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Ask the Experts: Questions and Answers

Remember: This information is not intended as a substitute for treatment. Don't start an exercise program without consulting your personal physician.

Question: A 40-year-old woman has experienced partial tears in her retina from no known cause. Laser surgery has been performed to correct the problem. Is weight lifting (free weight and/or machines) contraindicated?

Answer: A nontraumatic retinal tear is generally caused by vitreous traction. The vitreous is the jellylike substance that fills the back of the eye. There are certain individuals who are more predisposed to developing nontraumatic retinal tears, such as those who are nearsighted (myopic). Symptoms may include flashing lights and floaters. Flashing lights are caused by physical stimulation of the retina by vitreous traction and the floaters are caused by small opacities within the vitreous.

During laser surgery a laser is used to coagulate tissue; the specific term is photocoagulation. Light energy is absorbed by tissue and converted to heat energy, which causes a thermal burn. Photocoagulation creates retinal adhesions to the underlying choroid and surrounds the area of the tear in hopes of preventing a retinal detachment. (In simplified terms, picture a room as the inside of the eye, and the wallpaper is the retina. If the wallpaper tears, a heat gun (or stapler) seals the tear to prevent the rest of the wallpaper from detaching.)

Weight lifting or exercise machines are not a contraindication as long as the tear is well sealed with previous laser treatment. One must rule out other retinal or eye pathology. One strong recommendation is to wear protective sports goggles during participation in any contact sports or sports in which a projectile ball is used.

Bruce M. Zagelbaum, MD
Manhasset, New York

Question: In August 1997 I fell and twisted my ankle and hurt my foot. It was x-rayed and nothing was found at the time. However, 3 weeks later I was diagnosed with stress fractures in my left foot fifth metatarsal and cuboid. I was put into a walking aircast for 3 weeks and was then told I could start weaning myself from the cast. I went to physical therapy for a month and a half, but I still felt some pain, so I went to another orthopedist, who confirmed that the stress fractures had not completely healed. The cast was put back on for 4 weeks, and then I began weaning myself again, taking about another 3 weeks. I have since returned to the ortho and was told the fractures had healed.

My question relates to recovery from stress fractures. I do not have point tenderness, but when I walk my foot is very stiff—even in areas where the foot was not fractured—and it is easily fatigued. I still favor the foot a lot as well. Is stiffness normal? How long does it generally take for a foot to recover from an injury like mine? I'm a walker and very anxious to get back into the swing of things. Do you have any suggestions for rehabilitation? (I am unable to go to physical therapy.)

One last question: Today I was walking and felt a little release/pop in my foot in the area of the fractures. I assume it was just a release from the pressure that has built up on the foot since I started walking because I have no pain. Is this normal? I know I may sound high strung and hypochondriacal, but it has been 6 months, and I am nervous about walking on it again. I would appreciate your insights or suggestions. Thank you very much for your time and patience.

Answer: The question is a little perplexing because the diagnosis does not make a lot of sense. Stress injuries, also known as overuse injuries, occur from repetitive microtrauma. They occur insidiously or slowly over a period of time and usually in very active people. Sometimes stress injuries occur in patients who are increasing their level of activity, such as a new runner or walker who is suddenly trying to get into shape or an active runner who dramatically increases his or her workout in order to get ready for a marathon.

Your injuries are acute—related to a single traumatic incident—and thus seem unlikely to be "stress fractures." As such, they fall into the category of acute fracture of the midfoot. Nondisplaced fractures—in which the bones are still aligned normally—such as these certainly can occur in the manner described and are best treated by a period of immobilization or protection in an orthotic device.

Foot fractures are a little funny. They almost always heal within 6 to 8 weeks, but the pain from a foot fracture, even from a toe fracture, can linger for many months. This probably occurs because a patient who can walk does not really allow the foot to rest and heal. Immobilization in a cast can make the symptoms worse, causing additional stiffness, weakness, and even osteoporosis. For prolonged symptoms, a formal rehabilitation program consisting of range-of-motion exercises (to combat stiffness), strengthening, and physical therapy treatments can accelerate recovery. Since you can't attend physical therapy regularly, perhaps a home program could be worked out for you by going in for one or two visits or by returning to your orthopedist.

Finally, the little "pops" that patients feel after injuries such as this may be the tearing of an adhesion—scar tissue—and are usually of no clinical importance.

