Avoid Sports Injuries: Advice From an Olympic Doctor
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By Carol Peckham
Editor's Note: Gloria Beim, MD, is the Team USA chief medical officer (CMO) for the 2014 Winter Olympics in Sochi, Russia. This is the third Olympics she has served in and her first as CMO. She was the team physician for cycling and tae kwon do in the Athens 2004 Summer Olympics and was venue medical director and team physician for Team USA at the London 2012 Summer Olympics. Beim is the founder of Alpine Orthopaedics in Colorado. She is also an author, most recently of The Female Athlete's Body Book: How to Prevent and Treat Sports Injuries in Women and Girls.
Medscape: What can regular, non-Olympic athletic people or weekend warriors learn from Olympic athletes as far as training and competition?
Beim: What they should know is that Olympic athletes are training all the time. They are training in the on-season and the off-season, whereas weekend warriors often don't really train at all. They may work all week and then play tennis on the weekend, or go skiing twice a year, or play basketball once a month with their buddies. They may not stretch properly. They may not strengthen properly. They don't always have the greatest mechanics on the court or on the ski slopes, because they often don't have good teachers or coaches experienced in the proper mechanics for their sport.
Non-Olympic athletes who are really interested in playing a sport need to think about training during the off-season. Think about doing routine flexibility and strengthening exercises and keeping your body balanced, because that reduces injury. Proper biomechanics and muscular balancing reduces injury. It really does.
I will give you an example. I often see tennis players (and even golfers) in the summer with shoulder pain. They tell me, "Yeah, I didn't do anything all winter, but I just played tennis, five games, over the weekend, and my shoulder is killing me."
Well, that is not surprising. The Olympic athlete would never do that. They are training all the time and they are keeping in excellent fitness, excellent muscular balance. They have the coaching, the training, the physical therapist or athletic trainers -- all the resources to help them train properly and stay balanced and fit. They don't get the overuse injuries that a non-Olympian would who jumps into his sport now and again.
So in summary, what they can learn from Olympic athletes is to stay muscularly balanced and think about conditioning in the off-season or in between their ski trips or weekend games.
Medscape: Are there any specific exercises that you would recommend?
Beim: Strengthening of the hips. I always harp on people and their hips because many people do not think about them. Also, rotator cuff strength. You may see people in the gym pulling huge weights for the shoulders, but you rarely see them using bands and small weights to work their rotator cuff. These people are more likely to develop bursitis and impingement than the person who works their rotator cuff. If people added into their normal exercise regimen training some of the muscles that they don't usually think about, along with flexibility exercises and stretching, it could make a big difference in their performance and injury rate.
Medscape: What are the top three pieces of advice you would give athletes during competition?
Beim: That's easy. No. 1, get your rest. We make sure that the athletes get to the Games location in plenty of time before their competition so that they can get rest and their bodies can adapt to the different time zones.
No. 2, don't change anything. Don't start a new diet or take any new supplements. Don't change your routine. The Olympic Games is not a time to start something new. I have had athletes tell me about someone from another country who is using this or doing that and ask whether they should try it. And I say, "No, not now." During the Olympic Games is one of the worst times to change anything in your routine.
No. 3: Enjoy the Games. There is something so special about the Olympic Games. I am an athlete but not nearly at Olympic caliber. I am just there as a doctor, but when walking through an Olympic village, watching an event, or having a meal at the dining hall, the energy is so amazing. It is different from any other sporting competition that I have ever had the pleasure of attending. It is such an incredible experience and opportunity. So just take it all in and use it to accelerate your passion for what you are doing.
Injuries and Female Athletes
Medscape: Injuries, of course, are a concern. How can you reduce the rate of head injuries?
Beim: Certainly with helmets, obviously. Another way to help reduce the risk for serious head injury is to follow the rules, which just makes sense. Fortunately, the organizing committee in Sochi is going to have venues that are state-of-the-art and are going to be as safe as possible.
Of course, some sports are higher-risk than others, and there is no way to eliminate the risk for head injury. Some ski racers and freestyle skiers will use spinal protectors in their suits, which can help reduce back injury. And many athletes use mouth guards, which is really smart. If you take a good hit on the snow or ice, it would be sad to lose your teeth, so I think mouth guards are really important.
Medscape: I've read that female winter sports athletes are more prone to injuries than men are. Can you address this or any other issues related to injuries in female athletes?
Beim: I don't have the statistics in front of me, but in the Olympic arena, all athletes are so highly trained that I would guess that the male-to-female ratio of injuries is probably closer than in the non-Olympic and nonprofessional population. This is because Olympic athletes train and they train the right way. They have good coaching and good training techniques.
