship between ulnar variance and radiographic findings. The mean ulnar variance in nonelite gymnasts was between that measured for elite gymnasts and nongymnasts. These results indicate that stress injury of the distal radial growth plate occurs in a significant percentage of nonelite gymnasts. It also appears that ulnar variance is more positive than would otherwise be predicted, suggesting growth inhibition of the distal radius, a growth stimulation of the ulna, or a combination of both.

Lifestyles and health risks of collegiate athletes: a multi-center study.

OBJECTIVE: To determine whether college athletes are at greater risk for maladaptive lifestyle and health-risk behaviors than their nonathletic peers and to identify high risk taking groups by gender, sport, and other identifiers. DESIGN: Multicenter, cross-sectional study. SETTING: Seven major geographically represented collegiate institutions in the United States. PARTICIPANTS: A total of 2,298 college athletes and 683 randomized nonathlete controls completed a confidential survey questionnaire between the summer of 1993 and winter of 1994, assessing lifestyle and health-risk behaviors over the previous 12 months. MAIN OUTCOME MEASURES: Self-reports of lifestyle behaviors and health risks in the following areas: motor-vehicle safety, substance abuse, sexually transmitted diseases and contraception, mental health, cancer prevention, nutrition, exercise and general preventive health issues. RESULTS: Athletes demonstrated significantly higher risk-taking behaviors (p < 0.05) than their nonathlete peers in the following areas: less likely always to use seatbelts; less likely always to use helmets with motorcycles, mopeds, and bicycles; more often drive as a passenger with a driver under the influence of alcohol or drugs; greater quantity and frequency of alcoholic beverages; greater frequency of smokeless tobacco and anabolic steroid use; less-safe sex; greater number of sexual partners; less contraceptive use; and more involvement in physical fights. Female athletes reported a higher prevalence of irregular menses, amenorrhea, and stress fractures compared with female nonathletes. Male athletes had more risk-taking behaviors than did female athletes (p < 0.05), and athletes in contact sports demonstrated more risk-taking behaviors than did athletes in noncontact sports (p < 0.05). Athletes with one risk-taking behavior were likely to have multiple risk-taking behaviors (p < 0.05). CONCLUSIONS: College athletes appear to be at higher risk than their nonathletic peers for certain maladaptive lifestyle behaviors. Athlete subgroups at highest risk include male athletes and athletes participating in contact sports. Athletes at risk for one high-risk behavior demonstrated an increased risk for multiple risk-taking behaviors. Preventive health interventions deserve further study to determine strategies for risk reduction in high-risk groups.

Lower extremity alignment and risk of overuse injuries in runners.

A group of 304 runners enrolling in a marathon training program had alignment measurements performed and completed a questionnaire on training practices and injuries over the previous 12 months. The alignment measures consisted of arch index (AI), heel valgus (HV), knee tubercle-sulcus angle (TSA), knee varus (KV), and leg-length difference (LLD). Results indicated few consistent statistical associations between these alignment measures and risk of injuries, either bivariately or multivariately: left AI with hamstring injuries; right AI with shin injuries; right HV with back injuries; left TSA with ankle injuries; KV with hip injuries; and LLD with back, ankle, and foot injuries. A few statistically significant relationships were also found between other training and anthropometric factors and injuries: mileage with hamstring injuries; interval training with shin injuries; hard surfaces with back and thigh injuries; shoe use patterns with foot and overall injuries; and body mass index with heel injuries. We conclude that lower-extremity alignment is not a major risk factor for running injuries in our relatively low mileage cohort; however, prospective studies are necessary to confirm or refute these findings.

Factors associated with wrist pain in the young gymnast.

We conducted a cross-sectional survey of 52 nonelite gymnasts (32 girls, 20 boys; average age, 11.8 years) to assess their history of training and wrist pain within the last 6 months. An intensity index was created using the number of training hours per week and the athletes' skill levels. Wrist pain was prevalent in 38 (73%) of the gymnasts. Gymnasts with wrist pain were older (12.6 years versus 9.7 years; P = 0.0002), trained more hours per week (13.5 versus 7.7; P = 0.0002), trained at a higher skill level (P = 0.01), and began training at an older age (7.0 years versus 5.1 years; P = 0.006). Analysis of intensity versus age suggested that a threshold of training intensity may be important in the development of wrist pain. Logistical regression found these factors to be independently associated with wrist pain: intensity (P = 0.036), age > 10 years (P = 0.018), age < 14 years (P = 0.016), and the age of initiation of training (P = 0.020). This study demonstrates that wrist pain is a common problem among nonelite young gymnasts. Training intensity, relative to the age of the participant and the age when training was initiated, appears to be an important determinant of the development of wrist pain in this population.

Athletic amenorrhea and its influence on skeletal integrity.

Athletic amenorrhea is seen frequently in competitive athletes and is strongly associated with diminished bone mineral density and disordered eating behavior. It is important, however, to note that most of the studies performed to date have been influenced significantly by selection bias. A recent Scandinavian study has shown that the great majority of women who exercise at regular and moderate levels are not at significant risk for athletic amenorrhea and its adverse effect on bone mineral density. Nevertheless, athletic amenorrhea should never be minimized when detected, and appropriate evaluation should be undertaken to prevent the adverse effects of prolonged amenorrhea on skeletal integrity.

An unusual presentation of liver laceration in a 13-yr-old football player.