Matthew S. Shapiro, MD
Los Angeles, California

Question: The environmental conditions at the Nagano Olympics don't seem harsh, but the weather variations seem to have created problems with scheduling and snow condition. Do such conditions present any issues regarding performance or injury?

Answer: Experience is the key to dealing with variable snow conditions. The medal contenders and veteran competitors can adjust and perform at the highest level. The athletes with less experience or skill run the greatest risk of injury.

Delays in competition, regardless of the reason, can create problems for some athletes. Elite athletes have carefully planned programs designed to have them peak physiologically and psychologically at a certain time on a specific day. Any deviation from the published Olympic schedule can be detrimental to their performance. A change of a few hours may have a negligible effect, whereas a postponement of 1 or more days can interfere with their performance. Yet time changes are a part of competition. The athletes who are the most adaptable have the edge when external factors alter the schedule.

Phillip B. Sparling, EdD
Atlanta, Georgia

Question: I treat an occasional athlete or two who compete on the national and international level. I would like a list of banned substances and those for which competitive athletes are tested. For example, are all steroids banned, including glucocorticoids such as Depomedrol?

Answer: Experience is the key to dealing with variable snow conditions. The medal Banned substances and testing are confusing issues. Basically, two organizations are involved, the National Collegiate Athletic Association (NCAA) and the International Olympic Committee (IOC). Some of their rules are similar, but many are different and may even vary for the same sport. I recommend obtaining the Athletic Drug Reference, (Rosenberg, Fuentes, Davis (eds), Durham, North Carolina, Clean Data, 1996), a 500-page paperback that addresses the issues involved and includes lists for both the IOC and NCAA. (Given the recent controversy regarding marijuana use at the Olympics, athletes should also check with their individual sports federation regarding banned substances.)

Regarding corticosteroids, the NCAA has no restrictions on their use. However, the IOC bans the use of intravenous, intramuscular, or oral corticosteroids, while allowing topical formulations. Nasal and lung aerosols along with intra-articular, local injections are allowed by the IOC when a form is filled out. This form is available by calling 1-719-575-9651 from your fax machine handset and requesting form #9010.

Randall Swain, MD
Charleston, West Virginia

Question: US figure skater Michelle Kwan has had to train for the Olympics, despite a stress fracture of her left second toe. How do physicians manage stress fractures when patients cannot take a long rest from their activities?

Answer: Stress fractures are overuse injuries of the bone that frequently are associated with a change in training habits (especially an acute increase in intensity) and a change of the training surface (such as running on cement rather than a cinder track). An interesting study at a military academy showed that poorly conditioned female recruits are much more likely to suffer overuse injuries than their male counterparts. If the women undergo a 4 to 6 week period of preconditioning for boot camp, their injury patterns more closely mimic men's.

In general, stress fractures are more frequent in women and can be associated with disordered eating, anorexia, and absent menstrual periods (amenorrhea). This seems to occur more frequently in athletes who practice the aesthetic sports of ballet, dance, gymnastics, and figure skating, in which the athlete is partially judged on appearance.

Prior to the Atlanta Olympic Games, a number of our elite women gymnasts developed stress fractures, which undoubtedly affected the ultimate outcome. Challen Sievers, captain of the US Olympic Rhythmic Group Team, had a stress fracture in her tibia; Jessica Davis, the sole US individual rhythmic competitor, suffered a stress fracture of her tibia prior to the Olympic trials; and Shannon Miller had a stress fracture in her forearm. Dominique Moceanu had a stress fracture of her tibia, which prevented her from practicing dismounts and landings and led to missed landings on the vault during the team competition. This of course led to one of the defining moments of the Olympic Games, Kerri Strug's courageous vault for the gold medal.

Treatment for the average athlete usually includes rest and protection from the offending stresses. Stress fractures will usually heal with time. The athlete must be instructed to return to sports activities gradually or else the stress fracture may recur. A thorough analysis of risk factors including nutritional habits and menstrual history should be undertaken to rule out underlying problems.

In the elite or in-season athlete, treatment can be more challenging. For mid to lower tibial stress fractures, functional bracing with air stirrups can provide load sharing, which reduces pain and allows the athlete to continue competition. It should be emphasized, however, that the fracture will not heal until the bone is given the chance to rest. In addition, Moceanu, Sievers, Davis, and Miller also had treatment with electric and ultrasonic bone stimulation devices that may have sped up their healing process. These devices have been shown to assist the healing in fracture nonunions but are relatively unproven in the healing of stress fractures.

