Can Sports Injuries Lead to Osteoarthritis In Your Joints?

Picture by Liji Jinaraj from Flickr

The first question I get always get asked when an injured athlete sees me in our clinic is "How quickly can I get back to training?"

Actually it's not just the athletes, every single weekend warrior or physically active patient that I see will ask when they can get back to their usual activity or exercise.

I'm guilty of doing the same. That's exactly what I asked my doctor after my bicycle accident.

There is now evidence to show that if you rush to get back to playing, whether as part of a team or elite sport or simply just your usual weekly recreational tennis game or jogging you may not allow the injured joint to heal fully.

Adequate recovery includes strengthening the structures the support the injured joint. This will allow joint stability to reduce risk of re-injury and stave off irreparable joint damage. If you're not careful, irreparable joint damage can eventually lead to post traumatic osteoarthritis (OA).

OA is a degenerative joint disease. It happens when the protective articular cartilage lining the surfaces of bones wear out. This causes pain, stiffness, swelling and often disability that diminishes one's quality of life.

Post traumatic OA don't just happen to older patients. It can affect adolescents or young adults too.

Researchers suggest that acute joint damage can lead to a deterioration of the surface of the bone itself and structures that cushion and stabilize bones of a joint like the knee (Anderson et al, 2012).

That same study found that OA can develop in more than 40 percent of people who seriously injure their ligaments, the meniscus in the knee or articular surface of a joint.

They also found that people with a history of knee trauma are three to six times more likely to develop knee OA.

In order to better manage post traumatic OA, a group of Athletic Trainers (ATC) has suggested a more aggressive approach to both preventing and managing post traumatic OA. Especially in younger patients who get injured playing sports.

They suggested that having less deficits (between both legs) in muscle strength, endurance, balance movement quality and stability will reduce a person's risk of getting injured. After the initial injury, it should be properly managed to prevent additional injuries to the same joint or other joints to minimize OA developing. Ideally a structured rehab program should be maintained for six to nine months.

So don't be too impatient to return to your usual physical activity especially after a joint injury. You may have to modify the activities you do in order not to place unnecessary repetitive stress on the injured joint. Remember our articular cartilage likes and needs weight bearing forces for nutrition. Inactivity will cause the articular cartilage to deteriorate.


References

Anderson DD, Chubinskaya S, Guilak F et al (2012). Post-traumatic Osteoarthritis: Improved Understanding And Opportunities For Early Intervention. J Ortho Res. 29(6): 802-809. DOI: 10.1002/jor.21359

Palmeri-Smith RM, Cameron KL, DiStefano LJ et al (2017). The Role Of Athletic Trainers In Preventing And Managing Post Traumatic Osteoarthritis In Physically Active Populations: A Consensus Statement Of The Athletic Trainers' Osteoarthritis Consortium. J Athl Train. 52(6): 610-623. DOI: 10.4085/1062-6050-52.2.04.

Don't Drink The Pool Water!

During the last couple of days over National Day, we took a family staycation at the Goodwoodpark Hotel. I ended up spending lots of time in the pool with my two boys as you can see in the picture above. Probably ended up drinking some too.

Not the greatest thing to do if you read what Canadian researchers found when they tracked two public pools for three weeks. Olympic swimmers have admitted doing it and now evidence shows that the rest of the general public are doing it too.

Doing what? Peeing in the swimming pool that's what!

The researchers tracked the concentration of an artificial sweetener, acesulfame potassium (ACE), which is found commonly in processed food and passes through our bodies unaltered. Great for the researchers if you happen to eat processed food and pee in public pools.

By tracking ACE levels, the researchers calculated that swimmers released 75 litres of urine (enough to fill a medium sized dustbin) in the first public pool (830,000 litres, about one-third the size of an Olympic pool).

There was 30 litres of urine in the second public pool, which was around half the size of the first pool over this two week period.

