THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 2 - FEBRUARY 99
Body Piercing and Sports: An Opening for Trouble?
Ricky Williams, college football's 1998 Heisman Trophy winner, wears a tongue stud. Pro basketball player Dennis Rodman is known for his nose ring and other body art. And hosts of young people sport similar decor. What happens when people wearing metal rings or other ornaments through various parts of their bodies play rough-and-tumble sports?
So far, the medical literature doesn't answer that question. But given the nature of sports and the likelihood that participants don't always follow the rules against wearing body jewelry, physicians who treat active patients probably can expect to encounter infections and other problems related to body piercing sooner or later.
A Piercing Primer
Body piercing is booming. Pierced ears have been commonplace for many years, but devotees now are also piercing the nose, eyebrows, tongue, lip, navel, and even genital area.
There are no reliable estimates of the population involved, but piercing studios have multiplied. Myrna L. Armstrong, RN, EdD, a professor in the School of Nursing at Texas Tech University Health Sciences Center in Lubbock, has been tracking body art trends and their medical implications since 1991. She notes that in Texas, where tattoo and piercing studios must register, there are at least 250 businesses. "I suspect we aren't much different than the rest of the country," she says.
Body piercing is a quick procedure done without anesthesia (1). The piercer retracts the skin with a hemostat, pierces the skin with a hollow 12- to 16-gauge needle, attaches the jewelry to the needle, then threads the jewelry through the hole. Tongue piercing is a two-step procedure; a 14-gauge or larger "barbell" is initially placed to accommodate swelling.
A piercing can take a year or longer to heal. To form an adequate hole, the jewelry must be left in place for the first 6 to 10 months.
There are no national piercing standards, says Armstrong. She adds that do-it-yourself piercings at rock festivals or fraternity parties are not unusual.
Tor Shwayder, MD, director of pediatric dermatology at Henry Ford Hospital in Detroit, says the medical complications from piercings can include infection, granuloma formation, keloid formation, allergic contact dermatitis from nickel, aspiration, cyst formation, and disfigurement.
Problems in the Sports Setting
Most high school and college sports have rules that prohibit wearing jewelry during competition (2), and Armstrong says there are virtually no reports of sports-related body-piercing problems in the medical literature. Still, an athletic environment can breed problems, she says. "The combination of dirt, trauma, and sweat can lead to infection."
Shwayder says that in team sports the most obvious problems are friction and shearing forces that may rip the metal out of the skin. A player's body jewelry can also pose an abrasion hazard to opponents.
For solo exercisers, friction from clothing or from other body parts during exercise can traumatize piercings at the nipples, umbilicus, or genitals, Shwayder says.
Body jewelry should be removed during contact sports, but it should not be a problem during personal workouts as long as the device is comfortable and does not rub, says Shwayder.
Peter Shalit, MD, an internist in Seattle, says that in the absence of trauma, infection usually isn't a problem with healed piercings. Fresh piercings require special consideration, he says, and patients who play muddy or sweaty sports should be advised to make special efforts to clean the site after activity.
Armstrong recommends that athletes schedule their piercings during the off-season because new piercings require wearing the jewelry continuously until the skin inside the hole epithelializes.
Recommendations vary for swimmers and bathers who have new piercings. Shalit advises those with fresh piercings to avoid hot tubs and swimming in lakes and rivers because of the risk of pseudomonas infection. Armstrong advises patients to wear a waterproof bandage over the site, whereas Shwayder says patients can swim if they apply antibiotic ointment right before swimming and clean the site with soap and water and reapply antibacterial ointment afterward. Others advise patients to avoid swimming during the healing phase.
Above the neck. Patients who wear tongue barbells should ensure that the ends are securely fastened, Armstrong says. "With trauma, they can become dislodged and cause airway obstruction or become lodged in the GI tract," she says. Additional hazards during contact sports are tooth fractures and trauma to the tongue if intubation is needed.
Patients who have nose piercings should use adequate hygiene, especially when they have postnasal drip, says Armstrong. Staphylococcal infections are a risk, and one case of endocarditis has been associated with a nose piercing (3).
Below the neck. About half of navel piercings become infected, says Armstrong, who notes the area is prone to waistband irritation, moisture, and debris collection. "And patients don't look at the site frequently, so it's easy to forget about taking care of it," she says.
Shalit says the skin around genital piercings—particularly at the perineum—can become irritated from friction during running, biking, and wearing tight clothes. Patients can be reassured that the skin around the piercing often "toughens up" over time, he says. Activity-related friction can sometimes be reduced by stabilizing the body jewelry to the skin with a piece of paper tape.
