Attention deficit hyperactivity disorder and the athlete: an American Medical Society for Sports Medicine position statement.

Attention deficit hyperactivity disorder (ADHD) is an important issue for the physician taking care of athletes since ADHD is common in the athletic population, and comorbid issues affect athletes of all ages. The health care provider taking care of athletes should be familiar with making the diagnosis of ADHD, the management of ADHD, and how treatment medications impact exercise and performance. In this statement, the term "Team Physician" is used in reference to all healthcare providers that take care of athletes. These providers should understand the side effects of medications, regulatory issues regarding stimulant medications, and indications for additional testing. This position statement is not intended to be a comprehensive review of ADHD, but rather a directed review of the core issues related to the athlete with ADHD.

An approach to the diagnosis and treatment of plantar fasciitis.

Plantar fasciitis is a painful condition affecting many athletes. Anatomic and biomechanical factors combined with overuse can contribute to its genesis. Correction of gait disturbances, changes in footwear, use of tension night splints, and stretching of tight calf and plantar tissues have all be proven to relieve symptoms. Anti-inflammatory modalities, including medications, iontophoresis, and corticosteroid injection generally provide temporary improvement. Recent studies on the efficacy of extracorporeal shock wave therapy are conflicting. Injections with platelet-rich plasma or sclerotic agents are currently under investigation for use in this and other similar conditions. A small percentage of patients with refractory symptoms may benefit from surgical release of the plantar fascia. Diagnosis and correction of biomechanical factors leading to this condition should be a mainstay of treatment and may prevent recurrences.

Eating disorders among male athletes.

Eating disorders may affect some athletes at rates much greater than the general population. Among male athletes, eating disorders are on the rise. Studies show that males participating in sports in which leanness confers a competitive advantage may be at greater risk of eating disorders. No studies have shown that it is possible to prevent eating disorders in at-risk populations. Once present, eating disorders can be challenging to treat. Psychotherapy and medications have been shown to be helpful. A team approach to the treatment of eating disorders should be used, including regular interaction with a dietician, a mental health professional, a team physician, and other professionals as needed. To maintain participation, athletes must partner with the health care team in their treatment, maintain a healthy weight, and be clear in the understanding that their health is a greater priority than their sport.

Misrepresentation of research citations by applicants to a primary care sports medicine fellowship program in the United States.

OBJECTIVE: To determine the prevalence of misrepresentation of publications and national presentations claimed in applications to the Maine Medical Center (MMC) Primary Care Sports Medicine Fellowship Program from 2001 through 2004. DESIGN: A retrospective chart review study. SETTING: The Maine Medical Center Primary Care Sports Medicine Fellowship Program. METHODS: Presentations were confirmed in the program of the cited meeting or by contacting the sponsoring organization. Publications were verified by performing a MEDLINE search or by cross-referencing in Ulrich's International Periodicals Directory. If the title was listed, the citation was verified by contacting the publisher. RESULTS: Fifty applicants reported research publications. Of those, 14 applications had publications that could not be verified. The overall misrepresentation rate was 11.3%; among applicants claiming publications it was 28%. There was no difference in misrepresentation rate between specialties. Eighteen applicants reported giving national presentations, and nine presentations could not be verified, corresponding to an overall misrepresentation rate of 5.6%. Of applicants claiming presentations, 38.9% had at least one misrepresentation. CONCLUSION: Applicants to the Maine Medical Center Sports Medicine Fellowship Program were found to have high rates of misrepresentation in their citations of both publications and presentations.

The ergogenics of hypoxia training in athletes.

Hypoxia elicits hematopoiesis, which ultimately improves oxygen transport to peripheral tissues. In part because of this, altitude training has been used in the conditioning of elite endurance athletes for decades, despite equivocal evidence that such training benefits subsequent sea level performance. Recently, traditional live high-train high athletic conditioning has been implicated in a number of deleterious effects on training intensity, cardiac output, muscle composition, and fluid and metabolite balance--effects that largely offset hematopoietic benefits during sea level performance. Modified live high-train low conditioning regimens appear to capture the beneficial hematopoietic effects of hypoxic training while avoiding many of the deleterious effects of training at altitude. Because of the logistical and financial barriers to living high and training low, various methods to simulate hypoxia have been developed and studied. The data from these studies suggest a threshold requirement for hypoxic exposure to meaningfully augment hematopoiesis, and presumably improve athletic performance.

Awareness of altitude sickness among a sample of trekkers in Nepal.