The research team sampled a total 31 different swimming pools and eight hotel jacuzzi hot tubs in two Canadian cities. ACE was present in 100% of the pools and hot tubs!

Number of pool visitors were not monitored, but the results also suggested that urine content in the pool was added several times each day.

If you thought that the pool readings were bad, measurement in the eight jacuzzi hot tubs were much higher. One particular hotel jacuzzi had more than three times ACE levels than the worst swimming pool.

Just so you know, urine is sterile, but the compounds in urine (urea, ammonia and creatinine) can react with pool disinfectants cause eye and respiratory irritation. Long term exposure to these compounds has been linked to asthma.

The results were not surprising as another anonymous survey showed that 19% of adults polled admitted to having urinated in a swimming pool at least once. Professional swimmers have confessed to being among the worst offenders.

Have you ever peed in a swimming pool? Hmmm, let me ask Jo Schooling when he next comes and sees me in the clinic.


References

Blackstock LKJ, Wang W et al (2017). Sweetened Swimming Pools And Hot Tubs. Environ Sci Technol. 4(4): 149-153. DOI: 10.1021/acs.estlett.7b0043.

Wiant C (2012). New Public Survey Reveals Swimmer Hygiene Attitudes And Practices. Int J Aquatic Research Edu. 6(3): Article 4. http://scholarworks.bgsu.edu/ijare/vol6/iss3/4.

Researchers Lindsay Blackstock and Xing Fang Li testing for ACE

Joseph Schooling At Sports Solutions

Jo at Sports Solutions

For the past few days, our staff were already talking about taking pictures with him when they saw his name booked in for an appointment in our clinic today.

I was treating another patient when Jo arrived, so Jo went to see Aized for his appointment. My next patient was running late so I went to say hello to Jo. Aized said the first question he asked was "Where's Uncle Gino?"

Yes "Uncle Gino" is what Jo still calls me. We used to swim together from 2004 until early 2008 when we were both swimming at the Center of Excellence (COE) under coaches John Dempsey,  Au Yong Kim Moon and Herbert Yu. I used to treat all the swimmers there including Jo.

That was my agreement with head coach John Dempsey. He would allow me to swim with the COE swimmers (while I was still training for triathlons) on the condition that I treat all the swimmers who needed help.

In fact I first treated him at a swim meet in Kuala Lumpur, Malaysia in 2004. Jo used to kick my behind in the pool even when he was nine years young!

Great seeing you today Jo! As Aized said, our pleasure and honor to be treating you when you're home.

Rhabdomyolysis - The Scary Side Effects Of Exercise

My patient just attended her first spin class with her colleagues. Prior to this, she's been running and wakeboarding for exercise.

The doors to the studio were shut, while the air conditioning was turned off. Other than that, she didn't find pedaling fast on the stationary bike to rhythms of popular music while an instructor shouted motivation too difficult. Neither did she feel she pushed herself too hard. Her legs at the end of the hour long class weren't too sore or wobbly afterwards.

Over the next two days, her legs started throbbing and she came into the clinic to see me. I noticed bruises on her thighs and asked if she knocked them against the stationary bike. She said she didn't recall that happening.

The next day she noticed blood in her urine and checked herself into a hospital where she was warded and after blood and urine tests and was told her she had rhabdomyolysis.

Rhabdomyolysis is rare but can be a life threatening condition often caused by extreme exercise. It occurs when muscles that have been overworked dies and leak their contents into the bloodstream. This strains the kidneys and can cause severe pain.

My patient ended up staying in hospital for a few days before being discharged and has since recovered.

Subsequently I saw an article that documented three unusual cases of rhabdomyolysis, each occurring after a first spin class all treated by the same doctors (Brogan et al, 2017).

The article also described 46 other cases of people developing rhabdomyolysis after a spin class (42 of them in people taking their first spin class). The authors wrote that the condition was rare and not a reason to avoid high intensity exercise.

Another published study found 29 cases admitted to the emergency department between 2010-2014 for exercise induced rhabdomyolysis. Weight lifting, running, cross fit were some of the causes, but the most common cause was spinning classes!