Be Prepared for Problems
Physicians should be prepared to address piercing-related problems, particularly those that are advanced. "What I have found is that people who are pierced or tattooed usually don't seek medical advice in a timely fashion," Armstrong says. "By the time they seek medical care they have a fully blossomed medical problem." Piercing-related infections from pseudomonads, staphylococci, streptococci, and hepatitis B and C viruses have been documented, she says.
Shalit says such infections can be difficult to diagnose. "Signs of inflammation at a newly pierced site can mean several things: reaction to the trauma of piercing, an allergic reaction to the antiseptic or the metal of the jewelry, or normal healing," he says. Common signs of infection include green or gray discharge, progressive swelling beyond the normal tissue reaction that occurs in the first 24 hours after piercing, increasing warmth to the touch, and/or increasing pain.
For local infections, the jewelry should be left in place so that the infection does not become sealed within the pierced tract, says Shalit. "I use a topical antibiotic such as Bactroban [mupirocin] and work it into the piercing by turning the jewelry back and forth through the piercing," he says. Tissue warmth, swelling, or redness signals that a systemic antibiotic is needed, says Shalit. "Keflex [cephalexin] is the standard, but there are many possibilities."
Communicate With Patients
Armstrong, who has studied the attitudes of healthcare providers to tattooed patients (4), says young people who have piercings or tattoos report that the body art makes them feel special, not deviant. She advises providers to contain their negative feelings during interactions with patients. "If you turn them off because of their body art, they're not going to come back for anything," she says.
Armstrong says she can see why body-piercing has an allure for athletes. "Athletes are creative people. Their messages are in their sport," she says. Getting pierced or tattooed is often done as a team bonding ritual.
Accepting a young person's piercing decision does not mean healthcare providers should not talk to patients about the health risks, she says. "We need to make them more responsible for their skin care associated with body art, especially piercing." (See "Body Piercing: Eight Steps for Avoiding Infection," page 33: not shown.)
Will COX-2 Inhibitors Change Pain Management?
The recent approval by the US Food and Drug Administration of Celebrex (celecoxib), making it the first specific cyclooxygenase-2 (COX-2) inhibitor to reach the market, could change the way physicians prescribe medication for musculoskeletal pain.
Celecoxib, developed by G.D. Searle & Co and copromoted by Pfizer, Inc, received priority approval from the FDA in late December. An application for FDA approval for another COX-2 inhibitor, rofecoxib (Vioxx), was submitted by Merck in November.
Peter E. Lipsky, MD, a rheumatologist who directs the Harold C. Simmons Arthritis Research Center at the University of Texas Southwestern Medical Center in Dallas, says COX-2 inhibitors could change current prescribing patterns because the drugs are as effective as nonsteroidal anti-inflammatory drugs (NSAIDs) but do not cause gastrointestinal (GI) and bleeding side effects. Lipsky has been involved in basic research on specific COX-2 inhibitors.
Action and Dosage
NSAIDs exert their anti-inflammatory effects by inhibiting the cyclooxygenase pathway, limiting the synthesis of prostaglandins from arachidonic acid and the formation of byproducts that enhance inflammation and tissue damage (1).
Cyclooxygenase exists in two forms, a fact that was discovered in 1989, according to Lipsky. COX-1 is called a "housekeeper" enzyme because it synthesizes prostaglandins that regulate mucous production in the GI tract, the ability of platelets to control bleeding, and renal blood flow and sodium excretion. Thus, inhibition of COX-1 is an undesirable effect of NSAIDs. COX-2 is not present in the normal condition but is produced in response to inflammation and other physiologic and hormonal stresses, Lipsky says.
Though celecoxib was approved for osteoarthritis and rheumatoid arthritis pain, Lipsky says indications are likely to be added that will make it useful in sports medicine. "We don't have good information on the drug's effectiveness in different pain syndromes, but we know that COX-2 plays a role at the local and central levels in many models of pain," he says.
The recommended therapeutic dosage for osteoarthritis is 200 mg once daily or 100 mg twice daily, according to a Searle press release. For rheumatoid arthritis, the recommended dosage is 100 to 200 mg twice a day.
Weighing Risk Factors
Lipsky says 7,500 deaths in the United States are attributed to NSAID-related bleeding each year. Though the risks are greatest in older people who have chronic conditions such as peptic ulcers or kidney or liver disease, the risk for the younger, active population is also measurable, he says. On endoscopic studies, COX-2 inhibitors have been shown to produce significantly fewer gastric ulcers than NSAIDs and no more than placebo (2,3).
Another NSAID risk factor that should be considered in the context of contact sports is non-GI bleeding, says Lipsky. Unlike other NSAIDs, "COX-2 inhibitors don't affect platelet function. The lack of an effect on bleeding may become an important issue as time goes on."