On the other hand, some female and male weekend athletes may go skiing after not having done anything all year. They may have weak hips. They may have tight hamstrings. ... They may have a mismatch of their hamstring and quad strength. They just might pop their anterior cruciate ligament or medial collateral ligaments, and for women that's easier than for the man just because of the anatomy. That has been proven again and again. Noncontact injuries are more common in females than males. However, as you get into the more elite-athlete population, I think the difference between men and women probably goes down.
Medscape: Are there any vulnerabilities that might be specific to female athletes?
Beim: In my book, I always harp on the muscular imbalance in the lower extremities, which I see more in women than men (although I do see it in men), and it definitely increases the risk for overuse and traumatic injuries in the knee. No question. Women and some men tell me that their knee has been bothering them and that they have some patellar tendinopathy. But they also have very weak hips.
Many people do not think about working their hips. Many studies have proved that weak hips can lead to knee overuse injuries, and in my opinion that can also increase the risk for traumatic injury, particularly in skiing or basketball and other court sports.
So I am always harping on my patients to strengthen their hips. Hip abductors and adductor exercises are so important, but many people do not do them.
Medscape: I read that respiratory diseases are very common among Olympic athletes, particularly during the Winter Games. How do you deal with such illnesses, and where do you draw the line and tell them to withdraw?
Beim: A respiratory illness would have to be very severe for us to recommend that an athlete withdraw. Fortunately, I have not had to treat any serious cases at the Games. In fact, in all the Games I have been to, I cannot recall anybody who has been withdrawn because of a respiratory illness. We get colds or an occasional mild flu that someone may have gotten during their travels. We usually just treat these people symptomatically. Even with these illnesses, however, I have to follow the World Anti-Doping Agency (WADA) list of substances that we are allowed and not allowed to use.
Medscape: What about performance-enhancing drugs? Are you involved in checking for these?
Beim: Yes. Athletes can be tested anytime, anywhere. This is how it works: At the Olympic Games, athletes have to submit to the doping control agency -- usually by email -- a form that they fill out on where they are going to be training every day, where they live, and whether they are going to go somewhere else for a while. These are called "whereabouts."Athletes have to document where they are during the period of the Games, and the anti-doping agency can show up anywhere -- at the training facility, up at the village, at their housing, at the hotel. An athlete can be tested anywhere, anytime. Doping control is not going to do a drug test only on athletes who win gold medals.
I am involved, along with the medical director of the U.S. Olympic Committee, to make sure in advance that any medications that athletes are taking are allowed and are not prohibited (i.e. on the doping list). Right now we are reviewing all of the athlete history forms and are almost done. If an athlete is taking a banned substance for medical reasons, we have to make sure that they have the proper documentation, which is a therapeutic-use exemption that is filled out and must be approved by WADA.
So for instance, if athletes are on insulin, they have to have proper documentation in advance, stating that they are diabetic and need insulin. Then they can use it.
We are also involved when an athlete does get called for a doping test, and pretty much all of them will at some point. Then, either a team doctor or I will accompany the athlete to the doping control area and make sure that all of the paperwork is filled out properly and that all of the tests are done properly.
At this level, most of these athletes have been to World Championships or World Cup events, so this is now a normal procedure. Unfortunately, the clean athletes have to go through this process to make sure the cheaters don't get through.
Medscape: And we keep seeing new drugs that are even harder to identify.
Beim: Yes. When I was in Athens back in 2004, Scientific American had a really great article on gene doping. Have you heard of gene doping? Gene therapy has been tested on patients with Duchenne muscular dystrophy. It was theorized that some doctors may be using it for athletes, which would be absolutely undetectable. The Scientific American article predicted back then that Athens could be one of the last honest Games, because if gene doping becomes the mainstay, who will be able to tell? Whether it is happening now, I don't know, but that would be a tough one. I know that Team USA is 100% committed to clean sport, as am I.
New Treatments and Diagnostics
Medscape: You have seen so many treatment modalities in other countries during your travels. What have you learned about best practices, and what treatments have you been exposed to that you wouldn't have otherwise?
Beim: When I visit other countries, I am always intermixing with other doctors, sharing stories, learning about what they are doing, and teaching them what I am doing. It is a wonderful way to expand your mind about global medicine.
When I was the CMO at the Pan Am Games in 2011, some clinicians from the U.S. Olympic Committee were using diagnostic musculoskeletal ultrasound. I had read about it but had never really seen it used that much. For instance, the radiology department in my local hospital does not routinely do musculoskeletal ultrasound. When I saw it at the Pan Am Games, I was blown away and immediately hooked by what we could do with this approach. The minute I got back I bought a machine and started training very hard. Now I cannot imagine practicing without it. I don't do any injections without my ultrasound. I have reduced my MRI usage probably by 75% for shoulders -- and shoulder surgery is one of my specialties. It is amazing what you can "see with sound." It is great for the patient. For example: You have somebody with a possible rotator cuff tear. Ordinarily you'd order an MRI, get it preauthorized, wait for it to be scheduled, get it done, and get the patient back in the office to read it. How long are you talking about? If you're lucky, a week -- maybe more. Whereas with the diagnostic ultrasound, you are in the office, and within 5 minutes you can see the tear and show it to the patient. And you have spent about one-third of what an MRI would have cost.