Abdominal injury occurs infrequently from athletic trauma, yet when it does occur, it can be very serious. Although rupture of a major blood vessel can lead to rapid loss of blood, insidious blood loss can also result from apparently insignificant injury of the spleen, liver, or kidney and lead to delayed problems. Awareness of the potential for such injury is vital because outcome can be adversely affected by a low index of suspicion, and this can be compounded by the fact that the initial physical examination is not always a reliable indicator of the severity of injury. Classic reports of these injuries describe splenic injury from a left-sided blow and hepatic injury from right-sided trauma. We present a case report of liver laceration in a young football player not only to comment on its unusual mechanism and presentation, but also to illustrate the importance of rapid assessment and transport of the athlete with a serious abdominal injury to avoid the consequences of delayed diagnosis and treatment.

Attitudes toward and experience in research among family medicine chairs.

BACKGROUND: Productive research environments are important for the development of academic family medicine, yet many of the current family medicine chairs have had little research training or experience and have rated research skills as a low priority for themselves. The younger chairs, however, representing the next generation of academic leadership, may have more traditional academic values, including the promotion of research. METHODS: The 106 active and interim chairs of family medicine academic units were surveyed by mail to determine their characteristics and attitudes toward their work responsibilities. We compared chairs 50 years of age or younger with those over 50 years of age. RESULTS: Before attaining their positions, younger chairs, in general, were more likely than older chairs to have received formal training in management, patient care, and academic skills, but they shared similar work experiences. Specifically, younger chairs were more likely to have had formal research training but did not have a great deal more research experience. Younger chairs were more likely to consider research skills to be essential in their present work activities and to identify faculty with formal training and extensive experience in research as potential chair replacements. CONCLUSIONS: Younger chairs appear to have a greater appreciation for the importance of research, having received more formal training and valuing research skills in themselves and potential replacements. With the impending large turnover in family medicine leadership, there will be an opportunity to recruit chair replacements with similar viewpoints toward research, thus improving the outlook for research in academic family medicine.

Depression and chronic fatigue in athletes.

For the most part, the competitive athlete is a well-adjusted individual who demonstrates considerable vigor and well-being, as well as less depression, anxiety, and fatigue than nonathletic counterparts. The well-trained athlete, however, may also have a personality that is somewhat rigid, strongly goal oriented, and perfectionist. It is not unrealistic to expect that when confronted with diminished performance or success, such an athlete may be compelled to drive himself or herself harder to succeed. Such behavior typically leads to the phenomenon of overtraining, which can express itself in the form of chronic fatigue and depression. There are a number of other organic causes of chronic fatigue and depression, however, which must be excluded by careful evaluation and appropriate diagnostic testing. Although the evaluation of the athlete who presents with chronic fatigue and depression can be somewhat complex, a diagnostic framework has been outlined here to assist the clinician in the assessment of an athlete who presents with such complaints.

Lifestyles and health risks of collegiate athletes.

BACKGROUND: No study has comprehensively assessed the health behaviors of intercollegiate athletes. To determine whether they may be at increased risk for unhealthy lifestyle behaviors, we compared the lifestyle and health risk behaviors of a group of college athletes with those of their nonathletic peers. METHODS: A confidential survey questionnaire addressing preventable lifestyle behaviors was given to 109 intercollegiate athletes and 110 nonathlete controls. RESULTS: Athletes had a significantly (P less than .05) higher proportion of "risky" lifestyle behavior patterns compared with the nonathletes in the following areas: quantity of alcohol consumed; driving while intoxicated with alcohol or other drugs; riding with an intoxicated driver; use of seatbelts; use of helmets when riding a motorcycle or moped; use of contraception; number of sexually transmitted diseases; and number of sexual partners. CONCLUSIONS: College athletes appear to be at higher risk for certain maladaptive lifestyle behaviors. Comprehensive lifestyle assessment and preventive health intervention deserve further study to determine whether they can facilitate the adoption of positive lifestyle behaviors in this high-risk group.

Success strategies for departments of family medicine.

Strong departments of family medicine in academic medical centers help assure the future scope and quality of family practice patient care, the ongoing evolution of family medicine as a scholarly discipline, and a continued flow of qualified medical school graduates into family practice residency programs and eventually into practice. This report presents key strategies of six successful departments of family medicine and describes the methods and skills considered important by the leaders of these departments. Common themes that emerge are (1) recruit and mentor the best faculty, (2) build a reputation for clinical excellence of faculty and residents, (3) become part of schoolwide curriculum activities, (4) establish a scholarly presence, and (5) develop networks of support.

Depression and chronic fatigue in the college student-athlete.

For the most part, the intercollegiate athlete is a well-adjusted individual who demonstrates considerable vigor and well-being and less depression, anxiety, and fatigue when compared with nonathletic counterparts. The well trained athlete also demonstrates a personality that may be somewhat rigid, is strongly goal oriented, and strives for excellence. It is not unrealistic to expect that when confronted with diminished performance or success, athletes may be compelled to drive themselves harder to succeed. Such behavior typically leads to the phenomenon of overtraining, which can express itself in the form of chronic fatigue and depression. A number of other organic causes of chronic fatigue and depression must be excluded by careful evaluation and appropriate diagnostic testing. Although the evaluation of the athlete who presents with chronic fatigue and depression can be somewhat complex, a diagnostic framework has been outlined that may assist the clinician in the assessment of the athlete who presents with such complaints.