Because of the lower risk factor profile, Searle had hoped the FDA committee would recommend special labeling to set celecoxib apart from other NSAIDs. But for now, the FDA is requiring that the drug label carry a standard warning about the GI side effects of NSAIDs. The FDA press release notes that NSAIDs can cause a range of gastrointestinal problems and that patients who have endoscopic ulcers often recover without treatment and without having symptoms or complications. "Additional studies in many thousands of patients would be needed to see whether Celebrex actually causes fewer serious gastrointestinal complications than other NSAID products," the press release states.
What Role for Older NSAIDS?
Lipsky predicts that in the future the role of traditional NSAIDs in pain management will be "vanishingly small." However, he also says that COX-2 inhibitors may be more expensive than other NSAIDs and that the cost could influence the market. According to a spokesperson from Searle, the suggested retail price for a 200-mg tablet is $2.40.
Wayne Leadbetter, MD, an orthopedic surgeon in Rockville, Maryland, says he believes traditional NSAIDs will continue to play a role in the management of certain sports injuries, especially in younger people who have less risk of GI bleeding. "There will be pressure from managed care because of cost," he says. "Since efficacy is similar, the only justification may be for those who are at risk." Some managed care organizations are considering limits on coverage of the new drug, according to news reports.
The high cost of COX-2 inhibitors could force physicians to use them more cautiously than other NSAIDs, says Leadbetter. "Like NSAIDs, COX-2s should only be offered in the right context." When treating sports injuries, physicians must balance concerns about inflammation and structural damage, he adds. "Reversing inflammation won't correct structural damage. You're not going to treat an ACL injury with a pill. On the other hand, NSAIDs are appropriate for treating bursitis, tenosynovitis, and arthritis flare-ups."
Often, structural damage can be repaired only by addressing the underlying problem, Leadbetter says. For example, a patient with sore knees would be better off losing 10 lb, changing shoes, or wearing an orthosis than taking medication.
In a sports medicine setting, the patients who will benefit most from COX-2 inhibitors will be older people who are taking up exercise to lower their lipids or improve their cardiac status, Leadbetter says. "For them, the side effect issue is not a trivial matter."
Future Treatment Choices
With two COX-2 inhibitors on the market in the near future, how will physicians decide between the two? "From the studies we've seen, they're pretty equivalent. Vioxx features once-a-day dosing, but Celebrex is likely to be effective for once-a-day dosing, too," Lipsky says.
As with traditional NSAIDs, patients may respond better to one COX-2 inhibitor than another, he says. "Having a choice is a good thing." Lipsky predicts that within the next 5 years there will be 5 to 10 COX-2 inhibitors on the market.
Unusual Hazards for Skiers
Ice Rink Air Quality
According to a press release about the report, researchers measured the air quality at 19 enclosed rinks over three winters. They found that propane-powered machines produced five times more NO2 than their electric-powered counterparts. Increased NO2 levels can cause chest tightness, cough, shortness of breath, and hemoptysis. One group of teenage hockey players had symptoms after 30 minutes of exposure to 35 to 40 ppm of NO2.
The authors stated that modifications such as increasing ventilation and tuning up resurfacers can cut NO2 concentrations by about 65%.
A Genetic Ergogenic Aid?
The treatment involved injecting into muscle an engineered virus that contains a gene called insulin-like growth factor I (IGF-I), which helps stimulate muscle repair. Young adult mice receiving the IGF-I muscle injections increased their muscle strength by 15%, and older mice increased their strength 27%.
Ethical issues will arise if the same treatment proves effective in humans, said H. Lee Sweeney, PhD, senior investigator, in the press release. Though Sweeney notes the treatment will most likely be used to preserve muscle strength and reverse wasting in chronic diseases such as muscular dystrophy, the treatment could be used or abused for athletic or cosmetic purposes.
The findings were published in the December 22, 1998, issue of the Proceedings of the National Academy of Sciences.
Sudden-Death Gene Identified
Robert Roberts, MD, lead author of the study, said in the press release that before a screening test can be developed, researchers must first isolate and clone the gene, then identify the mutation. Roberts is a professor of medicine and cell biology at Baylor College of Medicine in Houston.
Pyramid Power for Vegetarians
The Vegetarian Diet Pyramid (page 34: not shown) emphasizes that fruits, vegetables, whole grains, and legumes should be eaten at every meal and also advocates daily exercise. A moderate intake of alcohol is considered optional because of the cardiac benefits for people who are not at risk for alcoholism or other health problems.
The Vegetarian Diet Pyramid, released in 1998, was designed to offer a healthful alternative to the 1992 US Food Guide Pyramid, which lumps animal and plant foods together, and to assist the growing vegetarian population. In a Cornell University press release, Oldways President K. Dun Gifford said that 14 million Americans consider themselves vegetarians, which is up from 9 million just a few years ago. More information on the Vegetarian Diet Pyramid can be found at https://www.oldwayspt.org/html/pyramid.htm.