Michelle Kwan underwent a period of rest but probably not long enough to fully heal the bone. The timing of the Olympic Games and National Championships precluded complete rest. Her fracture will most likely heal after the Olympic Games.

Foot and toe stress fractures can be particularly difficult to treat. The athletic demand on the foot precludes effective bracing that might share the load as in the tibia. Buddy-taping the toe to an adjacent toe can provide some support. Figure skating holds some advantage in that the boot is attached to a rigid skate, which permits the use of a more rigid boot sole that extends to the toe to relieve some of the pressure. However, one must take care not to alter the athlete's ability to perform. Electric and ultrasonic devices most probably were also used in Ms. Kwan's fracture.

Finally, it would be considered legal under the International Olympic guidelines to provide an anesthetic local block to the toe just prior to competition. The risk of fracture progression or displacement would be minimal if the toe were buddy-taped, and the athlete could compete for 3 to 4 hours with little pain.

Mark R. Hutchinson, MD
Chicago, Illinois

Question: Picabo Street's recovery from anterior cruciate ligament surgery last year is amazing. Are there any differences between the knee rehabilitation of an elite athlete and that of a recreational athlete?

Answer: The rehabilitation principles and specific program used for an elite athlete, such as Picabo Street, are the same as those used for a recreational athlete. The initial emphasis is on reducing postoperative pain and swelling and restoring the knee's full range of motion. Next, specific exercises are initiated to minimize loss of muscle strength, function, and endurance. Then, based on the type of surgery, the strength of the repair, tissue healing, and the athlete's initial response to therapy, the rehab program progresses toward helping the athlete regain function and return to sports participation. Some of the most important factors that determine an injured athlete's recovery time are not related to the rehab principles or program but to the individual athlete. These factors include (1) the initial extent of the injury and the surgical intervention required; (2) the athlete's preinjury level of muscular strength and endurance and cardiovascular fitness; and (3) the athlete's motivation and dedication to the rehab program.

Elite athletes, like Street, have some advantages over recreational athletes in rehabilitation. They are usually more fit than recreational athletes, and their daily life usually revolves around the rehab program and returning to their sport.

Whether the patient is an elite or recreational athlete, physicians, physical therapists, and athletic trainers use their knowledge to enable an athlete to return safely to his or her sport in the shortest time possible.

James Zachazewski, MS, PT
Newton, Massachusetts

Question: I am an active 15 year old female. Many times when I exercise strenuously, I get extreme pain in my lower stomach area. It feels almost as if I need to go to the bathroom, but I really don't have to. It has happened after running and swimming and is often followed by chills and goosebumps. I am very active and in good shape and can't see any relationship between the pain and my fitness level. I'm wondering if it is intestinal cramping, and what I can do to prevent this problem. Thanks a lot for any help you may have.

Answer: It sounds as if you are having hypoperfusion (decreased blood supply) to the intestinal tract during intense exercise. This is because during the first few minutes of exercise, 15% of your blood volume is shunted to the working muscles, and later, as your temperature rises, up to 20% of your blood volume is shunted to the skin for cooling. The result is a reduced blood flow to your intestines and cramping type of pain.

Usually we do not use medication to treat these symptoms. Treatment can vary according to the individual, but first improve hydration (drink more water) before activity—and during, if you can. Try to have a bowel movement before working out to reduce contents within the bowels. If your diet is low in fiber, increase fiber content to help maintain regular bowel habits. If these approaches don't work, reduce exercise intensity about 20% to 30% and then build back up slowly.

Leonard Wilkerson, DO
Kissimmee, Florida

Question: Are there any known side effects to using creatine as a performance enhancing supplement?

Answer: The best-documented side effect of creatine is weight gain (from a slight increase in muscle water)—2 to 6 lbs in as little as 1 week. For this reason, many female athletes don't like using creatine. There have been no long-term studies about the potential hazards of creatine supplementation. However, there has been some concern that it might delay the healing of muscle tears or be associated with vague myalgias. Further studies are necessary to assess such concerns. (For more information on creatine and other ergogenic supplements, see "Ergogenic Aids: What Athletes Are Using—and Why.")