The patients were not unfit, they were in fact being pushed too hard. Since they were not used to the new exercise, they ended up getting really bad muscle trauma.

Remember this next time you try a new exercise. Rhabdomyolysis occurs when you do not give your muscles time to adjust to a new aggressive exercise. When you stress your muscles too much, they tend to break down, releasing contents like myoglobin into your bloodstream which causes brown or tea colored urine, a classic symptom of rhabdomyolysis.

While any intense activity can cause rhabdomyolysis, it almost always strikes the person doing something new. So when you try a new exercise, start moderately first.

Know your limits, don't be pressured by the instructor. You can stop the exercise if you're struggling. Exercise can be dangerous when your body is not prepared for really intense levels.


References

Brogan M, Ledesma R et al (2017). Freebie Rhabdomyolysis: A Public Health Concern, Spin Class-Induced Rhabdomyolysis. AJM. 130(4): 484-487. DOI: 10.106/j.amjmed.2016.11.004.

Cutler TS, DeFilippis EM et al  (2016). Increasing Incidence And Unique Clinical Characteristics Of Spinning-induced Rhabdomyolysis. Clin J Sp Med. 26(5): 429-431. DOI: 10.1097/JSM.0000000000000281.

Here's a picture of a spin class.

Picture from Soulcycle.com

How Healthy Are Elite Athletes?

Taken with my iPhone off my computer from Cyclingnews.com

Compared to most people in the general population yes, elite athletes are very healthy if you read the article by Lemez et al (2015). However, this is a controversial topic that has been debated for years by athletes themselves, coaches and researchers.

I'm sure you've watched the riders at the Tour De France or the athletes competing at the Olympics. At these competitions, they usually rested and focused, look lean, powerful, slick and bursting with energy.

Can you guess how much it took for them to get there? All the grueling training and obsessive dedication required to reach those levels. Is at good for them? Will that pursuit of sustained excellence damage their health?

The answer depends on how you define health and who you compare elite athletes to.The findings from the comprehensive review on mortality and longevity in elite athletes is very clear. Elite athletes fare better than everyone else when it comes to longevity and disease if you define health as "the absence of disease and the capacity to enjoy life and withstand challenges."

That article by Lemaz et al (2015) examined more than 450, 000 athletes and found that elite athletes live four to eight years longer when compared to an equally matched control group in the general population.

Athletes who competed in running, cycling, soccer and swimming (sports with high aerobic demands) had the greatest benefits. Those athletes have lower rates of heart disease, stroke and smoke related cancers. The Tour de France cyclists for example have a 40 percent lower mortality rate than non athletes.

See how skinny he is (taken from Cyclingnews.com)

The other element of health is psychological, the question of enjoyment in life. That is difficult to quantify and answer.

Some studies show that elite athletes have better mental health after their retirement from elite sports. This may be due to the resilience they developed while competing or that exercise itself (trumps medication when treating depression).

However, other studies show comparable rates or even potentially increased risk for mental health issues. This is actually also dependent on the support the elite athletes received during their athletic career and early retirement (Rice et al, 2016).

Similar to an overworked doctor in the emergency department, corporate lawyer or investment banker, elite athletes often put into situations that require them to sacrifice a lot for their mind and body.

The best endurance athletes will push their bodies and their minds as far as humanly possible and this may not be good for them. If not controlled, that very same drive and determination that propels the elite athlete can eventually become harmful.


References

Lemez S, Baker J et al (2015). DO Elite Athletes Live Longer? A Systematic Review Of Mortality And Longevity In Elite Athletes. Sports Med Open. DOI: 10.1186/s40798-015-0024-x.

Rice SM, Purcell R et al (2016). The Mental Health Of Elite Athletes: A Narrative Systematic Review. Sports Med. 46(9): 1333-1353. DOI: 10.1007/s40279-016-0492-2.