Medscape: And you are using this at the Olympics?
Beim: Oh, yes. We will have two ultrasound machines. I have given talks to other orthopedists, trying to get them excited. Very few are using this technology themselves. It just hasn't become mainstream, and every year these machines get better. There is a learning curve, to be sure, and some doctors may be too busy.
Medscape: Are there other new treatment or diagnostic modalities that you've learned about during your travels?
Beim: Yes. One good example is instrument-assisted soft tissue mobilization (IASTM), which is used for patients with chronic muscle scar tissue from an injury, tendinitis, or plantar fasciitis. IASTM employs stainless-steel tools to free up all the adhesions, and it takes only about 5 minutes. The patient might need two or three treatments. Physical therapists and chiropractors can use it as well.
When I first learned about that technique, I came back to my practice and signed up not only myself but also three of my physical therapists for a course at the Olympic Training Center in Colorado Springs.
I learned it because sometimes when I travel with teams, I don't have a therapist or a trainer or anybody else with me; I may be it -- the doc, the psychologist, the trainer, the massage therapist, everything. So I like to have as many arrows in my quiver as I can to treat these people, and I love this technique.
During the Summer Olympics, a pole vaulter had an adhesion above the kneecap and was really limited by it. Three days before the competition, the athlete was in a lot of pain. I used this little technique and the athlete won a gold medal. Another recent instance: My husband is a ski racer, and just last week he had a quad injury. I did this technique on him and he won a silver medal in his giant slalom race. It is amazing.
Medscape: This is a totally noninvasive procedure?
Beim: Completely noninvasive. As a surgeon, here is what's so cool about it: Say I have a patient with a muscle or fascial restriction from a scar that wasn't responsive to therapy. What would I do ordinarily? For instance, I might see some hardware in there (for instance, a plate and screws from prior surgery) and the scar is in that area. I may take my scissors and pickups and free up the scar. With IASTM, I do the same thing -- release the adhesions and the scar -- but I don't make any incisions. It is remarkable. I don't work for this company and didn't even tell you the name of the company, so I can't get in trouble. But it is remarkable.
Medscape: Are there any other new treatments that you've learned about in your travels and think are useful?
Beim: Yes. Ultrasound-guided microtenotomy is amazing. You look at the tendon on ultrasound and the partial or chronic tearing and scarring. Then you make a tiny incision with a #11-blade scalpel and put this tiny probe, under ultrasound guidance, into this scar. The probe sends ultrasonic waves, which cuts it up, injects fluid, and sucks the tissue out all at the same time under live ultrasound imaging.
It takes about 60-70 seconds, all under local anesthesia. You don't even need a stitch because the incision is so small. The main indications for it now are patellar tendinitis, Achilles tendinitis, plantar fasciitis, tennis elbow, and golfer's elbow.
I have a great example of its use from the last Summer Olympics. A track-and-field athlete had had chronic patellar tendinitis for a year. Therapy had failed and he still had some muscle imbalances and hip weakness. I told him, "You know what? You need to do some hip strengthening." He came out to my clinic for a few weeks to work with my therapist and was maybe 60% better within about a year of therapy and conservative measures. At that point, he had an area of scarring embedded in his tendon that you could see on ultrasound and MRI. Because conservative measures were failing, this was an indication to surgically open up the tendon and clean out the scar -- open scar debridement of the tendon.
Fortunately I had learned about ultrasound-guided microtenotomy before this and had trained in it, so I performed it on this young man. He is currently, I think, 14 weeks out, and for the first time in 2 years he is absolutely pain-free and is doing great in his training. It is just miraculous.
Medscape: Is ultrasound-guided microtenotomy widely available now?
Beim: It was FDA-approved about a year and a half ago, and any surgeon can be trained to do it. However, you have to be a good ultrasonographer, which is, I think, the limiting step, because many orthopedists don't do ultrasound themselves. They might have their physician assistant or radiologist do it, but you really need to do it yourself to correctly perform this procedure. Once you are proficient at ultrasound, this procedure is quite simple. You just go in and take out the bad tissue and that's it. It just makes sense to use this approach rather than making a big incision and violating normal tissue to get to the diseased tissue.
This is another technique that I picked up through my travels and have taken into my practice. So, bottom line, being associated with these international Games has changed my practice for the better. It has been amazing.
SOURCES: Sweeney, H. Scientific American, 2004. Ireland, M. Journal of Orthopaedic & Sports Physical Therapy, 2003. Robinson, R. Journal of Orthopaedic & Sports Physical Therapy, 2007. Cichanowski, H. Medicine & Science in Sports & Exercise, 2007.