OBJECTIVE: To quantify awareness of altitude sickness in a sample of trekkers in Nepal and identify strategies for increasing knowledge in that population. METHODS: Sixty-five high-altitude trekkers were surveyed. Demographic data were gathered. Respondents were asked about their experience in high-altitude environments, and they answered clinical-vignette questions designed to test their abilities to recognize and identify treatments for common symptoms of altitude sickness. An altitude-awareness score was generated by tabulating correct answers to questions. Scores were correlated with demographic data. RESULTS: Respondents who scored highest (n = 8) had significantly more experience in high-altitude environments, averaging 5 to 10 years (P < .05), and achieved higher average altitudes on their treks of 5171 m (P < .05) than did low scorers. Respondents with low scores (n = 17) trekked to an average altitude of 4138 m. Seventy-three percent wanted to learn more about altitude sickness, 30% said they would prefer to learn from the Internet, and 27% said they would ask a doctor. CONCLUSION: This study suggests that a large population of at-risk high-altitude travelers may be relatively naive to the dangers of altitude sickness. Overall, respondents were interested in learning more about altitude sickness. Physicians and the Internet are the most attractive sources of information for this population.

Lower extremity soft tissue conditions.

Lower extremity soft tissue injuries and overuse conditions are frequently encountered among athletes. Muscles are frequently strained or contused, arteries and nerves can become entrapped, and tendons and bursae can become inflamed. Familiarity with the anatomy of the involved area is essential for making the correct diagnosis. The majority of these conditions can be accurately diagnosed based on a thorough history and physical examination alone, without the need for expensive imaging or invasive tests. Most of these conditions can be successfully managed conservatively, avoiding surgical intervention.

Management of heatstroke and heat exhaustion.

Heat exhaustion and heatstroke are part of a continuum of heat-related illness. Both are common and preventable conditions affecting diverse patients. Recent research has identified a cascade of inflammatory pathologic events that begins with mild heat exhaustion and, if uninterrupted, can lead eventually to multiorgan failure and death. Heat exhaustion is characterized by nonspecific symptoms such as malaise, headache, and nausea. Treatment involves monitoring the patient in a cool, shady environment and ensuring adequate hydration. Untreated heat exhaustion can progress to heatstroke, a much more serious illness involving central nervous system dysfunction such as delirium and coma. Other systemic effects, including rhabdomyolysis, hepatic failure, arrhythmias, disseminated intravascular coagulation, and even death, are not uncommon. Prompt recognition and immediate cooling through evaporation or full-body ice-water immersion are crucial. Physicians also must monitor electrolyte abnormalities, be alert to signs of renal or hepatic failure, and replace fluids in patients with heatstroke. Most experts believe that physicians and public health officials should focus greater attention on prevention. Programs involving identification of vulnerable individuals, dissemination of information about dangerous heat waves, and use of heat shelters may help prevent heat-related illness. These preventive measures, when paired with astute recognition of the early signs of heat-related illness, can allow physicians in the ambulatory setting to avert much of the morbidity and mortality associated with heat exhaustion and heatstroke.

Bag of worms.

In this story, I describe, from my perspective as a resident, working with a surgeon to resuscitate a woman who has suffered an avulsion of her pulmonary artery. The patient, a victim of a collision with an intoxicated driver, arrived at the hospital as I was caring for another patient who was undergoing his tenth admission for detoxification. Having been thrown unexpectedly into the fray, I looked upon a beating heart for the first time.

Soft-tissue injuries of the lower extremity.

A diverse set of conditions affect the lower extremities in athletes. Good history taking and knowledge of the anatomy of the affected areas can aid in accurate diagnosis. Most conditions can be treated conservatively with great success. Familiarity with rehabilitation strategies can assist physicians in working with physical therapists. New advances, especially in the therapy of plantar fasciitis, may aid physicians in more rapid treatment of conditions of overuse. Surgery can provide definitive relief from symptoms for athletes with whom conservative measures have failed.

The ergogenics of fluid and electrolyte balance.

Fluid and electrolyte balance within a fairly narrow range is a requirement for human life. Athletes, particularly endurance athletes, routinely stress their bodies to the point of altering fluid and electrolyte levels. In some cases, significant fluctuations can lead to deterioration in performance and even the athlete's health. The body's physiologic response to such fluctuations of fluid and electrolyte levels is complex and not completely understood. This article examines how the body copes with changes in fluid and electrolyte balance and how these changes may be minimized via replacement to sustain athletic performance.

Your life on film: teaching continuity to residents through powerpoint and videotaped interviews.

Residents often lack the context they need to care for challenging patients. We developed a curriculum using videotapes of patient visits to teach (1). knowing the patient's context, (2). time: the key to trust, (3). reciprocity in the patient-doctor relationship, and (4). overcoming resistance to care. This teaching was most effective when the patient was interviewed by his/her own resident physician, when a particular patient was shown over time, and when contrasting different methods of dealing with behaviors common to two patients was demonstrated. Residents rated conferences in the "excellent" range and demonstrated a deeper appreciation of the elements of continuity.