Rise In Singapore Teenagers' Use Of Steroids?

"Muscular kids" gym bound at Holland V MRT today

I was a little annoyed with myself when I saw the Channel NewsAsia (CNA) headline on their website this morning.

I actually read about a similar report in the Journal of the American Medical Association (JAMA) just two weeks ago and was going to write about it but I got sick last week and didn't write it yet. So CNA beat me to it. 

Well, my wife told me the journalist (from CNA) does this for a living, whereas I am just a Physiotherapist. So it's already good I have the ideas (but not the time to write it). Grrrrrrr, guess I have to blame it on the fact that our whole family fell sick recently. 

Next time .....

So what does an American journal finding got to do with our local youths?

Well, ever since Holland village has sprouted three gyms, I've noticed a lot more "muscular kids" walking around. Yes, we do have three gyms right here in Holland Village. First F45 set up shop, followed by Ritual gym  and then Virgin Active opened it's doors recently.

Similar to the American article, it may be a widespread misconception that anabolic steroids is only an issue in elite sports. Both the American article and the Channel NewsAsia article suggest that there may be more anabolic steroid users among our teenagers. The Jama article suggest that "most young men using these drugs are doing it to improve their appearance."

Personally, I don't think it's a new problem. I've definitely had cases of teenage bodybuilders and young adults see me in our clinics for sports injuries (and telling me in strict confidence of course) that they've been injecting themselves with anabolic steroids. And that's all I'm gonna say.

Reference

Pope HG Jr, Khalsa JH et al (2017). Body Image Disorders And Abuse Of Anabolic-Andrrogenic Steroids Among Men. JAMA. 317(1): 23-24. DOI: 10.1001/jama.2016.17441

Finding Our Way Back To Fitness

My wife resting and still not feeling quite right after 11 days

It definitely happens to us runners at some point. We get sick, busy or injured. Well, it just happened to my family.

First my wife fell sick last Tuesday. She had a really bad sore throat, viral fever and was feeling really terrible. She thought she could self medicate and had to take two Panadol tablets thrice a day "just to barely function" in her words. I brought her to see the doctor on Thursday and she got better with the stronger medication given by the doctor.

On Friday, my two and half year old boy woke up with a fever. Oh dear, my wife groaned, she had passed it to him. We had very little sleep that night as his temperature kept spiking during the night. Our helper had to help us throughout the night too. I ended up not going to my usual Saturday morning long bike ride.

Despite not sleeping well, I managed to see patients the whole Saturday. When I got home, my older seven year old boy was running a temperature.

We spend the whole Sunday resting and trying to keep everyone comfortable at home. Thanks to my helper who decided to forgo her off day to help us. Thanks Ami!

I was the last one standing, the "last of the Mohicans" or so I thought. I woke up with a fever at 3 am on Monday morning! Grrrrrrr. I thought I was strong/ healthy enough not to catch the bug but in the end I succumbed.

I ended up not working for the past few days. My wife still hasn't gone in to the clinic. Though she's feeling better, she just doesn't seem quite right. The older boy hasn't gone to school this whole week while the younger boy still gets a fever on and off. Now that was really strong bug that got us down.

A body at rest can and tends to remain at rest. My wife is just lamenting that her fitness is gone, poof just like that! How do we start running or exercising again?

If you've been away from running more than a week, the pool  is great for doing deep water running. If you prefer something land based, you should just try walking first. The goal is to be able feel strong going on a 30 minute walk. If that's too much try 10-15 minutes walking and build from there.

Next, add in some running. Throw in a 10-15 second run after walking  five minutes. If you feel good, you can continue with 10 seconds run / 40 seconds walk for 5-10 mins. Every other day add 3-5 minutes and you'll back on your way.

Your body will definitely tell you if you've done too much during your comeback- you just need to listen to it.

Hmmm, should I go for my long bike ride tomorrow?

Actually, my helper, Ami, is the last one standing, "the last of the Mohicans". Good on you Ami!