Creatine is filtered by the kidneys, where it is finally excreted in the urine, so athletes who use it should increase their water intake. Purity is always an issue with dietary supplements; many different manufacturers sell the product in many different forms, all claiming—without supportive data—that their product is the best on the market.

Christine A. Rosenbloom, RD, PhD
Atlanta, Georgia

Question: Are there any cases of eating disorders among Olympic participants? If so, in which countries are such disorders more common?

Answer: It is difficult to say if any or how many Olympic athletes have documented eating disorders. The desire for thinness and concern over body weight is prevalent among female athletes, especially among athletes who participate in certain sports in which low body weight is considered desirable. These sports include gymnastics, figure skating, distance running.

Christine A. Rosenbloom, RD, PhD
Atlanta, Georgia

Question: As an aging athlete with the onset of knee and hip osteoarthritis, I'm interested in an expert opinion on the following treatments that are being actively discussed, touted, or panned on the Internet and in the press: (1) glucosamine and chondroitin sulphate, (2) cetyl myristoleate, and (3) Synvisc (alone or possibly combined with the first or second).

Answer: An aging athlete who has knee and/or hip pain should first see a sports medicine specialist or an orthopedic surgeon for a proper diagnosis through a thorough history and physical exam. If osteoarthritis is the cause of symptoms, the physician can outline a conservative treatment program including the use of nonsteroidal anti-inflammatory medication or aspirin, exercise to promote joint mobility and strength, and fitness activities, which should be lower impact. (For more information on the important role of exercise in treating osteoarthritis, see "Osteoarthritis: How to Make Exercise Part of Your Treatment Plan," The Physician and Sportsmedicine, July 1997).

Glucosamine and chondroitin sulphate seem like promising supplements, but there have been only limited scientific studies to date. I'd encourage those interested in learning about these supplements to read the best-selling book The Arthritis Cure (by Theodosakis, Adderly, and Fox, St. Martin's Press). I do not know of any studies on cetyl myristoleate, so I cannot comment on its efficacy or safety. Synvisc (Biomatrix, Inc, Ridgefield, New Jersey) has been proven useful; it is a gel injected into the knee joint to enhance cushioning. It has been approved for use only in the knee and is used for osteoarthritis only after the usual conservative approaches have failed. There have been no studies on the use of Synvisc with the other two supplements. (For more information on Synvisc, call Wyeth Ayerst Pharmaceuticals at 1-800-999-9384.)

Nicholas DiNubile, MD
Havertown, Pennsylvania

Question: Is it possible to avulse the iliac epiphysis by just rotating the trunk while warming up for a basketball game? X-rays show the left iliac epiphysis fused (risser +5) and the right a risser 4. Initial impression by a family physician is avulsion. I'm wondering if the symptoms my 16 year old son is having are just from muscle strain and whether the lucency on the x-ray is just the growth plate not fused?

Answer: The growth plate does not always fuse at the same time on the right and left sides. It takes considerable force to avulse the growth plate, especially the whole length of the plate. Muscle strain or stress on the growth plate can occur ("hip pointer" like), causing pain and soreness.

Treatment should include avoiding weight lifting or stretching and straining the involved muscle group. Repeated application of ice to the site for 2 to 3 minutes followed by the application of heat for 2 to 3 minutes may be helpful.

David Apple Jr, MD
Atlanta, Georgia

Question: Should a recurring pneumothorax prevent athletes from competing at their highest levels? What restrictions would you recommend?

Answer: If the pneumothorax recurs in the same lung, it would depend on the number of recurrences and if they were activity related. Many times spontaneous pneumothoraces unrelated to activity are found in healthy adolescents who have no predisposing factors. In this situation, I do not feel the athlete should be restricted from any activities. However, if pneumothorax has happened multiple times—greater than two or three—the athlete may be a candidate for surgical or chemical procedures to prevent further episodes.

A second situation would be recurrent, same-lung pneumothoraces that occur in relation to exertion only. Weight lifters and those involved in contact sports like football have been reported to have these problems. If the pneumothoraces are related only to sporting activity, I would reduce the patient's activities to a noncontact, more aerobic sport with minimal or no weight lifting. I haven't seen any clinical guidelines related to this rare clinical entity.

Randall Swain, MD
Charleston, West Virginia